Original Article Nursing Knowledge and Beliefs Regarding Patient-Controlled Oral Analgesia (PCOA) ---
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From the Sunnybrook Health Sciences Centre, Holland Orthopaedic & Arthritic Centre, Toronto, Ontario, Canada. Address correspondence to Monakshi Sawhney, NP, MN, PhD (candidate), Sunnybrook Health Sciences Centre, Holland Orthopaedic & Arthritic Centre, 43 Wellesley Street East, Toronto, Ontario M4Y 1H1, Canada. E-mail: [email protected] Received March 28, 2011; Revised July 17, 2011; Accepted July 18, 2011. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2011.07.003
Monakshi Sawhney, NP, MN, PhD (candidate), and Eri Maeda, NP, MN, CNCC (c)
ABSTRACT:
Patient-controlled oral analgesia (PCOA) allows patients to selfadminister oral opioids for pain management. Advantages of PCOA include improved pain control with lower doses of opioids, decreased length of stay, increased patient satisfaction, and better functional outcomes than conventional nurse-administered oral analgesia. Sucessful PCOA programs are well described in the literature. However, nurses have concerns about allowing patients to self-administer opioids. The purpose of this study was to identify nurses’ knowledge and beliefs regarding PCOA. Nurses who work at the Holland Orthopaedic and Arthritic Centre were asked to complete a survey exploring their beliefs regarding PCOA. The nurses were asked to complete the same survey twice: before an education program in February 2010, and 3 months after implementation of PCOA in June 2010. In February 2010, 74 nurses and in June 2010, 32 nurses participated in the survey. Some nurses (18%) had previous experience with PCOA. At both the preeducation and the postimplementation times, nurses thought that the PCOA program reduced wait times for analgesics and improved patient satisfaction with pain management. Before program implementation, negative beliefs included that patients on the PCOA program would lose their analgesics, would give their analgesics to visitors or other patients, and were at risk for having their analgesics stolen and that the nurse was liable if the patient’s analgesics were lost or stolen. After program implementation, no nurse believed that patients would lose their analgesics or give their analgesics to visitors or other patients or that they were liable for lost or stolen analgesics. However, nurses continued to think that patients were at risk for having their analgesics stolen. We found that nurses were concerned that analgesics could be lost, misused, or stolen and that they would be liable for lost analgesics. These findings were consistent with literature discussing patients’ outcomes regarding PCOA. However, after education and experience these concerns decreased or resolved. It is important to address these concerns before PCOA program implementation. Ó 2013 by the American Society for Pain Management Nursing Pain Management Nursing, Vol 14, No 4 (December), 2013: pp 318-326
PCOA Knowledge and Attitudes
Patient-controlled oral analgesia (PCOA), in the hospital setting, is a unique way of allowing patients to self-administer oral analgesics as part of their pain management plan. PCOA programs have been in place since 1979, and successfully implemented in both oncology and surgical settings with adult and adolescent patients (Coyle, 1979; Jones, 1987; Kastanias, Gowans, Tumber, Snaith, & Robinson, 2010; Kastanias, Snaith, & Robinson, 2006; Litman & Shapiro, 1992; Pasero, 2000; Pasero & McCaffery, 2011; Riordan, Beam, & OkabeYamamura, 2004; Rosati, Gallagher, Shok, Luwisch, Favis, Deveras, et al. , 2007; Striebel, Romer, Kopf, & Schwagmeier, 1996; Striebel, Scheitza, Philippi, Behrens, & Toussaint, 1998). Advantages of PCOA include increased patient satisfaction, elimination of wait times for analgesics, independence from physician or nurse, better informed patients who are more capable of taking opioids at home, and noninvasiveness (Coyle, 1979; Jones, 1987, 1996; Kastanias et al., 2006; Riordan et al., 2004, Striebel et al., 1996). In an adolescent population, PCOA was found to be an effective method to augment patient autonomy and assist in the patients’ ability to decrease their opioid as their pain resolved (Litman & Shapiro, 1992). PCOA has been implemented in different ways, depending on the setting and institution. PCOA administration methods have varied from supplying opioids as an elixir in a modified IV PCA infusion device so the patient can ‘‘drink’’ their analgesic, or by supplying tablets either in a wrist pouch, in a medication vial stored at the bedside, or through high-tech secure devices that read a patient-specific barcode (Coyle, 1979; Jones, 1987; Kastanias et al., 2010; Kastanias et al., 2006; Litman & Shapiro, 1992; Pasero, 2000; Pasero & McCaffery, 2011; Riordan et al., 2004; Rosati et al., 2007; Striebel et al., 1996; Striebel et al., 1998). Randomized controlled trials have compared PCOA with traditional methods of opoid administration (nurse-administered subcutaneous analgesics or nurse-administered oral analgesics [NAOA] ) in patients after surgery. Jones (1987) examined the feasibility of implementing PCOA in a postoperative orthopedic setting. She randomized 48 patients to receive either PCOA or NAOA and found that there were no differences in the amount of analgesics consumed. When asked if they would use PCOA again, all participants in the PCOA group answered ‘‘yes.’’ Riordan et al. (2004) examined patients’ pain relief and satisfaction with PCOA. They randomized 36 postoperative patients to receive either PCOA or NAOA and found that patients using PCOA were more satisfied with their pain management, and 1 hour after taking analgesics patients using PCOA reached their target pain
319
intensity goal more often than patients in the NAOA group (93% of the time vs. 65% of the time). Striebel et al. (1996) conducted a randomized crossover study in which 20 postoperative orthopedic patients received either PCOA morphine elixir through a modified elastomeric pump followed by nurse-administered subcutaneous morphine or vice versa. They found no differences in the morphine requirements between the two groups; however, pain intensity in the PCOA group decreased over time, and this was not true when analgesics were administered by the nurse. In a second study, Striebel et al. (1998) randomized 60 patients undergoing elective orthopedic surgery to receive either intravenous patient-controlled analgesia (IVPCA) morphine or PCOA morphine elixir through a modified elastomeric pump. They found that there was no difference in pain intensity between the two groups over the 8-hour study period. Although the patients in the PCOA group used more morphine than patients in the IVPCA group, there were no differences in adverse effects of analgesics between the two groups, and there was no respiratory depression. Kastanias et al. (2010) randomized 90 elective total knee arthroplasty patients to receive either PCOA or NAOA as part of their postoperative pain management plan. Although they found no difference between the two groups regarding amount of analgesics used, pain, or satisfaction with pain management, they described PCOA as supporting a patient-centered care philosophy and assisting with the patient’s sense of control with their pain management. Descriptive studies and randomized controlled trials document the safety of PCOA, with all studies reporting no loss of drug, no theft, no diversion, and no overdose in patients using PCOA (Coyle, 1979; Jones, 1987; Kastanias et al., 2006; Kastanias et al., 2010; Litman & Shapiro, 1992; Riordan et al., 2004, Rosati et al., 2007; Striebel et al., 1996; Striebel et al., 1998). Despite the fact that PCOA is an effective and safe pain management program, the literature reports that nurses have concerns regarding the implementation of PCOA. These concerns include: an uneasy feeling regarding leaving opioids at the bedside; a doubt in the patients’ ability to administer their own medications; the possibility of patient overdose of opioids; and diversion, theft, or drug loss (Coyle, 1979; Jones, 1987, Riordan et al., 2004). The nursing role is an essential component for the success of a PCOA program implementation, and nurses’ concerns regarding PCOA need to be identified and addressed. Studies on nursing perceptions regarding pain management practice changes found nursing staff commitment, knowledge, beliefs, and attitudes toward pain management in
320
Sawhney and Maeda
general can be barriers to practice change to improve pain management (Brockopp, Brockopp, Warden, Wilson, Cappernter, & ban de Beer, 1998; Ely, 2001). Nurses are the first health care providers that patients approach when they have any questions or are seeking guidance regarding pain management while in the hospital (Linkewich et al., 2007). Changing the traditional ways that nurses participate in the management of postoperative pain can be challenging owing to many barriers, including personal beliefs, the subjective nature of pain, lack of knowledge regarding pain management techniques, nonfacilitative attitudes, and a lack of resources which limits their ability to provide satisfactory pain management to patients and their families (Brockopp et al., 1998; Kohr & Sawhney, 2005; McCaffery, Ferrell, & Pasero, 2000; Pasero & McCaffery, 2011). Many nurses have misconceptions or lack knowledge about addiction, physiologic dependence, and respiratory depression (Schafheutle, Cantrill, & Noyce, 2001; Sjostrom, Dahlgren, & Halijamae, 2000; Wilson, 2007). Also, nurses may develop inaccurate or misguided beliefs about certain pain treatments and their possible adverse effects (Guardini, Talamini, Fiorillo, Lirutti, & Palese, 2008). Nurses have individual beliefs and perceptions toward a PCOA program. Therefore, understanding nursing perceptions before and after PCOA program implementation may provide valuable and meaningful data illuminating the possible stumbling blocks to implementation and allowing for development of specific nursing education programs that will assist in the overall success and acceptance of a PCOA program. PCOA was first implemented at Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, in 2008, and the program was expanded to include patients undergoing elective orthopedic surgery in March 2010. The aim of the present study was to investigate nurses’ knowledge and beliefs regarding PCOA program before and after implementing the program with elective orthopedic surgical patients to help identify barriers and facilitators to PCOA program implementation. Innis et al. (2004) suggest that 3 months is a good time frame for reevaluation. It is hypothesized that nurse will have more positive beliefs and increased knowledge regarding PCOA after education and implementation of the PCOA program.
METHODS Subjects Following Research Ethics Board approval, a convenience sample of 74 nursing staff who work at the Holland Orthopaedic and Arthrtic Centre, Sunnybrook
Health Sciences Centre, were invited to participate in the study by completing an anonymous questionnaire. Inclusion criteria included Registered Nurses (RNs) or Registered Practical Nurses (RPNs) working on an inpatient orthopedic unit and who attended a formal education session regarding PCOA.
Instrument Difference in knowledge and beliefs regarding PCOA before and after education was assessed by an anonymous questionnaire before an education session and 3 months after the PCOA program implementation. Study participants completed a self-administered three-page questionnaire that included nine sets of questions (Appendix 1). The questionnaire included demographic information as well as specific questions that focus on experience with PCOA, beliefs about the PCOA program, and perceived advantages and disadvantages of a PCOA program. Because no questionnaire regarding nurses’ knowledge and beliefs regarding PCOA existed, the questions that were included were identified from the literature and from nurse practitioners who have implemented this program at other Canadian hospitals. Also, the questionnaire was designed to ask the same question in different ways to assist in validating the information participants provided.
Procedure In February 2010, after an explanation of the study by the study investigators, nurses were invited to complete a knowledge and attitudes questionnaire regarding PCOA. The questionnaire was completed before participating in a formal education session regarding PCOA. At the time of distribution of the preeducation questionnaire, nurses were informed that they would receive the same questionnaire 3 months after implementation of the PCOA program. In June 2010, the postimplementation questionnaire was attached to each participant’s pay stub and participants were asked to submit the completed questionnaire in an anonymous box placed on each of the inpatient units. Study participants were given 3 weeks to complete and return the questionnaire. Reminder e-mails and posters regarding the postimplementation questionnaires were sent to all study participants. Completion of the questionnaire was deemed to indicate consent to use the information provided. At both the preeducation and postimplementation time points, participants entered their names into a draw for one of six coffee cards as an incentive to complete the questionnaire.
321
PCOA Knowledge and Attitudes
Nursing Education A 1-hour-long formal PCOA education session was provided to all nurses by the Acute Pain Service Nurse Practitioners in February 2010. The education sessions included definitions of PCOA, reasons to implement a PCOA program, how PCOA works, nursing and patient responsibilities when using PCOA, patient criteria/eligibility for PCOA, case studies, and a questionand-answer session. During the education sessions, topics of frequently asked questions from the nurses who attended included: logistics, drug-dependent patients, patient misbehavior management, and handling of opioids. Data Analysis Data were entered into a Microsoft Excel database. Descriptive statistics were calculated for demographic data. Instat (version 3) was used to calculate differences in nursing knowledge and beliefs regarding a PCOA program between the preeducation and postimplementation questionnaires. The chi-square test was used for all ordinal parameters. Results of p # .05 were considered to be significant. Means were calculated for the advantages and disadvantages of a PCOA program.
RESULTS Demographics Seventy-four nurses (100%) returned the first questionnaire, and 32 (44%) returned the second questionnaire. The majority of the participants who completed the questionnaire were female RNs, between the ages of 31 and 50 years, with
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From the Sunnybrook Health Sciences Centre, Holland Orthopaedic & Arthritic Centre, Toronto, Ontario, Canada. Address correspondence to Monakshi Sawhney, NP, MN, PhD (candidate), Sunnybrook Health Sciences Centre, Holland Orthopaedic & Arthritic Centre, 43 Wellesley Street East, Toronto, Ontario M4Y 1H1, Canada. E-mail: [email protected] Received March 28, 2011; Revised July 17, 2011; Accepted July 18, 2011. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2011.07.003
Monakshi Sawhney, NP, MN, PhD (candidate), and Eri Maeda, NP, MN, CNCC (c)
ABSTRACT:
Patient-controlled oral analgesia (PCOA) allows patients to selfadminister oral opioids for pain management. Advantages of PCOA include improved pain control with lower doses of opioids, decreased length of stay, increased patient satisfaction, and better functional outcomes than conventional nurse-administered oral analgesia. Sucessful PCOA programs are well described in the literature. However, nurses have concerns about allowing patients to self-administer opioids. The purpose of this study was to identify nurses’ knowledge and beliefs regarding PCOA. Nurses who work at the Holland Orthopaedic and Arthritic Centre were asked to complete a survey exploring their beliefs regarding PCOA. The nurses were asked to complete the same survey twice: before an education program in February 2010, and 3 months after implementation of PCOA in June 2010. In February 2010, 74 nurses and in June 2010, 32 nurses participated in the survey. Some nurses (18%) had previous experience with PCOA. At both the preeducation and the postimplementation times, nurses thought that the PCOA program reduced wait times for analgesics and improved patient satisfaction with pain management. Before program implementation, negative beliefs included that patients on the PCOA program would lose their analgesics, would give their analgesics to visitors or other patients, and were at risk for having their analgesics stolen and that the nurse was liable if the patient’s analgesics were lost or stolen. After program implementation, no nurse believed that patients would lose their analgesics or give their analgesics to visitors or other patients or that they were liable for lost or stolen analgesics. However, nurses continued to think that patients were at risk for having their analgesics stolen. We found that nurses were concerned that analgesics could be lost, misused, or stolen and that they would be liable for lost analgesics. These findings were consistent with literature discussing patients’ outcomes regarding PCOA. However, after education and experience these concerns decreased or resolved. It is important to address these concerns before PCOA program implementation. Ó 2013 by the American Society for Pain Management Nursing Pain Management Nursing, Vol 14, No 4 (December), 2013: pp 318-326
PCOA Knowledge and Attitudes
Patient-controlled oral analgesia (PCOA), in the hospital setting, is a unique way of allowing patients to self-administer oral analgesics as part of their pain management plan. PCOA programs have been in place since 1979, and successfully implemented in both oncology and surgical settings with adult and adolescent patients (Coyle, 1979; Jones, 1987; Kastanias, Gowans, Tumber, Snaith, & Robinson, 2010; Kastanias, Snaith, & Robinson, 2006; Litman & Shapiro, 1992; Pasero, 2000; Pasero & McCaffery, 2011; Riordan, Beam, & OkabeYamamura, 2004; Rosati, Gallagher, Shok, Luwisch, Favis, Deveras, et al. , 2007; Striebel, Romer, Kopf, & Schwagmeier, 1996; Striebel, Scheitza, Philippi, Behrens, & Toussaint, 1998). Advantages of PCOA include increased patient satisfaction, elimination of wait times for analgesics, independence from physician or nurse, better informed patients who are more capable of taking opioids at home, and noninvasiveness (Coyle, 1979; Jones, 1987, 1996; Kastanias et al., 2006; Riordan et al., 2004, Striebel et al., 1996). In an adolescent population, PCOA was found to be an effective method to augment patient autonomy and assist in the patients’ ability to decrease their opioid as their pain resolved (Litman & Shapiro, 1992). PCOA has been implemented in different ways, depending on the setting and institution. PCOA administration methods have varied from supplying opioids as an elixir in a modified IV PCA infusion device so the patient can ‘‘drink’’ their analgesic, or by supplying tablets either in a wrist pouch, in a medication vial stored at the bedside, or through high-tech secure devices that read a patient-specific barcode (Coyle, 1979; Jones, 1987; Kastanias et al., 2010; Kastanias et al., 2006; Litman & Shapiro, 1992; Pasero, 2000; Pasero & McCaffery, 2011; Riordan et al., 2004; Rosati et al., 2007; Striebel et al., 1996; Striebel et al., 1998). Randomized controlled trials have compared PCOA with traditional methods of opoid administration (nurse-administered subcutaneous analgesics or nurse-administered oral analgesics [NAOA] ) in patients after surgery. Jones (1987) examined the feasibility of implementing PCOA in a postoperative orthopedic setting. She randomized 48 patients to receive either PCOA or NAOA and found that there were no differences in the amount of analgesics consumed. When asked if they would use PCOA again, all participants in the PCOA group answered ‘‘yes.’’ Riordan et al. (2004) examined patients’ pain relief and satisfaction with PCOA. They randomized 36 postoperative patients to receive either PCOA or NAOA and found that patients using PCOA were more satisfied with their pain management, and 1 hour after taking analgesics patients using PCOA reached their target pain
319
intensity goal more often than patients in the NAOA group (93% of the time vs. 65% of the time). Striebel et al. (1996) conducted a randomized crossover study in which 20 postoperative orthopedic patients received either PCOA morphine elixir through a modified elastomeric pump followed by nurse-administered subcutaneous morphine or vice versa. They found no differences in the morphine requirements between the two groups; however, pain intensity in the PCOA group decreased over time, and this was not true when analgesics were administered by the nurse. In a second study, Striebel et al. (1998) randomized 60 patients undergoing elective orthopedic surgery to receive either intravenous patient-controlled analgesia (IVPCA) morphine or PCOA morphine elixir through a modified elastomeric pump. They found that there was no difference in pain intensity between the two groups over the 8-hour study period. Although the patients in the PCOA group used more morphine than patients in the IVPCA group, there were no differences in adverse effects of analgesics between the two groups, and there was no respiratory depression. Kastanias et al. (2010) randomized 90 elective total knee arthroplasty patients to receive either PCOA or NAOA as part of their postoperative pain management plan. Although they found no difference between the two groups regarding amount of analgesics used, pain, or satisfaction with pain management, they described PCOA as supporting a patient-centered care philosophy and assisting with the patient’s sense of control with their pain management. Descriptive studies and randomized controlled trials document the safety of PCOA, with all studies reporting no loss of drug, no theft, no diversion, and no overdose in patients using PCOA (Coyle, 1979; Jones, 1987; Kastanias et al., 2006; Kastanias et al., 2010; Litman & Shapiro, 1992; Riordan et al., 2004, Rosati et al., 2007; Striebel et al., 1996; Striebel et al., 1998). Despite the fact that PCOA is an effective and safe pain management program, the literature reports that nurses have concerns regarding the implementation of PCOA. These concerns include: an uneasy feeling regarding leaving opioids at the bedside; a doubt in the patients’ ability to administer their own medications; the possibility of patient overdose of opioids; and diversion, theft, or drug loss (Coyle, 1979; Jones, 1987, Riordan et al., 2004). The nursing role is an essential component for the success of a PCOA program implementation, and nurses’ concerns regarding PCOA need to be identified and addressed. Studies on nursing perceptions regarding pain management practice changes found nursing staff commitment, knowledge, beliefs, and attitudes toward pain management in
320
Sawhney and Maeda
general can be barriers to practice change to improve pain management (Brockopp, Brockopp, Warden, Wilson, Cappernter, & ban de Beer, 1998; Ely, 2001). Nurses are the first health care providers that patients approach when they have any questions or are seeking guidance regarding pain management while in the hospital (Linkewich et al., 2007). Changing the traditional ways that nurses participate in the management of postoperative pain can be challenging owing to many barriers, including personal beliefs, the subjective nature of pain, lack of knowledge regarding pain management techniques, nonfacilitative attitudes, and a lack of resources which limits their ability to provide satisfactory pain management to patients and their families (Brockopp et al., 1998; Kohr & Sawhney, 2005; McCaffery, Ferrell, & Pasero, 2000; Pasero & McCaffery, 2011). Many nurses have misconceptions or lack knowledge about addiction, physiologic dependence, and respiratory depression (Schafheutle, Cantrill, & Noyce, 2001; Sjostrom, Dahlgren, & Halijamae, 2000; Wilson, 2007). Also, nurses may develop inaccurate or misguided beliefs about certain pain treatments and their possible adverse effects (Guardini, Talamini, Fiorillo, Lirutti, & Palese, 2008). Nurses have individual beliefs and perceptions toward a PCOA program. Therefore, understanding nursing perceptions before and after PCOA program implementation may provide valuable and meaningful data illuminating the possible stumbling blocks to implementation and allowing for development of specific nursing education programs that will assist in the overall success and acceptance of a PCOA program. PCOA was first implemented at Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, in 2008, and the program was expanded to include patients undergoing elective orthopedic surgery in March 2010. The aim of the present study was to investigate nurses’ knowledge and beliefs regarding PCOA program before and after implementing the program with elective orthopedic surgical patients to help identify barriers and facilitators to PCOA program implementation. Innis et al. (2004) suggest that 3 months is a good time frame for reevaluation. It is hypothesized that nurse will have more positive beliefs and increased knowledge regarding PCOA after education and implementation of the PCOA program.
METHODS Subjects Following Research Ethics Board approval, a convenience sample of 74 nursing staff who work at the Holland Orthopaedic and Arthrtic Centre, Sunnybrook
Health Sciences Centre, were invited to participate in the study by completing an anonymous questionnaire. Inclusion criteria included Registered Nurses (RNs) or Registered Practical Nurses (RPNs) working on an inpatient orthopedic unit and who attended a formal education session regarding PCOA.
Instrument Difference in knowledge and beliefs regarding PCOA before and after education was assessed by an anonymous questionnaire before an education session and 3 months after the PCOA program implementation. Study participants completed a self-administered three-page questionnaire that included nine sets of questions (Appendix 1). The questionnaire included demographic information as well as specific questions that focus on experience with PCOA, beliefs about the PCOA program, and perceived advantages and disadvantages of a PCOA program. Because no questionnaire regarding nurses’ knowledge and beliefs regarding PCOA existed, the questions that were included were identified from the literature and from nurse practitioners who have implemented this program at other Canadian hospitals. Also, the questionnaire was designed to ask the same question in different ways to assist in validating the information participants provided.
Procedure In February 2010, after an explanation of the study by the study investigators, nurses were invited to complete a knowledge and attitudes questionnaire regarding PCOA. The questionnaire was completed before participating in a formal education session regarding PCOA. At the time of distribution of the preeducation questionnaire, nurses were informed that they would receive the same questionnaire 3 months after implementation of the PCOA program. In June 2010, the postimplementation questionnaire was attached to each participant’s pay stub and participants were asked to submit the completed questionnaire in an anonymous box placed on each of the inpatient units. Study participants were given 3 weeks to complete and return the questionnaire. Reminder e-mails and posters regarding the postimplementation questionnaires were sent to all study participants. Completion of the questionnaire was deemed to indicate consent to use the information provided. At both the preeducation and postimplementation time points, participants entered their names into a draw for one of six coffee cards as an incentive to complete the questionnaire.
321
PCOA Knowledge and Attitudes
Nursing Education A 1-hour-long formal PCOA education session was provided to all nurses by the Acute Pain Service Nurse Practitioners in February 2010. The education sessions included definitions of PCOA, reasons to implement a PCOA program, how PCOA works, nursing and patient responsibilities when using PCOA, patient criteria/eligibility for PCOA, case studies, and a questionand-answer session. During the education sessions, topics of frequently asked questions from the nurses who attended included: logistics, drug-dependent patients, patient misbehavior management, and handling of opioids. Data Analysis Data were entered into a Microsoft Excel database. Descriptive statistics were calculated for demographic data. Instat (version 3) was used to calculate differences in nursing knowledge and beliefs regarding a PCOA program between the preeducation and postimplementation questionnaires. The chi-square test was used for all ordinal parameters. Results of p # .05 were considered to be significant. Means were calculated for the advantages and disadvantages of a PCOA program.
RESULTS Demographics Seventy-four nurses (100%) returned the first questionnaire, and 32 (44%) returned the second questionnaire. The majority of the participants who completed the questionnaire were female RNs, between the ages of 31 and 50 years, with
