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Pain Medicine 2014; 15: 1027–1035 Wiley Periodicals, Inc.
ACUTE PAIN & PERIOPERATIVE PAIN SECTION Original Research Articles Health Care Workers and ICU Pain Perceptions
Ravali Tarigopula, MD,* Naveen K. Tyagi, MD,† Jill Jackson, APN,*§ Chaitali Gupte, MD,* Pooja Raju, MD,*‡ and Jennifer LaRosa, MD* Departments of *Pulmonary and Critical Care Medicine, †Internal Medicine, Newark Beth Israel Medical Center, Newark; ‡Department of Neurology, Sleep Medicine, John F Kennedy Medical Center, Edison; §Palliative Care, Meridian Care Journey, Neptune, New Jersey, USA Reprint requests to: Jennifer LaRosa, MD, Department Pulmonary and Critical Care Medicine, Newark Beth Israel Medical Center, 440 Timber Drive, Berkeley Heights, NJ 07922, USA. Tel: 917-969-1818; Fax: 973-926-6799; E-mail: [email protected]. Disclosure and Conflicts of Interest: Our work was funded by a 3-year $100,000.00 grant from the MayDay Fund, and we have no conflicts of interest. All authors are listed and have contributed to this body of work.
Methods. Responses were provided using a Likert scale and scored on subscales of hemodynamic instability, addiction and tolerance, pain expression, legal issues, and education. Results. The results demonstrated that characteristics such as age and race were significant predictors of perceptions regarding addiction subscale scores (β = −0.256, P = 0.006 and β = 0.183, P = 0.053, respectively). Race proved to be a significant factor in pain expression scores (β = 0.183, P = 0.053). Work-related variables, such as being in or out of active medical training and being within the critical care specialty itself, were significant predictors of addiction subscale scores as well (β = −0.238, P = 0.012 and β = 0.191, P = 0.050, respectively). Conclusion. Health care providers’ race, age, level of education, and medical subspecialty were significant factors affecting their perceptions of pain management and intended treatment. Key Words. Pain Management; Perception; Race Disparities; Sociocultural
Abstract Objective. Our study examined the effect of health care workers’ personal characteristics on how they perceive and intend to treat patients’ pain in the intensive care unit. Though pain perceptions have been well established from the patient’s perspective, less is known about how variations in health care workers may affect their perceptions of pain. Design. This study consisted of a 28-item questionnaire distributed to 122 medical staff personnel over a 12-month period. The questionnaire included items regarding respondent characteristics such as age, gender, race, ethnicity, and level of training. Subjects and Setting. The questionnaire was distributed to physicians and nurses working in the critical care setting.
Introduction The undertreatment of both acute and chronic pain has been documented by studies since the inception of modern medicine [1]. The majority of investigations on pain recognition and treatments have been aimed at patients with advanced malignancies. Up to 90% of such patients experience intractable pain despite the widespread use of opioids [2]. Literature has cited some of the following factors as causes of poor pain recognition and management: 1) inappropriate attitudes regarding the use of opioids; 2) lack of knowledge of the types and appropriate dosages of analgesics; 3) assignment of a low priority to pain management; 4) lack of understanding of the pathophysiology of cancer pain; 5) patients’ reluctance to report pain; and 6) overconcern about the development of tolerance to analgesic medications [2–4]. No such studies have been performed solely in the critical care setting. 1027
Tarigopula et al. Pain assessment and management remain integral parts of patient care in critical care settings [5]. Despite extensive research, guideline development and distribution, and intense educational efforts, there remains clear evidence that critical care patients have pain that is poorly recognized and inconsistently treated [6]. It is estimated that approximately 70% of patients experience at least moderate intensity pain during their intensive care unit (ICU) admission [6]. ICU patients, in particular, are at risk for poor pain management, yet relatively little is known about pain assessment and control in this population [7]. A study performed in 2004 by Erdek and Provonost demonstrated that by implementing a “plan-do-studyact” model in a critical care setting, they were able to improve pain assessment and treatment over a 2-week period [8]. When evaluating optimal pain management, the patient, the health care team, and the health care system are areas wherein change may be implemented [6,8]. Some of the most common obstacles to overcome pain include a failure to assess and acknowledge the existence of pain, outdated prescribing habits, inadequate quality improvement monitoring, and a lack of accountability for unsatisfactory outcomes related to poorly managed pain [6,8]. In addition, specific barriers such as clinician-related barriers, personal and cultural bias, and communication difficulties between the patient and health care team contribute considerably to suboptimal pain management in the ICU setting [6]. The relationship between health care workers’ personal characteristics and their perceptions and intended treatment of pain in the critically ill remains vague. Few studies in the field of nursing have examined the influence of nurses’ personal and professional characteristics on the assessment of pain [9–11]. No relationship between nurses’ pain assessment and their years in practice, age, relative job satisfaction, educational preparation, clinical practice area, or shift assignment was apparent [9,12,13]. No such studies have been undertaken across the board with respect to physicians and nurses in the critical care setting with a global review and assessment of their personal characteristics. Extensive literature reveals racial and ethnic disparities in pain epidemiology, including access to quality pain care, pain assessment and treatments, and pain-related outcomes. Patient-related barriers include differences in pain thresholds and tolerances, as well as pain-related attitudes and beliefs. Limited access to health care and lack of insurance or underinsurance also pose significant hurdles in pain expression, and therefore adequate management in certain groups [14]. Again, however, the link between health care workers’ personal characteristics and pain perception and intended treatment in the intensive care setting has never been clearly investigated or established. A cornerstone for quality pain care is optimizing and standardizing the providers’ pain assessment and knowing how personal characteristics may affect such assessment [14]. 1028
The perception of patients’ pain may be additionally affected by the attitudes of the health care providers toward pain and its impact on the patient [4]. We hypothesized that such a relationship would exist and that certain health care workers’ personal characteristics would be likely to predict how they perceived and intended to treat pain in the critically ill population. Materials and Methods Design and Setting This prospective questionnaire-based study took place over a 12-month period in our 673-bed, universityaffiliated teaching hospital in Newark, New Jersey. The voluntary pain assessment questionnaire (Appendix 1) included 28 questions: 12 devoted to identification of personal characteristics and 16 regarding pain perceptions and intended treatment patterns. Our study protocol was reviewed and approved by our Institutional Review Board (IRB) and assigned an IRB# 2011.04. Questionnaires were distributed in person by one of four investigators to those eligible to complete the survey. Eligible participants included critical care nurses, including registered nurses (RNs) and registered nurse practitioners (RNPs), physicians (medical doctors and doctors of osteopathic medicine) in critical care training (residents and fellows), and attending physician intensivists working in one of three medical and/or surgical ICUs. Informed consent was obtained from each participant. Investigators waited while the questionnaire was completed, and it was then folded and placed in a lock box by the respondent. Participants were given a $5 gift card as incentive to complete the questionnaire. The participant’s name was crossed off a master list so that no person completed the survey twice. To ensure anonymity, after each set of 15–20 surveys, the lock box was opened, and the questionnaire information was entered into a database. The database did not include participant names or any other identifying information. Instrument The questionnaire consisted of a total of 28 questions. The first 12 questions were devoted to identifying the respondents’ personal characteristics, including age, gender, race, ethnicity, marital status, and degree. Sixteen questions followed which randomly queried providers about their perceptions and treatment patterns with respect to pain in the critically ill. Questions addressed the five main areas including hemodynamic instability (questions 3, 4, 5), addiction and tolerance (questions 1, 2, 13), pain expression (questions 6, 7, 8, 11, 14), legal issues (questions 9, 10), and training/education (questions 15, 16). Responses were based on a 5-point Likert scale, and answers were scored according to whether or not the provider was considered liberal or conservative with regard to pain perceptions. Common analgesic options used on our ICU, with which our health care providers are familiar, include the
Health Care Workers and ICU Pain Perceptions following: 1) continuous or intermittent opioids; 2) epidural infusions; 3) acetaminophen; and 4) nonsteroidal antiinflammatory drugs.
Table 2
Study Population
Race White/Caucasian Black/African American/ Caribbean Native Hawaiian/Pacific Islander Asian Missing Country of origin Philippines United States Canada Trinidad Haiti India Myanmar Pakistan Iran Romania Ukraine Puerto Rico Russia Taiwan Nigeria Kenya England Dominican Republic Missing
Inclusion criteria were as follows: age >21 years old with a good command of written and spoken English language; employment at Newark Beth Israel Hospital in the combined medical and surgical ICU, the coronary care unit, or the cardiothoracic surgical ICU; holding an RN, RNP, MD, or DO professional degree. Statistical Analysis The SPSS 17 (SPSS Inc., Chicago, IL, USA) was used for all analyses. Frequencies and descriptives were run on the personal characteristic variables, and regression analyses were used to determine whether the personal characteristic variables predicted scores on the subscales of hemodynamic instability, addiction and tolerance, pain expression, legal issues, and training and education. t-Tests and ANOVAs were used to determine whether there were any differences between groups on the various subscale scores. Results A total of 122 surveys (N = 122) were administered and returned. Women made up two-thirds of the respondents (N = 75, 61.5%), whereas a third were men (N = 35, 28.7%). Most respondents were married (N = 84, 68.9%, see Table 1). The vast majority of the respondents identified themselves as non-Hispanic/Latino (N = 101, 82.8%), whereas the remaining were identified as Hispanic/Latino (N = 6, 4.9%). The race and country of origin of the respondents are displayed in Table 2. Respondents ascribed to a wide range of religions (see Table 3). Approximately 56% of the respondents were RNs (N = 68, 55.7%), 41% were MDs (N = 50), whereas about 3% were
Frequency
Percentage
33 22
27.0 18.0
16
13.1
48 3
39.3 2.5
20 31 8 17 16 8 1 3 1 1 1 1 1 1 1 1 1 1 8
16.4 25.4 6.6 13.9 13.1 6.6 0.8 2.5 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 6.6
DOs (N = 3, 2.5%). Among the respondents, 55.7% were no longer in training (N = 68), but 37.3% were in training (N = 46). Respondents had varying degrees of experience working in critical care units, and most listed medical ICU as their subspecialty (see Table 4).
Table 3 Table 1
Race and country of origin
Religion
Marital status and age Frequency
Marital status Married Single Divorced Other Missing Age 20–29 30–39 40–49 50–59 60–69 Missing
Frequency
Percent
38 6 22 17 12 2 1 2 1 8 1 1 1 10
31.1 4.9 18.0 13.9 9.8 1.6 0.8 1.6 0.8 6.6 0.8 0.8 0.8 8.2
Percent
84 28 6 1 3
68.9 23.0 4.9 0.8 2.5
30 35 35 15 3 4
24.6 28.7 28.7 12.3 2.5 3.3
Catholic Lutheran Hindu Methodist Christian Jewish None Episcopalian Pentecostal Islam Sikh Mysticism Agnostic Missing
1029
Tarigopula et al. reported having no pain education during training, but 23 (18.9%) indicated they received only minimum training. When asked if they had ever personally experienced severe pain, 76 (62.3%) individuals stated they had, whereas 31 (25.4%) indicated that they had not.
Table 4 Years working in any ICU and ICU subspecialty
Years working in any ICU 1–2 3–5 5–10 10–19 >20 Missing ICU subspecialty Cardiac CT surgery Medical ICU Surgical ICU Missing
Frequency
Percent
33 25 12 27 23 2
27.0 20.5 9.8 22.1 18.9 1.6
26 19 61 2 14
21.3 15.6 50.0 1.6 11.5
Certain work-related variables were significant predictors of the addiction severity index. Whether or not the respondent was in training was a significant predictor of the addiction severity index (β = −0.238, P = 0.012) and accounted for 6% of the variance. There were no significant differences on addiction subscale scores between trainees and nontrainees (P = 0.083) (see Tables 5 and 6) The ICU subspecialty was also a significant predictor (β = 0.191, P = 0.050), accounting for 4% of the variance in how respondents perceived the potential for patients to become addicted to opioids and other analgesics used in pain management. There were no significant differences between ICU subspecialties in their addiction subscale scores (P = 0.203) (See Tables 7 and 8).
CT = cardiothoracic surgery; ICU = intensive care unit.
Respondents were asked to indicate the degree of pain education they received during their training. Most individuals reported that their training was adequate (N = 54, 44.3%), whereas a smaller number indicated their training was extensive (N = 15, 12.3%). Only one individual (0.8%)
Table 5
Addiction subscale score
Table 6
Personal characteristic variables were also significant predictors of the addiction subscale scores. Age was an excellent predictor of the addiction subscale scores (β = −0.256, P = 0.006) and accounted for a significant proportion of the variance (7%). There were no significant differences in addiction subscale scores among the different age groups (P = 0.705) (See Tables 9 and 10). Race also accounted for a significant proportion of the variance (11%) in the addiction subscale scores (β = 0.330, P = 0.000), but there were no significant differences between the races on the addiction subscale scores (P = 0.227). (See Tables 11 and 12). Taken together, race, religion, ethnicity, and country of origin approached significance as predictors of the addiction subscale scores (R2 = 0.128, F [4, 65] = 2.395, P = 0.059), accounting for 13% of the variance in the
Group statistics In Training
N
Yes No
45 66
Mean
Standard Deviation
Standard Error of the Mean
8.58 7.23
4.325 3.603
0.645 0.443
Independent samples test Levene’s Test for Equality of Variances
t-Test for Equality of Means 95% Confidence Interval of the Difference
F Addiction Equal 3.060 subscale variances score assumed Equal variances not assumed
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Significance
t
0.083
1.787 109
1.726
df
Standard Significance Mean Error (two-tailed) Difference Difference Lower
Upper
0.077
1.351
0.756
−0.148 2.849
82.918 0.088
1.351
0.782
−0.206 2.907
Health Care Workers and ICU Pain Perceptions
Table 7
Descriptives addiction subscale score 95% Confidence Interval for Mean
Cardiac CT surgery Medical ICU Surgical ICU 5 Total
N
Mean
Standard Deviation
Standard Error
Lower Bound
Upper Bound
Minimum
Maximum
18 18 52 2 16 106
7.89 6.39 7.79 9.50 9.56 7.87
3.394 3.760 4.267 2.121 3.098 3.909
0.800 0.886 0.592 1.500 0.774 0.380
6.20 4.52 6.60 −9.56 7.91 7.12
9.58 8.26 8.98 28.56 11.21 8.62
2 1 1 8 4 1
14 13 15 11 16 16
CT = cardiothoracic surgery; ICU = intensive care unit.
respondents’ perceptions of patients’ addiction potential to pain management medications. Race was a significant predictor of pain expression scores (β = 0.183, P = 0.053), accounting for 3% of the variance in the respondents’ perceptions of how patients express their pain. No variables examined in this study were significant predictors of the hemodynamic instability subscale scores or the legal subscale scores. Discussion We found that some personal characteristics may be significant predictors of how health care providers perceive
Table 8
ANOVA
addiction subscale score
Sum of Squares
df
Mean Square
F
Significance
1.518
0.203
Between groups Within groups Total
90.985
4
22.746
1513.166
101
14.982
1604.151
105
Table 9
Descriptives addiction subscale score
critically ill patients’ pain and report pain treatment patterns. There was a statistically significant relationship between race and pain expression. This indicates that race may be a predictor of how poorly or how thoroughly providers perceive pain in their critically ill patients. Race and ethnicity have been cited as important cultural barriers in communication between patients and physicians. This is due to several factors. It has been repeatedly documented that certain populations describe a higher prevalence of pain. As studied by Green et al. in Bressler et al. [15] and Turk et al. [16], minorities and women report higher pain prevalence than men and non-Hispanic whites. In addition, racial variability may predict different levels of pain tolerance [17]. Our study similarly suggests that race, pain perception, and tolerance may be deeply intertwined. Addiction was strongly modified individually by whether or not the provider was in training, as well as by providers’ ICU subspecialty, age, and race. Taken together race, religion, ethnicity, and country of origin approached significance as predictors of the addiction subscale scores. In our study, several factors influenced how health care providers perceive traditional pain management strategies. Such individual factors included critical care specialty, training status, age, and race. Concomitant factors included race, religion, ethnicity, and country of origin.
95% Confidence Interval for Mean
20–29 30–39 40–49 50–59 60–69 Total
N
Mean
Standard Deviation
Standard Error
Lower Bound
Upper Bound
Minimum
Maximum
30 34 34 15 2 115
7.67 8.44 8.09 6.73 8.00 7.90
4.365 4.215 3.596 2.815 2.828 3.882
0.797 0.723 0.617 0.727 2.000 0.362
6.04 6.97 6.83 5.17 –17.41 7.19
9.30 9.91 9.34 8.29 33.41 8.62
1 2 1 2 6 1
14 16 14 10 10 16
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Tarigopula et al.
Table 10
ANOVA
addiction subscale score
Sum of Squares Between groups Within groups Total
Mean Square
df
33.230
4
8.308
1684.718
110
15.316
1717.948
114
Table 12
F
Significance
0.542
0.705
There are limitations to this study. First, this was a singlecenter study done at an urban tertiary facility, and these results may not be reproducible across different medical
Table 11
addiction subscale score
Sum of Squares Between groups Within groups Total
Many authors have documented a lack of knowledge by health professionals about the anatomy and physiology of pain, pain assessment, differences between acute and chronic pain, and pharmacological and nonpharmacological management of pain [9]. Opioid analgesics are traditionally the treatment of choice for moderate to severe acute and cancer pain [18]. They are commonly used in critical care settings to control pain due to the availability of various formulations, quick onset of action, and effectiveness. In a study done by Upshur et al. in 2006, however, physicians were concerned that prescribing medications for legitimate medical purposes can unintentionally contribute to illicit use and create addiction in their patients [18,19]. It could be hypothesized that physicians in training undertreat pain due to inadequate experience and incomplete knowledge regarding addiction. Similarly, many nurses did not know that the incidence of opioid addiction during pain treatment is believed to be considerably less than 1% [9]. A study done by Erkes et al. [20] concluded that critical care nurses had low scores on the Nurses’ Knowledge and Attitudes survey regarding pain, and over 50% of the scores improved after an educational intervention. There were no variables that significantly modified questions related to hemodynamic instability or legal issues. On the other hand, in terms of hemodynamic instability, most health care workers are not worried about such instability with pain medications.
ANOVA
df
Mean Square
F
Significance
1.469
0.227
66.204
3
22.068
1682.554
112
15.023
1748.759
115
settings. Second, there was a potential for a selection bias as the survey was personally handed out by the investigators, and certain groups, such as night shift nurses, may have been underrepresented. Further investigation with a wider range of groups would be a worthy undertaking. Third, though we were aware of the potential side effect of morphine-induced hypotension, the aim of our study was to describe relationships between health care providers’ personal characteristics and their perceptions and intended treatment of critical ill patients’ pain. We were only assessing provider perceptions, not prescribing patterns. Such additional investigation into prescribing patterns would be an interesting follow-up study. Fourth, given that this was a preliminary and more exploratory type of study on a few subjects, our intent was to look at the overall characteristics of the providers (e.g., race, ethnicity, religion, etc.) rather than specifics (e.g., African American vs Caucasian or Catholic vs Islamic) to see if they influenced or predicted the addiction severity index. Thus, the comparison of these variables was not the intent of our initial study. Furthermore, the sensitive nature of the information warrants a larger study that will be undertaken once the instrument is perfected. Conclusion Our results suggest that there may be a relationship between some health care workers’ personal characteristics and their perceptions of critically ill patients’ pain and intended pain treatment. The most notable of these was the relationship between race and
Descriptives addiction subscale score 95% Confidence Interval for Mean
Mean
Standard Deviation
Standard Error
Lower Bound
Upper Bound
Minimum
Maximum
33 21 16
7.61 6.52 8.56
3.535 3.628 4.049
0.615 0.792 1.012
6.35 4.87 6.40
8.86 8.18 10.72
2 1 3
14 13 16
46 116
8.50 7.90
4.146 3.900
0.611 0.362
7.27 7.18
9.73 8.61
1 1
15 16
N White, Caucasian Black, African American, Caribbean Native Hawaiian or Pacific Islander, including Philippines Asian Total
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Health Care Workers and ICU Pain Perceptions pain perception and the relationship between addiction and training level. Addiction and the collective assessment of age, subspecialty, and race was also a significant finding. Further investigation and continuing education programs are critical to elaborating more on these relationships and identifying ways to overcome such barriers to adequate pain perception and management.
10 McCaffery M, Ferrell BR Nurses’ knowledge of doses and psychological dependence. J Nurs Professional Dev 1992;8:77–84.
References 1 Visina CE, Chen J, Gerthoffer TD, Biggs R, Ting D. Community hospital physician and nurse attitudes about pain management. J Pain Palliat Care Pharmacother 2003;17:51–62.
12 Hamilton J, Edgar L. A survey examining nurses’ knowledge of pain control. J Pain Symptom Manage 1992;7:18–26.
2 Elliott TE, Murray DM, Elliott BA, et al. Physician knowledge and attitudes about cancer pain management: A survey from the Minnesota cancer pain project. J Pain Symptom Manage 1995;10:494–504. 3 Charap AD. The knowledge, attitudes, and experience of medical personnel treating pain in the terminally ill. Mt Sinai J Med 1978;45:561–80. 4 Cleeland CS, Cleeland LM, Dar R, Rinehardt LC. Factors influencing physician management of cancer pain. Cancer 1986;58:796–800. 5 Puntillo KA, Smith D, Arai S, Stotts N. Critical care nurses provide their perspectives of patients’ symptoms in intensive care units. Heart Lung 2008;37:466– 75. 6 Pasero C, Puntillo K, Li D, et al. Structured approaches to pain management in the ICU. Chest 2009;135:1665–72. 7 McCaffery M, Ferrell BR. Nurses’ knowledge of pain assessment and management: How much progress have we made? J Pain Symptom Manage 1997; 14:175–88.
11 Watt-Watson JH. Nurses’ knowledge of pain issues: A survey. J Pain Symptom Manage 1987;2:207– 11.
13 Ferrell BR, McCaffery M, Ropchan R. Pain management as a clinical challenge for nursing administration. Nurs Outlook 1992;40:263–8. 14 Anderson KO, Green CR, Payne R. Racial and ethnic disparities in pain: Causes and consequences of unequal care. J Pain 2009;10:1187– 204. 15 Bressler LR, Geraci MC, Schatz BS. Misperceptions and inadequate pain management in cancer patients. DICP 1991;25:1225–30. 16 Turk DC, Brody MC, Okifuji EA. Physicians’ attitudes and practices regarding the long-term prescribing of opioids for non-cancer pain. Pain 1994;59:201– 8. 17 Nayak S, Shiflett SC, Eshun S, Levine FM. Culture and gender effects in pain beliefs and the prediction of pain tolerance. Cross-Cultural Res 2000;34:135– 51. 18 Wolfert MZ, Gilson AM, Dahl JL, Cleary JF. Opioid analgesics for pain control: Wisconsin physicians’ knowledge, beliefs, attitudes, and prescribing practices. Pain Med 2010;11:425–34.
8 Erdek MA, Pronovost PJ. Improving assessment and treatment of pain in the critically ill. Int J Qual Health Care 2004;16:59–64.
19 Upshur CC, Luckmann RS, Savageau JA. Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med 2006;21:652–5.
9 Clarke EB, French B, Bilodeau ML, et al. Pain management knowledge, attitudes and clinical practice: The impact of nurses’ characteristics and education. J Pain Symptom Manage 1996;11:18–31.
20 Erkes EB, Parker VG, Carr RL, Mayo RM. An examination of critical care nurses’ knowledge and attitudes regarding pain management in hospitalized patients. Pain Manage Nurs 2001;2:47–53.
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Tarigopula et al. Appendix 1
Perceptions of pain in the intensive care unit
Age: 20–29 30–39 40–49 Gender: M F Marital status: Single Married Divorced Religion:_______________________ Race/Ethnicity: see chart on back & specify number:________________ Country of birth:___________________________ Degree: RN APN MD In training: Yes No Years working in any 1–2 3–5 5–10 ICU: ICU subspecialty: Cardiac CT surgery Medical ICU Describe your pain education during training: None Minimum Adequate Extensive
50–59
60–69
70+
Other (specify):______
DO 10–19
>20
Surgical ICU
Have you ever experienced severe pain? If so, please describe. __________________________________________________________________ Please answer each of the following on a Likert scale of 1–5 as follows: 1 = Strongly disagree 2 = Somewhat disagree 3 = Neither agree nor disagree 4 = Somewhat agree 5 = Strong agree Giving your patient regular narcotic medicine to treat pain is likely to result in an addiction to narcotics. 1-----2-----3-----4—-5 Patients requesting frequent narcotic pain medications (“watching the clock”) are drug seeking. 1-----2-----3-----4—-5 Giving your patient regular narcotic medicine to treat pain will likely result in hemodynamic instability (i.e., lower blood pressure, changes in heart rate). 1-----2-----3-----4—-5 Giving your patient regular narcotic medicine to treat pain will likely result in depression of respiratory drive. 1-----2-----3-----4—-5 Giving your patient regular narcotic medicine to treat pain will likely hasten death. 1-----2-----3-----4—-5 Patients who are sedated on non-narcotic agents such as propofol or versed typically have adequate treatment of their pain.
1034
Health Care Workers and ICU Pain Perceptions 1-----2-----3-----4—-5 Patients with dementia, delirium or other forms of altered mental status can adequately express their pain. 1-----2-----3-----4—-5 Pain should be assessed more than once per 12-hour shift. 1-----2-----3-----4—-5 I might be sued for giving too little narcotic pain medicine. 1-----2-----3-----4—-5 I might be sued for giving too much narcotic pain medicine. 1-----2-----3-----4—-5 Sleeping patients can experience pain. 1-----2-----3-----4—-5 Patients with a history of drug abuse need higher doses of narcotic pain medication to adequately control their pain. 1-----2-----3-----4—-5 Tolerance develops to narcotic pain medications when they are used for more than 2-3 consecutive days. 1-----2-----3-----4—-5 Someone who does not report pain does not have pain. 1-----2-----3-----4—-5 I received adequate training in pain management. 1-----2-----3-----4-----5 Would further education be likely to change your attitudes about pain perception and management? 1—-2—-3—-4—-5 Is there anything additional you would like to comment on regarding pain perceptions and/or treatment in NBI ICUs? Thank you for participating in this study! NIH definitions: Please respond to both categories Ethnic Categories 1. Hispanic/Latino 2. Non-Hispanic/Latino Racial Categories 1. White, Caucasian, including Europe, the Middle East, or North Africa 2. Black, African American, Caribbean 3. Native Hawaiian or Pacific Islander, including Philippines 4. Asian: Far East, Southeast Asia, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Thailand, and Vietnam. 5. American Indian or Alaskan Native: North, Central, or South America
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Pain Medicine 2014; 15: 1027–1035 Wiley Periodicals, Inc.
ACUTE PAIN & PERIOPERATIVE PAIN SECTION Original Research Articles Health Care Workers and ICU Pain Perceptions
Ravali Tarigopula, MD,* Naveen K. Tyagi, MD,† Jill Jackson, APN,*§ Chaitali Gupte, MD,* Pooja Raju, MD,*‡ and Jennifer LaRosa, MD* Departments of *Pulmonary and Critical Care Medicine, †Internal Medicine, Newark Beth Israel Medical Center, Newark; ‡Department of Neurology, Sleep Medicine, John F Kennedy Medical Center, Edison; §Palliative Care, Meridian Care Journey, Neptune, New Jersey, USA Reprint requests to: Jennifer LaRosa, MD, Department Pulmonary and Critical Care Medicine, Newark Beth Israel Medical Center, 440 Timber Drive, Berkeley Heights, NJ 07922, USA. Tel: 917-969-1818; Fax: 973-926-6799; E-mail: [email protected]. Disclosure and Conflicts of Interest: Our work was funded by a 3-year $100,000.00 grant from the MayDay Fund, and we have no conflicts of interest. All authors are listed and have contributed to this body of work.
Methods. Responses were provided using a Likert scale and scored on subscales of hemodynamic instability, addiction and tolerance, pain expression, legal issues, and education. Results. The results demonstrated that characteristics such as age and race were significant predictors of perceptions regarding addiction subscale scores (β = −0.256, P = 0.006 and β = 0.183, P = 0.053, respectively). Race proved to be a significant factor in pain expression scores (β = 0.183, P = 0.053). Work-related variables, such as being in or out of active medical training and being within the critical care specialty itself, were significant predictors of addiction subscale scores as well (β = −0.238, P = 0.012 and β = 0.191, P = 0.050, respectively). Conclusion. Health care providers’ race, age, level of education, and medical subspecialty were significant factors affecting their perceptions of pain management and intended treatment. Key Words. Pain Management; Perception; Race Disparities; Sociocultural
Abstract Objective. Our study examined the effect of health care workers’ personal characteristics on how they perceive and intend to treat patients’ pain in the intensive care unit. Though pain perceptions have been well established from the patient’s perspective, less is known about how variations in health care workers may affect their perceptions of pain. Design. This study consisted of a 28-item questionnaire distributed to 122 medical staff personnel over a 12-month period. The questionnaire included items regarding respondent characteristics such as age, gender, race, ethnicity, and level of training. Subjects and Setting. The questionnaire was distributed to physicians and nurses working in the critical care setting.
Introduction The undertreatment of both acute and chronic pain has been documented by studies since the inception of modern medicine [1]. The majority of investigations on pain recognition and treatments have been aimed at patients with advanced malignancies. Up to 90% of such patients experience intractable pain despite the widespread use of opioids [2]. Literature has cited some of the following factors as causes of poor pain recognition and management: 1) inappropriate attitudes regarding the use of opioids; 2) lack of knowledge of the types and appropriate dosages of analgesics; 3) assignment of a low priority to pain management; 4) lack of understanding of the pathophysiology of cancer pain; 5) patients’ reluctance to report pain; and 6) overconcern about the development of tolerance to analgesic medications [2–4]. No such studies have been performed solely in the critical care setting. 1027
Tarigopula et al. Pain assessment and management remain integral parts of patient care in critical care settings [5]. Despite extensive research, guideline development and distribution, and intense educational efforts, there remains clear evidence that critical care patients have pain that is poorly recognized and inconsistently treated [6]. It is estimated that approximately 70% of patients experience at least moderate intensity pain during their intensive care unit (ICU) admission [6]. ICU patients, in particular, are at risk for poor pain management, yet relatively little is known about pain assessment and control in this population [7]. A study performed in 2004 by Erdek and Provonost demonstrated that by implementing a “plan-do-studyact” model in a critical care setting, they were able to improve pain assessment and treatment over a 2-week period [8]. When evaluating optimal pain management, the patient, the health care team, and the health care system are areas wherein change may be implemented [6,8]. Some of the most common obstacles to overcome pain include a failure to assess and acknowledge the existence of pain, outdated prescribing habits, inadequate quality improvement monitoring, and a lack of accountability for unsatisfactory outcomes related to poorly managed pain [6,8]. In addition, specific barriers such as clinician-related barriers, personal and cultural bias, and communication difficulties between the patient and health care team contribute considerably to suboptimal pain management in the ICU setting [6]. The relationship between health care workers’ personal characteristics and their perceptions and intended treatment of pain in the critically ill remains vague. Few studies in the field of nursing have examined the influence of nurses’ personal and professional characteristics on the assessment of pain [9–11]. No relationship between nurses’ pain assessment and their years in practice, age, relative job satisfaction, educational preparation, clinical practice area, or shift assignment was apparent [9,12,13]. No such studies have been undertaken across the board with respect to physicians and nurses in the critical care setting with a global review and assessment of their personal characteristics. Extensive literature reveals racial and ethnic disparities in pain epidemiology, including access to quality pain care, pain assessment and treatments, and pain-related outcomes. Patient-related barriers include differences in pain thresholds and tolerances, as well as pain-related attitudes and beliefs. Limited access to health care and lack of insurance or underinsurance also pose significant hurdles in pain expression, and therefore adequate management in certain groups [14]. Again, however, the link between health care workers’ personal characteristics and pain perception and intended treatment in the intensive care setting has never been clearly investigated or established. A cornerstone for quality pain care is optimizing and standardizing the providers’ pain assessment and knowing how personal characteristics may affect such assessment [14]. 1028
The perception of patients’ pain may be additionally affected by the attitudes of the health care providers toward pain and its impact on the patient [4]. We hypothesized that such a relationship would exist and that certain health care workers’ personal characteristics would be likely to predict how they perceived and intended to treat pain in the critically ill population. Materials and Methods Design and Setting This prospective questionnaire-based study took place over a 12-month period in our 673-bed, universityaffiliated teaching hospital in Newark, New Jersey. The voluntary pain assessment questionnaire (Appendix 1) included 28 questions: 12 devoted to identification of personal characteristics and 16 regarding pain perceptions and intended treatment patterns. Our study protocol was reviewed and approved by our Institutional Review Board (IRB) and assigned an IRB# 2011.04. Questionnaires were distributed in person by one of four investigators to those eligible to complete the survey. Eligible participants included critical care nurses, including registered nurses (RNs) and registered nurse practitioners (RNPs), physicians (medical doctors and doctors of osteopathic medicine) in critical care training (residents and fellows), and attending physician intensivists working in one of three medical and/or surgical ICUs. Informed consent was obtained from each participant. Investigators waited while the questionnaire was completed, and it was then folded and placed in a lock box by the respondent. Participants were given a $5 gift card as incentive to complete the questionnaire. The participant’s name was crossed off a master list so that no person completed the survey twice. To ensure anonymity, after each set of 15–20 surveys, the lock box was opened, and the questionnaire information was entered into a database. The database did not include participant names or any other identifying information. Instrument The questionnaire consisted of a total of 28 questions. The first 12 questions were devoted to identifying the respondents’ personal characteristics, including age, gender, race, ethnicity, marital status, and degree. Sixteen questions followed which randomly queried providers about their perceptions and treatment patterns with respect to pain in the critically ill. Questions addressed the five main areas including hemodynamic instability (questions 3, 4, 5), addiction and tolerance (questions 1, 2, 13), pain expression (questions 6, 7, 8, 11, 14), legal issues (questions 9, 10), and training/education (questions 15, 16). Responses were based on a 5-point Likert scale, and answers were scored according to whether or not the provider was considered liberal or conservative with regard to pain perceptions. Common analgesic options used on our ICU, with which our health care providers are familiar, include the
Health Care Workers and ICU Pain Perceptions following: 1) continuous or intermittent opioids; 2) epidural infusions; 3) acetaminophen; and 4) nonsteroidal antiinflammatory drugs.
Table 2
Study Population
Race White/Caucasian Black/African American/ Caribbean Native Hawaiian/Pacific Islander Asian Missing Country of origin Philippines United States Canada Trinidad Haiti India Myanmar Pakistan Iran Romania Ukraine Puerto Rico Russia Taiwan Nigeria Kenya England Dominican Republic Missing
Inclusion criteria were as follows: age >21 years old with a good command of written and spoken English language; employment at Newark Beth Israel Hospital in the combined medical and surgical ICU, the coronary care unit, or the cardiothoracic surgical ICU; holding an RN, RNP, MD, or DO professional degree. Statistical Analysis The SPSS 17 (SPSS Inc., Chicago, IL, USA) was used for all analyses. Frequencies and descriptives were run on the personal characteristic variables, and regression analyses were used to determine whether the personal characteristic variables predicted scores on the subscales of hemodynamic instability, addiction and tolerance, pain expression, legal issues, and training and education. t-Tests and ANOVAs were used to determine whether there were any differences between groups on the various subscale scores. Results A total of 122 surveys (N = 122) were administered and returned. Women made up two-thirds of the respondents (N = 75, 61.5%), whereas a third were men (N = 35, 28.7%). Most respondents were married (N = 84, 68.9%, see Table 1). The vast majority of the respondents identified themselves as non-Hispanic/Latino (N = 101, 82.8%), whereas the remaining were identified as Hispanic/Latino (N = 6, 4.9%). The race and country of origin of the respondents are displayed in Table 2. Respondents ascribed to a wide range of religions (see Table 3). Approximately 56% of the respondents were RNs (N = 68, 55.7%), 41% were MDs (N = 50), whereas about 3% were
Frequency
Percentage
33 22
27.0 18.0
16
13.1
48 3
39.3 2.5
20 31 8 17 16 8 1 3 1 1 1 1 1 1 1 1 1 1 8
16.4 25.4 6.6 13.9 13.1 6.6 0.8 2.5 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 6.6
DOs (N = 3, 2.5%). Among the respondents, 55.7% were no longer in training (N = 68), but 37.3% were in training (N = 46). Respondents had varying degrees of experience working in critical care units, and most listed medical ICU as their subspecialty (see Table 4).
Table 3 Table 1
Race and country of origin
Religion
Marital status and age Frequency
Marital status Married Single Divorced Other Missing Age 20–29 30–39 40–49 50–59 60–69 Missing
Frequency
Percent
38 6 22 17 12 2 1 2 1 8 1 1 1 10
31.1 4.9 18.0 13.9 9.8 1.6 0.8 1.6 0.8 6.6 0.8 0.8 0.8 8.2
Percent
84 28 6 1 3
68.9 23.0 4.9 0.8 2.5
30 35 35 15 3 4
24.6 28.7 28.7 12.3 2.5 3.3
Catholic Lutheran Hindu Methodist Christian Jewish None Episcopalian Pentecostal Islam Sikh Mysticism Agnostic Missing
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Tarigopula et al. reported having no pain education during training, but 23 (18.9%) indicated they received only minimum training. When asked if they had ever personally experienced severe pain, 76 (62.3%) individuals stated they had, whereas 31 (25.4%) indicated that they had not.
Table 4 Years working in any ICU and ICU subspecialty
Years working in any ICU 1–2 3–5 5–10 10–19 >20 Missing ICU subspecialty Cardiac CT surgery Medical ICU Surgical ICU Missing
Frequency
Percent
33 25 12 27 23 2
27.0 20.5 9.8 22.1 18.9 1.6
26 19 61 2 14
21.3 15.6 50.0 1.6 11.5
Certain work-related variables were significant predictors of the addiction severity index. Whether or not the respondent was in training was a significant predictor of the addiction severity index (β = −0.238, P = 0.012) and accounted for 6% of the variance. There were no significant differences on addiction subscale scores between trainees and nontrainees (P = 0.083) (see Tables 5 and 6) The ICU subspecialty was also a significant predictor (β = 0.191, P = 0.050), accounting for 4% of the variance in how respondents perceived the potential for patients to become addicted to opioids and other analgesics used in pain management. There were no significant differences between ICU subspecialties in their addiction subscale scores (P = 0.203) (See Tables 7 and 8).
CT = cardiothoracic surgery; ICU = intensive care unit.
Respondents were asked to indicate the degree of pain education they received during their training. Most individuals reported that their training was adequate (N = 54, 44.3%), whereas a smaller number indicated their training was extensive (N = 15, 12.3%). Only one individual (0.8%)
Table 5
Addiction subscale score
Table 6
Personal characteristic variables were also significant predictors of the addiction subscale scores. Age was an excellent predictor of the addiction subscale scores (β = −0.256, P = 0.006) and accounted for a significant proportion of the variance (7%). There were no significant differences in addiction subscale scores among the different age groups (P = 0.705) (See Tables 9 and 10). Race also accounted for a significant proportion of the variance (11%) in the addiction subscale scores (β = 0.330, P = 0.000), but there were no significant differences between the races on the addiction subscale scores (P = 0.227). (See Tables 11 and 12). Taken together, race, religion, ethnicity, and country of origin approached significance as predictors of the addiction subscale scores (R2 = 0.128, F [4, 65] = 2.395, P = 0.059), accounting for 13% of the variance in the
Group statistics In Training
N
Yes No
45 66
Mean
Standard Deviation
Standard Error of the Mean
8.58 7.23
4.325 3.603
0.645 0.443
Independent samples test Levene’s Test for Equality of Variances
t-Test for Equality of Means 95% Confidence Interval of the Difference
F Addiction Equal 3.060 subscale variances score assumed Equal variances not assumed
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Significance
t
0.083
1.787 109
1.726
df
Standard Significance Mean Error (two-tailed) Difference Difference Lower
Upper
0.077
1.351
0.756
−0.148 2.849
82.918 0.088
1.351
0.782
−0.206 2.907
Health Care Workers and ICU Pain Perceptions
Table 7
Descriptives addiction subscale score 95% Confidence Interval for Mean
Cardiac CT surgery Medical ICU Surgical ICU 5 Total
N
Mean
Standard Deviation
Standard Error
Lower Bound
Upper Bound
Minimum
Maximum
18 18 52 2 16 106
7.89 6.39 7.79 9.50 9.56 7.87
3.394 3.760 4.267 2.121 3.098 3.909
0.800 0.886 0.592 1.500 0.774 0.380
6.20 4.52 6.60 −9.56 7.91 7.12
9.58 8.26 8.98 28.56 11.21 8.62
2 1 1 8 4 1
14 13 15 11 16 16
CT = cardiothoracic surgery; ICU = intensive care unit.
respondents’ perceptions of patients’ addiction potential to pain management medications. Race was a significant predictor of pain expression scores (β = 0.183, P = 0.053), accounting for 3% of the variance in the respondents’ perceptions of how patients express their pain. No variables examined in this study were significant predictors of the hemodynamic instability subscale scores or the legal subscale scores. Discussion We found that some personal characteristics may be significant predictors of how health care providers perceive
Table 8
ANOVA
addiction subscale score
Sum of Squares
df
Mean Square
F
Significance
1.518
0.203
Between groups Within groups Total
90.985
4
22.746
1513.166
101
14.982
1604.151
105
Table 9
Descriptives addiction subscale score
critically ill patients’ pain and report pain treatment patterns. There was a statistically significant relationship between race and pain expression. This indicates that race may be a predictor of how poorly or how thoroughly providers perceive pain in their critically ill patients. Race and ethnicity have been cited as important cultural barriers in communication between patients and physicians. This is due to several factors. It has been repeatedly documented that certain populations describe a higher prevalence of pain. As studied by Green et al. in Bressler et al. [15] and Turk et al. [16], minorities and women report higher pain prevalence than men and non-Hispanic whites. In addition, racial variability may predict different levels of pain tolerance [17]. Our study similarly suggests that race, pain perception, and tolerance may be deeply intertwined. Addiction was strongly modified individually by whether or not the provider was in training, as well as by providers’ ICU subspecialty, age, and race. Taken together race, religion, ethnicity, and country of origin approached significance as predictors of the addiction subscale scores. In our study, several factors influenced how health care providers perceive traditional pain management strategies. Such individual factors included critical care specialty, training status, age, and race. Concomitant factors included race, religion, ethnicity, and country of origin.
95% Confidence Interval for Mean
20–29 30–39 40–49 50–59 60–69 Total
N
Mean
Standard Deviation
Standard Error
Lower Bound
Upper Bound
Minimum
Maximum
30 34 34 15 2 115
7.67 8.44 8.09 6.73 8.00 7.90
4.365 4.215 3.596 2.815 2.828 3.882
0.797 0.723 0.617 0.727 2.000 0.362
6.04 6.97 6.83 5.17 –17.41 7.19
9.30 9.91 9.34 8.29 33.41 8.62
1 2 1 2 6 1
14 16 14 10 10 16
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Tarigopula et al.
Table 10
ANOVA
addiction subscale score
Sum of Squares Between groups Within groups Total
Mean Square
df
33.230
4
8.308
1684.718
110
15.316
1717.948
114
Table 12
F
Significance
0.542
0.705
There are limitations to this study. First, this was a singlecenter study done at an urban tertiary facility, and these results may not be reproducible across different medical
Table 11
addiction subscale score
Sum of Squares Between groups Within groups Total
Many authors have documented a lack of knowledge by health professionals about the anatomy and physiology of pain, pain assessment, differences between acute and chronic pain, and pharmacological and nonpharmacological management of pain [9]. Opioid analgesics are traditionally the treatment of choice for moderate to severe acute and cancer pain [18]. They are commonly used in critical care settings to control pain due to the availability of various formulations, quick onset of action, and effectiveness. In a study done by Upshur et al. in 2006, however, physicians were concerned that prescribing medications for legitimate medical purposes can unintentionally contribute to illicit use and create addiction in their patients [18,19]. It could be hypothesized that physicians in training undertreat pain due to inadequate experience and incomplete knowledge regarding addiction. Similarly, many nurses did not know that the incidence of opioid addiction during pain treatment is believed to be considerably less than 1% [9]. A study done by Erkes et al. [20] concluded that critical care nurses had low scores on the Nurses’ Knowledge and Attitudes survey regarding pain, and over 50% of the scores improved after an educational intervention. There were no variables that significantly modified questions related to hemodynamic instability or legal issues. On the other hand, in terms of hemodynamic instability, most health care workers are not worried about such instability with pain medications.
ANOVA
df
Mean Square
F
Significance
1.469
0.227
66.204
3
22.068
1682.554
112
15.023
1748.759
115
settings. Second, there was a potential for a selection bias as the survey was personally handed out by the investigators, and certain groups, such as night shift nurses, may have been underrepresented. Further investigation with a wider range of groups would be a worthy undertaking. Third, though we were aware of the potential side effect of morphine-induced hypotension, the aim of our study was to describe relationships between health care providers’ personal characteristics and their perceptions and intended treatment of critical ill patients’ pain. We were only assessing provider perceptions, not prescribing patterns. Such additional investigation into prescribing patterns would be an interesting follow-up study. Fourth, given that this was a preliminary and more exploratory type of study on a few subjects, our intent was to look at the overall characteristics of the providers (e.g., race, ethnicity, religion, etc.) rather than specifics (e.g., African American vs Caucasian or Catholic vs Islamic) to see if they influenced or predicted the addiction severity index. Thus, the comparison of these variables was not the intent of our initial study. Furthermore, the sensitive nature of the information warrants a larger study that will be undertaken once the instrument is perfected. Conclusion Our results suggest that there may be a relationship between some health care workers’ personal characteristics and their perceptions of critically ill patients’ pain and intended pain treatment. The most notable of these was the relationship between race and
Descriptives addiction subscale score 95% Confidence Interval for Mean
Mean
Standard Deviation
Standard Error
Lower Bound
Upper Bound
Minimum
Maximum
33 21 16
7.61 6.52 8.56
3.535 3.628 4.049
0.615 0.792 1.012
6.35 4.87 6.40
8.86 8.18 10.72
2 1 3
14 13 16
46 116
8.50 7.90
4.146 3.900
0.611 0.362
7.27 7.18
9.73 8.61
1 1
15 16
N White, Caucasian Black, African American, Caribbean Native Hawaiian or Pacific Islander, including Philippines Asian Total
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Health Care Workers and ICU Pain Perceptions pain perception and the relationship between addiction and training level. Addiction and the collective assessment of age, subspecialty, and race was also a significant finding. Further investigation and continuing education programs are critical to elaborating more on these relationships and identifying ways to overcome such barriers to adequate pain perception and management.
10 McCaffery M, Ferrell BR Nurses’ knowledge of doses and psychological dependence. J Nurs Professional Dev 1992;8:77–84.
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Tarigopula et al. Appendix 1
Perceptions of pain in the intensive care unit
Age: 20–29 30–39 40–49 Gender: M F Marital status: Single Married Divorced Religion:_______________________ Race/Ethnicity: see chart on back & specify number:________________ Country of birth:___________________________ Degree: RN APN MD In training: Yes No Years working in any 1–2 3–5 5–10 ICU: ICU subspecialty: Cardiac CT surgery Medical ICU Describe your pain education during training: None Minimum Adequate Extensive
50–59
60–69
70+
Other (specify):______
DO 10–19
>20
Surgical ICU
Have you ever experienced severe pain? If so, please describe. __________________________________________________________________ Please answer each of the following on a Likert scale of 1–5 as follows: 1 = Strongly disagree 2 = Somewhat disagree 3 = Neither agree nor disagree 4 = Somewhat agree 5 = Strong agree Giving your patient regular narcotic medicine to treat pain is likely to result in an addiction to narcotics. 1-----2-----3-----4—-5 Patients requesting frequent narcotic pain medications (“watching the clock”) are drug seeking. 1-----2-----3-----4—-5 Giving your patient regular narcotic medicine to treat pain will likely result in hemodynamic instability (i.e., lower blood pressure, changes in heart rate). 1-----2-----3-----4—-5 Giving your patient regular narcotic medicine to treat pain will likely result in depression of respiratory drive. 1-----2-----3-----4—-5 Giving your patient regular narcotic medicine to treat pain will likely hasten death. 1-----2-----3-----4—-5 Patients who are sedated on non-narcotic agents such as propofol or versed typically have adequate treatment of their pain.
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Health Care Workers and ICU Pain Perceptions 1-----2-----3-----4—-5 Patients with dementia, delirium or other forms of altered mental status can adequately express their pain. 1-----2-----3-----4—-5 Pain should be assessed more than once per 12-hour shift. 1-----2-----3-----4—-5 I might be sued for giving too little narcotic pain medicine. 1-----2-----3-----4—-5 I might be sued for giving too much narcotic pain medicine. 1-----2-----3-----4—-5 Sleeping patients can experience pain. 1-----2-----3-----4—-5 Patients with a history of drug abuse need higher doses of narcotic pain medication to adequately control their pain. 1-----2-----3-----4—-5 Tolerance develops to narcotic pain medications when they are used for more than 2-3 consecutive days. 1-----2-----3-----4—-5 Someone who does not report pain does not have pain. 1-----2-----3-----4—-5 I received adequate training in pain management. 1-----2-----3-----4-----5 Would further education be likely to change your attitudes about pain perception and management? 1—-2—-3—-4—-5 Is there anything additional you would like to comment on regarding pain perceptions and/or treatment in NBI ICUs? Thank you for participating in this study! NIH definitions: Please respond to both categories Ethnic Categories 1. Hispanic/Latino 2. Non-Hispanic/Latino Racial Categories 1. White, Caucasian, including Europe, the Middle East, or North Africa 2. Black, African American, Caribbean 3. Native Hawaiian or Pacific Islander, including Philippines 4. Asian: Far East, Southeast Asia, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Thailand, and Vietnam. 5. American Indian or Alaskan Native: North, Central, or South America
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