Original Article Nurses’ Experiences of Patients with SubstanceUse Disorder in Pain: A Phenomenological Study Georgina Morley, MSc, BA, RN,*,† Emma Briggs, PhD, BSc, RN, PGCAP,* and Gillian Chumbley, PhD, BSc, RN†

---

-

From the *King’s College London, Florence Nightingale Faculty of Nursing and Midwifery, London; † Imperial College Healthcare NHS Trust, Charing Cross Hospital, London. Address correspondence to Georgina Morley, MSc, BA, RN, Barts Health NHS Trust, Barts Heart Centre, King George V Building, St Bartholomew’s Hospital, West Smithfield, London, United Kingdom. E-mail: Georgina. [email protected] Received September 20, 2014; Revised March 17, 2015; Accepted March 17, 2015.

ABSTRACT:

Patients with substance-use disorder and pain are at risk of having their pain underestimated and undertreated. Unrelieved pain can exacerbate characteristics that are believed to be ‘drug-seeking’ and in turn, perceived drug-seeking behavior can contribute to a patient being stigmatized and labeled ‘difficult’. Previous literature has indicated that negative attitudes towards patients with substance-use disorder may affect their pain management but little is known about the specific barriers. This study explored nurses’ experiences of working with patients with substance-use disorder in pain, providing an indepth insight into their perspective. Descriptive phenomenology was employed as a framework for conducting semi-structured interviews to reveal the experiences of registered nurses. A convenience sample of registered nurses from a variety of clinical backgrounds were recruited and interviewed. This rich data was analyzed according to Giorgi’s five-stage approach. Participants described feelings of powerlessness and frustration due to patient non-compliance, discrepancies in patient management amongst team members and external pressures effecting pain management. Participants described characteristics believed to be common, including psychosocial factors such as complex social backgrounds or mental health issues. Nurses’ education and support needs were identified. Stereotyping and stigmatism were found to potentially still exist, yet there was also a general awareness of some specific clinical issues such as opioid tolerance and opioid-induced hyperalgesia. Further emphasis is required on interprofessional education and communication to improve patient management, alongside an appreciation of patient’s rights facilitated by a concordance model of care. Ó 2015 by the American Society for Pain Management Nursing

1524-9042/$36.00 Ó 2015 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2015.03.005

Pain Management Nursing, Vol -, No - (--), 2015: pp 1-11

2

Morley, Briggs, and Chumbley

BACKGROUND In the United Kingdom, nurses make up 27% of the National Health Service (NHS) workforce (Health and Social Care Information Centre, 2013); in the United States, 62% of the 3.1 million nurses are in acute care (U.S. Department of Health and Human Services, 2010). Nurses are often the main point of contact with patients in pain, conducting assessments and providing medications and interventions (Morgan, 2013). Inadequate pain management in hospitals is a well-documented issue. Recent statistics have shown that the number of people with substance-use disorder (SUD) is increasing within the acute-care setting in the UK; in 2000-2001, there were 25,683 admissions due to primary or secondary drug-related mental health and behavioral disorders, and by 2011-2012 this number more than doubled to 57,733 (Health and Social Care Information Centre, 2012). As a result of this rise, nurses will increasingly find themselves responsible for patients with SUD who require pain management. Patients with SUD are at a higher risk of experiencing severe pain due to their related disorders, such as opioid-induced hyperalgesia, opioid withdrawal, or opioid tolerance, resulting in pain being underestimated and undertreated (Bell, Reed, Gross, & Witton, 2013). Unrelieved pain can exacerbate characteristics that are believed to be ‘‘drug-seeking,’’ such as asking for pain medication before it is due, ‘‘clock-

watching,’’ or requesting specific drug treatments (McCaffery, Grimm, Pasero, Ferrell, & Uman, 2005; McCaffery & Vourakis, 1992). This perceived drugseeking behavior can contribute to a patient being stigmatized and labeled ‘‘difficult’’ (Macdonald, 2003). The aim of this study was to explore nurses’ experiences of patients with SUD in pain to reveal the perceived challenges in managing their pain and to identify the support and educational needs of registered nurses. A phenomenological approach was adopted in order to explore the experiences of nurses; the aim was to illuminate the potential barriers between nurses and patients with SUD, and why pain management may be compromised. Table 1 outlines the key terms and definitions utilized within this study.

LITERATURE REVIEW Nurses’ Attitudes toward Patients with Substance-Use Disorder Research relating to nurses’ experiences of patients with SUD in pain is limited and falls into two categories: those that explore nurses’ attitudes toward patients with SUD and those that explore nurses’ general attitudes toward patients with SUD in pain. Of the former, research consistently reveals the existence of negative attitudes toward patients with SUD. However, it has been quantitative in nature and has therefore failed to explore potential reasons behind the negative

TABLE 1. Key Terms Pain Substance-Use Disorder

Label Stigma

Stereotype

‘‘Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’’ (International Association for the Study of Pain, 2011). Refers to patients who use illicit or illegal substances as defined by the World Health Organization (1994). These are not necessarily illicit in and of themselves, but by virtue of their production, sale, or use in specific circumstances in a given jurisdiction. These include amphetamines, cannabis, cocaine, crack cocaine, ecstasy, volatile substances, heroin, ketamine, legal highs, LSD (lysergic acid diethylamide), mephedrone, methadone, and tranquilizers (Health and Social Care Information Centre, 2012). The term will not be used in the broader medical sense in which substances such as alcohol, caffeine, and tobacco may be included. Society labels behaviors that do not conform to normal expectations; according to Goffman (1968), to label a person as different is applying a stigma. The concept of stigma is based upon Erving Goffman (1968), a social psychologist, who theorized that there are three types of stigma. The first stigma is of physical deformities; the second is tribal, and is associated with race and religion; and the third, most relevant to this study, is referred to as ‘‘blemishes of individual character’’ and includes prisoners, the unemployed, and those with addiction, alcoholism, and mental disorder. These people have the ever-present potential to be stigmatized. Goffman (1968) believed there is an intimate association between stigmatism and stereotype. Stereotypes facilitate stigma since certain attributes, such as occupation or character, are not discreditable intrinsically but by the construction of stereotypes (Goffman, 1968).

Patients with Substance-Use Disorder in Pain

attitudes. McCaffery et al. (2005) surveyed general, emergency, and pain management nurses (N ¼ 369) in North America to explore beliefs surrounding the term ‘‘drug seeking.’’ The majority (83.2%) of nurses agreed that the term has a negative meaning, and is likely to mean the patient is addicted (60.2%), abusing their pain medicine (67.2%), and is ‘‘difficult’’ and manipulative. Natan, Beyil, and Neta (2009) used a questionnaire to test the Theory of Reasoned Action, examining Israeli nurses’ (N ¼ 135) attitudes and their actual, or intended, care of patients with SUD. They also found the perception that patients with SUD were difficult to care for. Their questionnaire revealed a negative correlation between nurses’ reports of difficulty in caring for patients with SUD and their actual behavior (p < .001). This indicated that nurses who perceived SUD patient care as difficult believed the quality of care provided in practice to be lower (Natan et al., 2009). This was despite the fact that most of the respondents reported feeling confident to provide adequate care and felt they had the necessary training, knowledge, tools, and experience to do so. Stereotyping was also found to affect quality of care. A negative correlation was reported between nurses’ level of stereotypes and their actual behavior (p < .01) (Natan et al., 2009). Nurses with more stereotypical views of patients with SUD perceived the quality of their care to be lower, whereas more positive attitudes were associated with stronger intentions to provide quality care. Natan et al. (2009) found the most common stereotypical views included being violent, unhygienic, dangerous, scary, and of weak character. It is worth noting that the use of the term ‘‘actual’’ behavior, within this study, does not refer to observed practice but is part of the terminology of their framework of the Theory of Reasoned Action, in which it is hypothesized that intention to act determines actual behavior. These studies indicate patients with SUD can be viewed negatively and as ‘‘difficult’’ and that this potentially affects care. The concept that certain patients are ‘‘difficult’’ has been acknowledged as a stigmatizing term (Macdonald, 2003). According to Goffman (1968), people with addiction are already regarded as at risk of being stigmatized due to their blemish of individual character. They are seen to possess a trait that others may not find acceptable and thus have the potential to be stigmatized (Macdonald, 2003). Furthermore, Goffman (1968) believed that stereotypes facilitate stigma since certain attributes, such as occupation or character, are not discreditable intrinsically but by the construction of stereotypes. Therefore, it may be concluded that patients with SUD are not

3

only at risk of being stigmatized, but may also face being stereotyped. Nurses’ Attitudes toward Patients with Substance-Use Disorder in Pain The risk of stereotyping and being stigmatized is supported by Morgan (2006), who found that hospitalized SUD patients in pain felt as if they were treated like a ‘‘junkie,’’ and this represented the disdain and lack of respect they felt. In the grounded theory study, strategizing in order to obtain pain relief was a behavior discussed by all participants (N ¼ 18), irrespective of whether they felt respected during a particular encounter. The expectation of being disrespected had affected their experiences so much that strategizing had formed part of their routine when in hospital. Morgan’s 2006 paper formed the foundation for the next study (Morgan, 2013), in which nurses’ attitudes to patients with SUD in pain were explored. Following interviews with nurses (N ¼ 14), a model was developed that presented three pathways illustrating nurses’ possible reactions to an SUD patient’s pain report. In two pathways the nurse encounters barriers, while in the third pathway the nurse is able to understand the patient’s pain behavior and bypasses the barriers, getting directly to the patient and pain treatment. However, the pathway that is presented is arguably linear and reductionist, meaning that the existing barriers between the nurse and the patient’s pain treatment have not been fully explored. Nonetheless, the data highlight how a patient with SUD’s pain management is influenced by the nurses’ attitudes about pain and SUD. Nurses mentioned their own cultural background, years of experience as a nurse, education, personal experience of pain, family attitudes, and values about pain and addiction as contributing factors to understanding the patient’s pain behavior (Morgan, 2013). In another grounded theory study, McCreaddie et al. (2010) interviewed patients with SUD (N ¼ 11) and conducted focus groups with nurses (N ¼ 22) and found that both nurses and patients struggled to understand one another. Drug users discussed their expectations for compassionate care, while nurses felt their caring ideals were diminished when caring for patients with SUD. McCreaddie et al. (2010) concluded that these differences were due to their differing moral viewpoints and provided moral relativism as the theoretical underpinning for these misunderstandings— the theory that states moral judgments are not absolute, but are relative and subjective to individuals or groups. Differences in moral outlook were reported as exacerbated by the constraints of routines, rituals,

4

Morley, Briggs, and Chumbley

sensitivities, and stigmas; hospitals tend to be highly organized and structured, whereas patients with SUD can lead chaotic lifestyles and are often used to selfmedicating (McCreaddie et al., 2010). Nurses often work on a priority of needs basis, whereas patients may believe the nurse is there to serve them (Macdonald, 2003).

PURPOSE OF THE STUDY The literature review served to highlight the existence of negative attitudes toward patients with SUD and suggested that pain management in patients with SUD is suboptimal. However, only one study by McCreaddie et al. (2010) was conducted in the United Kingdom. This by itself is not sufficient in explaining why patients with SUD receive poor pain management in UK hospitals. The purpose of this study is to gain a deeper understanding of the experiences of nurses, and the barriers between them and patients with SUD experiencing pain. The phenomenological approach undertaken focuses upon nurse’s experiences, allowing for rich and in-depth descriptions to be gathered.

METHODS Design and Sample A descriptive phenomenological approach was adopted based upon the work of Edmund Husserl. Phenomenology seeks to explore the dynamic whole of the human experience (Omery, 1983). Nurses’ lived experiences became the focus of the study, allowing rich data to be yielded (Todres & Holloway, 2006). Ethical approval was obtained from the King’s College London Psychiatry, Nursing, and Midwifery Research Ethics Committee (PNM/12/13-140). A convenience sample of post-registration nurses studying at King’s College London were invited to participate via email and provided with a participant information sheet and consent form. Inclusion criteria allowed for nurses with varying degrees of experience of working with patients with SUD in pain, in order to strengthen representativeness and transferability of results. Snowball sampling was also utilized as potential participants were asked to pass on the researchers’ contact details to colleagues who were interested in taking part. Three of the participants were recruited via email and two recruited via the latter method. Data Collection Semi-structured interviews were conducted (between 40 and 80 minutes) with an interview guide adapted from Morgan (2013) (Appendix A). Participants were

initially asked for a description of a situation where they had experienced the phenomenon and focus was maintained upon this experience. This allowed the interview to be open for the participant to take the researcher on their narration (Koch, 1996). The aim was to seek as complete a description as possible and probes were used to thoroughly explore responses. A reflexive diary was kept throughout data collection and analysis, and bracketing was used to document the researcher’s preconceptions, suspending them to focus on the experience of the participants (Koch, 1996). The criteria put forward by Lincoln and Guba (1985) were utilized to achieve trustworthiness and transparency. Table 2 compares the traditional quantitative criteria to the qualitative equivalent and describes how these criteria were followed within this project. Data Analysis Giorgi argued that Husserl’s method was only suitable for philosophical reduction and not the analysis of raw data; therefore, the method espoused by Giorgi and Giorgi (2009) for scientific analysis was used and is outlined in Table 3.

FINDINGS Demographic data were collected from participants and are shown in Table 4. The main themes and subthemes that emerged from the five interviews are summarized in Table 5. The quotations presented here have been chosen because they best reflect the results of each theme. Patient Characteristics Patients with SUD in Pain are ‘‘Difficult’’. The word ‘‘difficult’’ was used several times by each participant, describing both ‘‘difficult’’ patients with SUD in pain and patients who contributed to a ‘‘difficult’’ situation. Participants described experiences where they perceived patients with SUD in pain to be difficult, manipulative, aggressive, noncompliant, distrustful, unhygienic, and generally challenging: ‘‘I think that it is difficult sometimes to take away the fact that this gentleman was quite a difficult character, quite manipulative. He would shout at you if you didn’t give him pain relief immediately. he was quite a difficult character and it is a little difficult to specifically focus on his pain relief because that was all part of this personality, manipulation and that sort of thing.’’ (Participant B)

Another participant described how characteristics impacted their perceptions of the patient and his pain assessment:

Patients with Substance-Use Disorder in Pain

5

TABLE 2. Quantitative Versus Qualitative Criteria to Achieve Trustworthiness Quantitative Criteria

Qualitative Criteria

Rigor

Trustworthiness

Reliability

Dependability

Validity

Credibility: 1. Prolonged Engagement 2. Persistent observation

Generalizability (external validity)

Transferability

Objectivity

Confirmability

Use in this Study By adhering to the below steps, trustworthiness is inherent within the research project. Coupled with confirmability: to be carried out in the same way as a fiscal audit. The ‘‘confirmability audit’’ consisted of an excerpt from the reflexive research diary and data analysis, ethical approval, and interview guide. 1. The researcher engaged in the research topic for one year, carrying out an in-depth literature search and review, data collection, analysis, and conclusions. 2. Data analysis carried out according to Giorgi’s method: the transcript is read multiple times, with ‘‘meaning units’’ identified and grouped into themes. To allow someone else to make a judgment about whether the findings are transferable, thick description of the interviews with direct quotations have been used. Achieved by maintaining a reflexive research diary that acts as a ‘‘super’’ audit trail: a trail that recounts the rationale underpinning the research and the decisions taken en route. Contains the moral, social, and political stance of the researcher and aids in the bracketing process.

Adapted from Lincoln and Guba (1985).

‘‘He just wasn’t reacting normally, he was high, he was drunk and he was also in pain, so it was hard to see where one thing stopped and the next thing started. He was just a strange man.’’ (Participant C)

Patients with SUD are ‘‘Noncompliant’’. Participants discussed the perception that patients with SUD would not participate in aspects of their care causing them to be perceived as noncompliant: ‘‘He could be a bit noncompliant, let’s say, with his care, so things like if they were going to try and get him to have a wash he wouldn’t be interested at all, always demanding more and more and more drugs, more and more painkillers, so he was tricky. He wouldn’t engage with certain

aspects of his care, so if the physiotherapists came to see him he wouldn’t do his physiotherapy. If they came to do his dressing he would have a reason why he didn’t want his dressing done at the time.’’ (Participant B)

Although there is some debate surrounding the legitimacy of using the word ‘‘noncompliant,’’ it has been used in direct quotations from the participants. It may be worth noting that one participant mentioned this controversy but used the word anyway, feeling that it best described how she felt. Patients with SUD are not all the Same. Despite generalizing that patients with SUD were

TABLE 3. Giorgi’s Five-Stage Approach to Data Analysis Stage One Stage Two Stage Three Stage Four Stage Five

Read the transcript in its entirety to gain a holistic sense of the whole. Re-read the transcript with the aim of discriminating ‘‘meaning units.’’ These are not theoretically important, but practically important, and allow the researcher to make note of relevant parts in relation to the phenomenon under study. Express the insight contained in each meaning unit. The transformed series of meaning units must then be connected together to describe the general structure of the phenomenon. The common themes are then highlighted from the thematized meaning units and illustrated by quotes from participants (Holloway & Wheeler, 2010). The common themes are elaborated upon, related together and to the whole (Penner & McClement, 2008). Although structure of experience is uncovered from each participant, rather than focusing on individual narratives, the focus must be maintained upon the phenomenon and the themes generated (Holloway & Wheeler, 2010).

Adapted from Giorgi and Giorgi (2009).

6

Morley, Briggs, and Chumbley

TABLE 4. Demographic Information Collected From Participants Age

Clinical Area

Years since Registration

A B

20–29 50–59

Emergency Department Vascular, Education

20

C D

20–29 30–39

10

E

40–49

Trauma & Orthopedics Accident & Emergency, Prison Service Palliative Care, Pain Services

Participant

noncompliant or difficult, most of the participants explicitly stated that each patient with SUD in pain is different and consequently needed to be treated holistically and individually. Patient Management Experience aids Better Management. The three most experienced participants discussed the belief that more experience with patients with SUD in pain equated to better management, with two of them perceiving that junior staff members struggled, stating: ‘‘Experience is quite valuable in acquiring the confidence to give them quite high doses of opiate drugs because some people, particularly junior members of staff, feel quite uncomfortable about that.’’ (Participant B)

The importance of experience also carried over to the doctors, as Participants B and D described feeling

>10

Highest Qualification Diploma in Adult Nursing Postgraduate Certificate in Education for Nursing Postgraduate Diploma in Adult Nursing Postgraduate Certificate as an Emergency Nurse Practitioner Masters in Pain Management

that junior doctors struggled with knowing how to manage a patient with SUD in pain. Doing the ‘‘Right Thing’’. This sub-theme had two elements: participants’ perception of patients doing the right thing, and their perception of staff doing the right thing. In relation to the former, one participant suggested that patients with SUD seeking help or on a Methadone replacement program were perceived more favorably, since they were judged to be doing the ‘‘right thing’’: ‘‘I think if someone is in a program and they come in and can say I am on this much Methadone, or this much whatever, that maybe has more of an air of acceptability about it because a professional is involved and is managing it and the person is trying to do the right thing, whereas maybe if you are just buying things randomly off the Internet or off a dealer it is more kind of underhand and illicit.’’ (Participant E)

TABLE 5. Themes and Sub-themes Theme Patient Characteristics Patient Management

Pressures and Targets Affecting Pain Management Psychosocial Factors Education and Support Needs Note: SUD ¼ substance-use disorder.

Sub-Theme Patients with SUD in pain are ‘‘difficult’’ Patients with SUD are noncompliant Patients with SUD are not all the same Experience aids better management Doing the ‘‘right thing’’ Discrepancies in management between doctors and nurses Suspicions of drug-seeking behavior Clinical issues (tolerance and hyperalgesia) Nurses workloads and staffing External pressure Psychological factors Social factors Discussion of patients with SUD in pain on compulsory pain study days Value of the Pain Team

Patients with Substance-Use Disorder in Pain

In relation to staff ‘‘doing the right thing,’’ one participant described a dilemma of knowing what to do and the responsibility of being the main healthcare provider: ‘‘It is really difficult to know what the right thing to do is.It is really difficult as a nurse because you are on the front line.’’ (Participant A)

Discrepancies in Management between Doctors and Nurses. Nurses reported feeling that doctors made the ultimate decisions regarding prescriptions for pain management. For the two less-experienced nurses, this produced feelings of powerlessness to treat pain because they could not prescribe and felt the prescriptions they had were insufficient. The second reason cited was that participants felt that doctors were preoccupied with wanting to ‘‘fix’’ patients’ addiction issues, rather than treating their pain. ‘‘[S]ometimes that is part of our role as well, to go and just outline to people that patient doesn’t fit that mold, it is nobody’s fault he is here and we have to try and manage that and work with that as best we can. I remember one of the juniors [doctors] in particular said, ‘I am so glad you have said that.our consultant just thinks we can get him fixed’ and I said yes, well they will, that is their mindset but this is our reality.’’ (Participant E)

Suspicions of Drug-seeking Behavior. All of the participants stated how patients with SUD in pain often requested increasing amounts of analgesics, or specific medication at certain doses. The participants all interpreted this behavior differently. Despite only two participants using the actual term ‘‘drug-seeking,’’ three participants described feeling suspicious of the pain reported. Participants A and C believed doctors could also be suspicious of drug-seeking behavior and found it difficult to remain impartial. Clinical Issues (Tolerance and Hyperalgesia). Three of the participants discussed specific clinical issues, such as the effect tolerance can have on patients with SUD in pain and that management ought to be tailored accordingly. Participant E, a pain specialist, was the only one to speak about the challenges of hyperalgesia. Pressures and Targets Affecting Pain Management Nurses’ Workloads and Staffing. Nurses reported feeling increasing amounts of strain on workloads and pressure when caring for patients with SUD in pain, perceiving them as being demanding of time and attention. Participant E perceived ward nurses as frustrated by the combination of a busy workload and caring for patients sometimes identified as

7

‘‘noncompliant.’’ Staffing was also reported to affect the challenges faced by nurses: ‘‘I am aware of certain ward areas where they are running at routinely 15% agency [temporary] staffing. So they are coming to work, it’s difficult because it’s busy, and the work that they have is challenging and it’s stressful because of the type of issues patients might be facing, and all that sort of emotional distress around them, from the patients and the families. And you don’t actually know who you have on shift with you from one day to the next.therefore I guess their [staff nurses’] reserves for dealing with that patient who does appear to be difficult and not wanting to engage and wanting things a very particular way and not able to have any room for maneuver is inevitably going to be the one they will avoid and spend less time with, but you know they are the one who needs the more time-spending because they have those difficulties and you are stuck in that paradox.’’ (Participant E)

External Pressures. Participants B and E both discussed how external pressures exacerbated the perception of patients with SUD as noncompliant because they were seen as not working toward recovery and occupying valuable hospital beds, and they consequently received unsympathetic views: ‘‘The doctors have got targets they have got to meet and an IV user comes in and sits in a bed for weeks on end with a wound breaking down, keeps disappearing off the ward, keeps taking their dressings off themselves and things like this and they are just very unsympathetic and don’t really want to talk about it if you say, well, they are still having a lot of pain, I think the doctor would probably say ‘and.’’’ (Participant B)

Two participants thought that financial pressures on hospitals had affected resources, which led to a lack of protected time for teaching and professional development, and that policies with an emphasis on avoiding hospitalization and optimizing quick recovery had contributed to doctors’ attitudes of ‘‘fixing’’ patients. Psychosocial Factors Participants discussed how it was common for patients with SUD to have complex social and psychological needs, and how an awareness of these needs could enable collaborative, holistic, person-centered care. It was expressed that patients suffering from SUD often use illicit substances to cope with the difficulties in their lives. Given the added complication of pain, it is important to remain flexible and tolerant of a patient’s pain needs. Participants also discussed experiences where patients with SUD did not want to leave the hospital because it was safe, warm, clean, and secure. Although sympathetic, participants felt they

8

Morley, Briggs, and Chumbley

remained noncompliant, which led to reported feelings of frustration.

DISCUSSION Patient Characteristics: Stereotyping and Stigmatizing The potential for stereotyping and stigmatizing was present within the findings. The word ‘‘difficult’’ featured heavily amongst participants and became a common theme in which other negative characteristics could be represented, such as being manipulative, unhygienic, and aggressive, a finding supported by Natan et al. (2009). However, contrary to this, many of the participants also expressed the opinion that patients with SUD are not all the same and thus require holistic treatment. This is a positive step toward addressing possible stigmatization of this patient group. Natan et al. (2009) found that personal attitudes were the most determinant factor for nurses’ impetus to deliver high-quality care to patients with SUD and suggested that nurse educators ought to explore staff attitudes, beliefs, and expectations before implementing educational programs. Noncompliance Participants indicated that they found patients with SUD in pain to be noncompliant, and this directly impacted upon patients’ pain management. In a review of the literature on noncompliance, Russell, Daly, Hughes, and Op’T Hoog (2003) stated that noncompliance is often perceived as a problem to be resolved, with nurses recognizing, diagnosing, and aiming to cure these patients of their noncompliance by encouraging them to follow prescribed treatment; this is described as another source of potential stigmatization. Instead, the authors proposed that noncompliance should be viewed in the social context of patients’ lives and that ‘‘good holistic nursing practice means that nurses must recognize the social factors that constrain people’s capacity to change’’ (Russell et al., 2003). The emphasis therefore shifts from labeling and stigmatizing patients to building genuine, dynamic partnerships. The word ‘‘compliance’’ is controversial, as it assumes patients are passive recipients of health care who should obey instructions from professionals and is suggestive of a paternalistic view of healthcare professionals (Gray, Wykes, & Gournay, 2002; Playle & Keeley, 1998). Instead, it is suggested that use of the word ‘‘concordance’’ ought to be encouraged. Concordance emphasizes patient rights, the need for information, the importance of two-way communication and decision making, and advocating a patient’s right to decide

even when the clinician disagrees (Gray et al., 2002). Within this study, concordance was not a term utilized by participants, despite discussion of the requirement of holistic person-centered care. Whether this was simply due to a lack of awareness of the term ‘‘noncompliant’’ as controversial or because participants held contradictory views is not clear. These views warrant further investigation in future research. Patient Management: Discrepancies in Management between Doctors and Nurses The reported discrepancies between doctors and nurses illustrates an important point also made by Bell et al. (2013), who discussed the differences in approaches between addiction medicine and pain medicine. In addiction medicine, practitioners are often aware that patients may not be open about their addiction, may have skills in manipulating doctors, and may not want to comply with treatment. Consequently, risk management is an important part of prescribing, with urine monitoring, supervision of administration, and corroboration of self-report as essential features of patient management (Bell et al., 2013). In pain medicine, the gold standard is believed to be patient report. In treating a patient with SUD in pain, both doctors and nurses are confronted with the challenges of juggling these two specialties. Perhaps, inevitably, this leads to discrepancies in patients’ pain management and therefore creates a barrier between the patient and their pain management. Improvements in communication between doctors and nurses may help to overcome these issues. Many of the participants in this study stated the desire for doctors to partake in the same training as them regarding pain management, with further emphasis on communication and multidisciplinary teamwork to encourage joint pain management plans. Pressures and Targets Affecting Pain Management Nurses described how patients with SUD could be demanding of time and attention, and they struggled to marry this with the requirements of their other patients. This finding links back to previous studies; Natan et al. (2009) found patients with SUD were disruptive to department routines, while McCreaddie et al. (2010) described strains in the nurse–patient relationship. Patients with SUD were perceived as chaotic; as hospitals tend to be highly organized, this results in difficulties for nurses managing their competing workloads (McCreaddie et al., 2010). Participants also discussed feeling that they were facing increasing external pressures: from reaching performance targets, such as the target to treat, admit, and discharge within four hours in the Emergency

Patients with Substance-Use Disorder in Pain

Department; to staff shortages; to shortages of beds. Nurses reported feeling unable to achieve holistic, person-centered care when also feeling external pressures placed upon them. A recent UK report concluded that barriers relating to time and inadequate resources, including staffing levels, needed addressing, as these were the most significant barriers to quality of care (The King’s Fund, 2013). It is beyond the scope of this paper to discuss these issues in-depth, but the findings of this study suggest that nurses are feeling increasingly pressured due to external pressures, workloads, and staffing. Further research is required to understand whether this extends more broadly amongst the nursing population and its effects on patient care and pain management. Psychosocial Factors Participants discussed the impact psychosocial factors had on patients with SUD and often found they had complex social backgrounds or suffered from mental disorder(s). Indeed, Bakken, Landheim, and Vaglum (2003) found a strong link between sufferers of SUD and mental disorders. Participants perceived these factors as impacting upon the way patients with SUD interacted and added to the perception they were distrustful, noncompliant, and disruptive to department routines. This finding suggests that more work is needed to encourage and foster trusting and effective working relationships between nurses and patients with SUD and pain. As argued by Russell et al. (2003), more could be done to incorporate the social context of patient’s lives into daily care to develop concordance and truly work holistically. Implications for Clinical Practice and Research Discrepancies between nurses’ and doctors’ management was cited as a barrier to pain management, a finding supported by Bell et al. (2013), who found there is poor communication between healthcare professionals. In order to develop collaborative pain management plans, healthcare professionals need to improve communication amongst their multidisciplinary teams. Training for communication skills in complex situations may be required in order to improve pain management. In particular, there was agreement among participants that doctors should attend the same pain management education sessions as nurses. For many, this consisted of an in-house pain study day, during which participants requested issues relating to patients with SUD pain management be discussed. It is during these study days that further emphasis on a concordance model of care ought also be explored.

9

Study Limitations This study interviewed a small number of female nurses from one geographical area of the United Kingdom, and this may be a limitation for the results. However, the participants came from a range of clinical backgrounds, with varying amounts of experience. The method may be critiqued since the focus is on the participant’s reports of practice, not an actual observation of what has happened, and is therefore an interpretation of the experience. However, the intended focus was nurses’ experiences and an indepth insight was gained from those who took part. Although the results are not easily generalizable, the study is easily replicable and therefore could be conducted with another sample elsewhere. Further phenomenological study is recommended with a larger sample size involving staff from different professional groups to capture a wider perspective. UK guidelines regarding treatment of patients with SUD and pain are due for release (Bell et al., 2013) and further research following guideline implementation is warranted.

CONCLUSIONS Patients with substance-use disorder are at high risk for inadequate pain management, further exacerbated by perceived ‘‘drug-seeking’’ characteristics. Previous literature suggests that perceived drug-seeking behavior contributes to a patient being stigmatized and labeled ‘‘difficult.’’ This study found evidence to support that view, as patients with SUD in pain were described as ‘‘difficult’’ and ‘‘noncompliant.’’ However, participants were aware that patients with SUD in pain are different and therefore face a variety of complex clinical issues, such as opioid-induced hyperalgesia, tolerance, and the effects of psychosocial factors. A myriad of factors affect patients’ pain management, such as discrepancies in management between doctors and nurses, difficulties in managing workloads, lack of experience, and external pressures. The results of this study highlight the potential barriers between nurses and patients with SUD in pain; more work needs to be done in clinical practice, research, and education toward understanding the complexities in pain management for this patient group. Acknowledgments To the nurses who took part in this study and shared their personal experiences, opinions and valuable time: thank you. I would also like to thank Imperial College Healthcare NHS Trust for providing the module costs to undertake this project, and Professor Christine Norton for her support.

10

Morley, Briggs, and Chumbley

REFERENCES Bakken, K., Landheim, A. S., & Vaglum, P. (2003). Primary and secondary substance misusers: Do they differ in substance-induced and substance-independent mental disorders? Alcohol and Alcoholism, 38(1), 54–59. Bell, J., Reed, K., Gross, S., & Witton, J. (2013). The management of pain in people with a past or current history of addiction. Salisbury, England: National Addiction Team, King’s College London. Giorgi, A. P., & Giorgi, B. M. (2009). The descriptive psychological phenomenological method. In A. P. Giorgi (Ed.), The descriptive phenomenological method in psychology: A modified Husserlian approach. Pittsburgh, PA: Duquesne University Press. Goffman, E. (1968). Stigma: Notes on the management of spoiled identity. Middlesex, England: Penguin. Gray, R., Wykes, T., & Gournay, K. (2002). From compliance to concordance: A review of the literature on interventions to enhance compliance with antipsychotic medication. Journal of Psychiatric and Mental Health Nursing, 9, 277–284. Health and Social Care Information Centre, Lifestyle Statistics. (2012). Statistics on drug Misuse. England: Health and Social Care Information Centre.. Retrieved March 17, 2015, from http://www.hscic.gov.uk/catalogue/PUB09140/ drug-misu-eng-2012-rep.pdf. Health and Social Care Information Centre, Workforce and Facilities Team. (2013). NHS Workforce: Summary of staff in the NHS: Results from September 2012 Census.Retrieved March 17, 2015, http://www.hscic.gov.uk/catalogue/ PUB10392/nhs-staf-2002-2012-over-rep.pdf. Holloway, I., & Wheeler, S. (2010). Qualitative research in nursing and healthcare (3rd ed) (pp. 213–231). Oxford, England: Wiley-Blackwell. International Association for the Study of Pain. (2011). IASP Taxonomy. Retrieved March 17, 2015, from http:// www.iasp-pain.org/Taxonomy King’s Fund. (2013). Patient-centred leadership: Rediscovering our purpose. London, England: The King’s Fund. Koch, T. (1996). Implementation of a hermeneutic inquiry in nursing: Philosophy, rigour and, representation. Journal of Advanced Nursing, 24(1), 174–184. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. California: Sage. Macdonald, M. (2003). Seeing the cage: Stigma and its potential to inform the concept of the difficult patient. Clinical Nurse Specialist, 17(6), 305–310, quiz 311–302.

McCaffery, M., Grimm, M. A., Pasero, C., Ferrell, B., & Uman, G. C. (2005). On the meaning of ‘ drug seeking’’. Pain Management Nursing, 6(4), 122–136. McCaffery, M., & Vourakis, C. (1992). Assessment and relief of pain in chemically dependent patients. Orthopaedic Nursing, 11(2), 13–27. McCreaddie, M., Lyons, I., Watt, D., Ewing, E., Croft, J., Smith, M., & Tocher, J. (2010). Routines and rituals: A grounded theory of the pain management of drug users in acute care settings. Journal of Clinical Nursing, 19(19–20), 2730–2740. Morgan, B. D. (2006). Knowing how to play the game: Hospitalized substance abusers’ strategies for obtaining pain relief. Pain Management Nursing, 7(1), 31–41. Morgan, B. D. (2013). Nursing attitudes toward patients with substance Use disorders in pain. Pain Management Nursing, 15(1), 165–175. Natan, M. B., Beyil, V., & Neta, O. (2009). Nurses’ perception of the quality of care they provide to hospitalized drug addicts: Testing the theory of reasoned action. International Journal of Nurse Practitioners, 15(6), 566– 573. Omery, A. (1983). Phenomenology: A method for nursing research. Advances in Nursing Science, 5(2), 49–64. Penner, J. L., & McClement, S. E. (2008). Using phenomenology to examine the experiences of family caregivers of patients with advanced head and neck cancer: reflections of a novice researcher. International Journal of Qualitative Methods, 2(7), 92–101. Playle, J. F., & Keeley, P. (1998). Noncompliance and professional power. Journal of Advanced Nursing, 27(2), 304– 311. Russell, S., Daly, J., Hughes, E., & Op’T Hoog, C. (2003). Nurses and ‘‘difficult’’ patients: Negotiating non-compliance. Journal of Advanced Nursing, 43(3), 281–287. Todres, L., & Holloway, I. (2006). Phenomenology. In K. Gerrish, & A. Lacey (Eds.), The Research Process in Nursing (pp. 224–238). Oxford, England: Blackwell. U.S. Department of Health and Human Services, Health Resources and Services Administration. (2010). The registered nurse population: Findings from the 2008 national sample Survey of registered nurses. Washington, D.C.: U.S. Department of health and human service. World Health Organization. (1994). Lexicon of alcohol and drug terms. Geneva, Switzerland: World Health Organization.

Patients with Substance-Use Disorder in Pain

11

APPENDIX A Interview Guide Broad Beginning Question: 1. Please can you describe, in as much detail as possible, a time that you have looked after a patient who has had substance-use disorder and had been experiencing pain? Probes: Can you describe how you were involved in their care? Can you describe how their pain was managed? Can you describe any problems you encountered with controlling their pain? Can you describe how the experience made you feel? Can you provide a background of the patient, for instance why they were in hospital and some information about which substances they used? Can you describe another time that you have looked after a patient who has had substance-use disorder and had been experiencing pain?

2. How have these experiences affected the way you would work with an SUD patient in the future? 3. Information and support needs: What sort of support do nurses receive to help people with SUD and managing their pain? What support, information, or education would help nurses in similar situations?

Examples of general, open-ended questions that can be used as prompts:      

Can you tell me a bit more about that? And then what happened? How do you feel about this? What was the most difficult/positive aspect? What has helped? What help would you have liked?