burns 41 (2015) 864–871
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Nurses’ perceptions and experiences regarding Morphine usage in burn pain management J. Bayuo a, P. Agbenorku b,* a
Burns Intensive Care Unit, Reconstructive Plastic Surgery & Burns Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana b Reconstructive Plastic Surgery & Burns Unit, Komfo Anokye Teaching Hospital, School of Medical Sciences, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
article info
abstract
Article history:
Introduction: Morphine, a classical example of opioid has been described as one of the
Accepted 30 October 2014
analgesics of choice for burn pain management but there have been reports of under utilization of the medication and subsequent poor pain management. Nurses have a pivotal
Keywords:
role in successful burn pain management and should therefore possess positive perception
Nurses
as well as strong knowledge base of pain care.
Perception
Aim: In light of this realization, this study sought to investigate the perception and
Experiences
experiences of nurses working in the burns unit possess towards the medication.
Morphine
Methodology: Purposive sampling approach was used to select twenty (20) nurses. Descrip-
Burn pain
tive and themed content analysis approaches were used to analyze data.
Addiction
Results: Mean years in general nursing practice and practice in the burns unit were obtained as 7.4 and 3.4 years respectively. Results indicate that nurses have a clear understanding of the intensity of burn pain but perception towards morphine was mixed and some respondents were unsure about some of the pertinent facts of morphine and thus, would prefer other medications such as paracetamol, diclofenac and pethidine. Addiction to the medication and morphine causing death were major themes identified. Conclusion: The resultant effect of these perception and experiences imply and confirm the under usage of morphine. It is therefore recommended that nurses within the burn unit be taken through training modules on the suitability of morphine in burn pain management. # 2014 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Unrelieved pain in the burn injured client has been described as a significant public health problem [1–7]. Burn pain has also been described as a major clinical problem over two decades ago and several studies have confirmed the under treatment of burns associated pain [1–7]. This is of major concern as poorly managed pain contributes to
long term sensory problems such as chronic pain, paresthesis [8–13] etc. as well as debilitating psychological conditions [14]. Pain in the burned patient has been described as a tormenting consequence of burn and wound healing [15]. Burn pain is thought to have both nonciceptive and neuropathic pain components [16]. If pain is not handled well, the physiological perturbations it leads to further contributes to the already established deleterious hypermetabolic status of the patient.
* Corresponding author at: University PO Box 448, KNUST, Kumasi, Ghana. Tel.: +233 24 459 9448; fax: +233 32 207 4222. E-mail address: [email protected] (P. Agbenorku). http://dx.doi.org/10.1016/j.burns.2014.10.031 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
burns 41 (2015) 864–871
The primary pain from burn itself is intense in the initial acute post burn phase. In the next few weeks thereafter, until the skin heals, the pain intensity remains high because of treatment induced pain [16]. Wound cleaning, dressing change, physical therapy etc. can all cause intense pain. Discomfort related to tissue healing such as itching, tingling and tightness of contracting skin and joints adds to the duration, if not the intensity [16]. Opioids are among the world’s oldest known drugs used chiefly as analgesic. Besides been used in managing pain, opioids have proved competent in managing dyspnoea and will also reduce distressing cough and diarrhea. Morphine sulphate which is a classical example of an opioid has been described as one of the analgesic of choice in managing burn pain. There is evidence that despite the varied physiological changes associated with burn, the kinetics of morphine is not impaired and that systemic clearance may actually be enhanced in larger burns [17,18]. Apart from been useful in managing burn associated pain, morphine has been cited as decreasing cardiac work load. Alternative opioids such as methadone and pethidine have been used but long term use of pethidine is contraindicated because of the accumulation of toxic metabolites and methadone has been cited as been expensive [19,20]. Despite these benefits, usage of morphine in the burns unit appears to be a challenge and paucity of research is available on the actual perception that nurses within the unit possess towards the medication. Nurses have a pivotal role in burn pain management and must therefore possess a strong foundation and positive attitude towards pain care. A study that investigated nurses’ attitudes towards pain management with opioids revealed they possessed negative attitudes towards the usage of the medication and fear of possible addiction [21]. However, although the development of opioid addiction is a potential concern, there is no evidence that it is a problem in patients with burn [19]. In Switzerland, nurses are allowed to prescribe and administer morphine in emergency situations but studies indicate they are often reluctant to do so for pain management in patients [22]. Despite the fact that several evidence-based guidelines have been developed [23], inadequate attitude towards morphine administration for pain relief is still been observed among health professionals [24]. Research suggests that procedural, background and breakthrough pain can be treated with the use of rapid release oral morphine. Similarly, morphine sulphate sustainedrelease formulations are a good choice in the management of background pain. In the Komfo Anokye Teaching Hospital, pain assessments are routinely performed with pain rating scales prior and after pain medication administration. Furthermore, morphine sulphate is readily available in the oral and parenteral forms. Despite this, there are still complaints of pain from burned patients prior to wound care procedures and pain scores reported represent only a slight reduction in pain. It is thus in light of this realization that this study was designed to investigate the perception and experiences nurses’ within the burns unit possess towards morphine usage.
2.
Methodology
2.1.
Setting
865
The Komfo Anokye Teaching Hospital (KATH) in Kumasi is the second-largest hospital in Ghana and the only tertiary health institution in the middle belt of the country. It is the main referral hospital for the Ashanti, Brong Ahafo, the Northern, Upper West and Upper East regions of the country. The hospital was built in 1954 and affiliated to the School of Medical Sciences (SMS) of the Kwame Nkrumah University of Science and Technology (KNUST). The hospital currently has 1000 beds, with an annual hospital attendance of about 679,050 patients made up of both out- and in-patients [25].
2.2.
Data collection
A cross-sectional descriptive approach was utilized. Ten (10) nurses were selected each from the two burn units namely Burns Intensive Care Unit (BICU) and Burns Ward–Ward D2C using purposive sampling method within the period March to April 2014. A structured questionnaire was used to collect data using a survey approach. Data analysis took the form of themed content analysis and descriptive statistics. All questionnaires were completed and returned. No missing answers were also identified. Prior to the actual study a pilot project was carried out with five nurses selected at convenience from the surgical units. Amendments were made to the instrument before the actual study took off.
2.3.
Data analysis
The data was entered in to excel as well as a graph drawn using excel.
2.4.
Ethical clearance
Ethical approval for the study was obtained from the Committee on Human Research, Publications and Ethics of the School of Medical Sciences, Kwame Nkrumah University of Science and Technology and Komfo Anokye Teaching Hospital.
2.5.
Limitations
This study used respondents from the burn units and therefore findings are specific to that setting.
3.
Results
3.1.
Characteristics of respondents
Table 1 shows the professional distribution of the respondents based on their grades, years in general nursing practice, years worked in the burns unit and whether they have attended any pain management workshop.
866
burns 41 (2015) 864–871
Table 1 – Characteristics of respondents. Characteristic
Frequency
Professional grade 3 Principal nursing officers Nursing officers 2 6 Senior staff nurses 5 Staff nurses Enrolled nurses 4 20 Total Years in general nursing practice 17 1–10 years 11–20 years 1 1 21–30 years 1 31–40 years 20 Total Years worked in the burns unit 17 1–5 years 2 6–10 years 11–15 years 1 20 Total Attended training on pain management 6 Yes No 14 20 Total
Percentage 15 10 30 25 20 100 85 5 5 5 100 85 10 5 100 30 70 100
3.2. Perception towards Morphine usage in burns pain management All nurses described burn pain using adjectives such as excruciating, severe and some even indicated it had been worse than labor pains. In terms of managing the pain satisfactorily, 9 (45%) indicated they perceived they managed both background and procedural pain well as evidenced by patients verbalizing reduction in pain whilst the remaining 11 (55%) indicated they could not manage the pain well. The former stated using approaches such as diversion, reassurance, fluids and prescribed analgesics to manage the pain. Analgesics of choice include diclofenac-8, pethidine-5, paracetamol-8 and morphine-3; the latter indicated they faced some barriers such as not having access to potent but less addictive analgesics and fear of addiction to opioids. In terms of morphine administration, if added to the treatment plan of clients, 10 (50%) indicated giving the medication whilst one respondent stated not having the opportunity to administer it and the remaining 9(45%) would not administer it due to reasons such as prevention of addiction and total dependence or tolerance to the medication. If it had to be prescribed, 19 (95%) would however prefer the oral route or give in limited doses if oral type is unavailable and 7 (35%) would opt for the intravenous route. Reasons for such preferences were however not provided. Four (20%) respondents gave the medication prior to wound care and 16 (80%) stated that if administered prior to dressing change, it made the patient drowsy and as such wound care procedures became difficult; 10 (50%) gave it after wound care procedures; 3 (15%) gave it prior to physiotherapy; 8 (40%) gave it only when the patient complained of pain and 12 (60%) administered the medication when the client complained of difficulty in sleeping to achieve the sedative effect.
Furthermore, 13 (65%) respondents indicated morphine caused addiction and would prefer other analgesics but 4 (20%) were unsure it could result in addiction; 10 (50%) indicated it could hasten the death of a burn patient whilst 6 (30%) were uncertain. In addition, 12 (60%) respondents cited that patients developed tolerance to the medication but 6 (30%) respondents indicated not been certain about this.
3.3.
Experiences with Morphine usage
Five themes were identified from the data collected. These are as follows: patients became addicted to the medication (13 responses); best analgesic ever for burn pain management (3 responses); caused immediate death in some clients (10 responses); patients developed tolerance and became dependent on the medication (5 responses); discharged clients abused the medication if added to discharge medications (1 response).
4.
Discussion
4.1.
Perception towards Morphine usage
Generally, mixed perceptions towards morphine as well as uncertainties have been identified among respondents. Though all respondents identified burn pain to be intense and highly incapacitating, 9 (45%) respondents indicated been able to manage both procedural and background pain satisfactorily as evidenced by patients’ reports of reduction in pain with approaches such as diversion, reassurance and use of analgesics (morphine was however the least mentioned: 15%). Seventeen (85%) respondents would however prefer analgesics such as paracetamol, diclofenac injection and pethidine to morphine citing absence of addiction and prevention of tolerance as the main reasons. The effectiveness of diclofenac and paracetamol is however limited to mild and moderate pain but pethidine whose usage in burn pain management have been reported has toxic effects in case of prolonged use. The non pharmacological approaches reported by respondents have limited benefit to burn pain management. This therefore poses a question as to how effective the pain is managed in light of morphine under utilization. In cases when morphine was prescribed, 19 (95%) would prefer the oral route whilst 7 (35%) would go for the intravenous route. In relation, 13 (65%) respondents cited fear of addiction as a reason to administer in limited doses whilst 10 (50%) indicated morphine hastened a patient’s death even as 6 (30%) were unsure. In addition, 12 (60%) respondents cited that patients developed tolerance to the medication and these perceptions may account for the reason why most respondents would prefer to give the medication orally. Though majority affirm the complete treatment of burn pain, practitioners seem to possess some fears and uncertainties which hinders them from fully utilizing morphine in managing burn associated pain though it is the most readily available opioid within the hospital. Nevertheless, 4 (20%) respondents indicated administering morphine prior to wound care, 16 (80%) respondents also
burns 41 (2015) 864–871
indicated that the medication made the patient drowsy and as such end up making the wound care procedure very difficult as well as causing death even in some instances. This is a matter of consideration as if this is the case, then it implies that the pain is not well managed prior to wound care and as such the patient has to endure both background and procedural pain and will require higher doses of the medication afterwards. It may be this issue that makes respondents believe patients get addicted to the medication as they may require higher than usual doses. Fear of addiction is a major barrier identified but it is however worth noting that no evidence currently supports the development of addiction to morphine by burns patients as well as hastening death of a client. It is however surprising that 12 (60%) respondents would administer morphine if a patient complained of not been able to sleep but 8 (40%) respondents would serve it only when the burned victim complained of pain. It could therefore be deduced that nurses preferred the sedative effect of the medication rather than its analgesic effect. Adverse effects such as nausea, vomiting, urine retention, pruritus, respiratory depression are common from morphine usage [26]. Due to the related side effects of opioids, non-opioids analgesics have been used in order to lessen the morphine side-effects [27,28]. It is important for the nurse to know the mechanism of action of drugs so that they would know how long it takes for some drugs to be cleared from the body to reduce side effects. When a nurse has adequate knowledge about a particular pain reliever, it would help to reduce pain and anxiety of the patient. The need to control pain helps to reduce hospital stay as well as reduction in wound care and other therapies the patient may have to undergo [29]. When a patient is given assurance by hospital staff, their pain can be managed as it provides them with much relief even if nothing is actually done about their pain since most patients do not know what pain management is all about or what to expect or not [30]. Most commonly opioids are used in the management of pain. However, inability of hospital staff to assess and estimate the severity of pain has been reported as well as misinterpretation of other behaviour such as anxiety in which case may require an anxiolytic; but because of the misinterpretation, the patient may be given opioids resulting in overdose [30]. Studies by Donovan and Kuhn revealed patients have low prospect concerning pain relief [31,32]. The issue of patient’s low expectation may negatively impact on pain management and if staff is not able to understand the patient behaviour, it could also lead to under medication [30]. Most of the fears, uncertainties and perception respondents possess are uncorroborated but confirms previous studies [30] and will require training to relieve them of such since most respondents certified that it was better to treat the pain entirely. As 14 (70%)
867
respondents indicated not having attended any workshop on pain management, it may be necessary to develop such programs to help strengthen their knowledge base which will definitely impact their attitudes and perception positively.
4.2.
Analysis and impact of nurses’ experiences
The major theme identified from the experiences of respondents was that of patient addiction. Other noted themes of much importance include morphine causing immediate death in some patients, development of tolerance and total dependence on the medication. However, some indicated that morphine was the best analgesic for burn pain management. In some situations, the usual dosage of morphine given to the patient may not bring much relief and may require an excess dose. This result in constant struggle between the patient and the nurse as when the drug is not administered in the greater dose, the patient will still continue to be in pain. Administration of large dose may result in side effects such as nausea and mental clouding and may lead to addiction [33]. Another method to reduce or prevent addiction is to give the patient regular medication which will control the pain so as not to allow the patient to continuously request for medication but that the dosage given to the patient could provide relief for a period before the next dosage is administered; thus, addiction could be prevented as well as side effects and frequent reporting of pain by the patient [33].
5.
Conclusion
Generally, unwarranted fears as well as uncertainties have been recognized as existing among nurses working in the burn units. Perception towards morphine is mixed. Though morphine is readily available, there is under utilization and high possibility of pain under management. It is therefore recommended that training programs be developed and executed to improve their knowledge base which in turn will impact attitudinal change.
Conflict of interest None declared.
Acknowledgement The authors sincerely thank the participants of this study whose responses formed the basis of this article.
868
burns 41 (2015) 864–871
Appendix
RESEARCH QUESTIONNAIRE To the respondent, This study aims to understand the attitude and experiences of nurses regarding opioid usage and the impact of these on the medication usage in the burns unit. It is not compulsory to participate in this study though your participation will be highly appreciated. Information provided will be treated with utmost confidentiality and not disclosed to anyone. If you accept to participate in this study, please do affirm that by appending your signature in the space provided below Thank You Signature ……………………………………….. SECTION A
1. Rank………………………………………………………………………………. 2. Number of years/ months in practice………………………………………………. 3. Number of years/ months working in the burns unit………………………………..
SECTION B: KNOWLEDGE AND ATTITUDES 4. Have you ever attended a workshop on pain management
yes
[ ]
No
[ ]
5. If yes, please state year attended………………………… 6. How best can you describe the pain experienced by burn patients………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… …………… 7. Are you able to manage the background/ pain during a procedure very well Yes
[ ]
No
[ ]
8. If yes, please state how you manage
it and possible pain results
achieved……………………………….…………………………………………………... ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… 9. If no, please state your reasons……………...……………………………………………... ……………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………………………
869
burns 41 (2015) 864–871
10. Have you ever administered morphine to any of your clients in the management of background pain or pain during a procedure? Yes [ ]
No
[
]
11. Which route was the medication administered…………………………………………… 12. In which of the following circumstances did you administer the medication (select all that apply) a. Before wound care procedure
[
]
b. After wound care procedure
[
]
c. Before physiotherapy
[
]
d. Client complaints of pain
[
]
e. Client complaints of inability to sleep
[
]
13. Any other circumstance, please specify……………………………………………….. 14. Would you prefer to use another medication in place of morphine? Yes
[
]
No[
]
15. If yes, please state the preferred medication and reasons………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………..
Please select the most suitable response in your opinion to the following questions: 16. Morphine used in burns patients can cause them to be addicted to the medication
17. Morphine can hasten the death of a burn patient
18. It is better to treat the pain partially than entirely
Yes
[
]
No
[
]
Unsure [
]
Yes
[
]
No
[
]
Unsure [
]
Yes
[
]
No
[
]
Unsure [
]
19. Morphine administered prior to dressing change makes the patient drowsy and as such makes the procedure difficult
yes
[
]
No
[
]
Unsure [
]
870
burns 41 (2015) 864–871
SECTION C: EXPERIENCES WITH USAGE OF OPIOID Please describe your experience with using morphine in the management of background/ procedural pain in burns……………………………….…………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………
references
[1] Carrougher GJ, Ptacek JT, Sharar SR, Wiechman S, Honari S, Patterson DR, et al. Comparison of patient satisfaction and self-reports of pain in adult burn injured patients. J Burn Care Rehabil 2003;24:1–8. [2] Carrougher GJ, Ptacek JT, Honari S, Schmidt AE, Tini-nenko JR, Gibran NS, et al. Self-reports of anxiety in burn-injured hospitalized adults during routine wound care. J Burn Care Res 2006;27:676–81. [3] Choinie`re M, Melzack R, Rondeau J, Girard N, Paquin MJ. The pain of burns: characteristics and correlates. J Trauma 1989;29:1531–9. [4] Choinie`re M. Burn pain. A unique challenge. Pain-clinical updates. International Association for the Study of Pain IX; 2001. [5] Melzack R. The tragedy of needless pain. Sci Am 1990;262:27–33. [6] Perry S, Heidrich G, Ramos E. Assessment of pain in burned patients. J Burn Care Rehabil 1981;2:322–6. [7] Perry S. Undermedication for pain on a burn unit. Gen Hosp Psychiatry 1984;6:308–16. [8] Woolf CJ, Manion RJ. Neuropathic pain: aetiology, symptoms, mechanisms, and management. Lancet 1999;353:1959–64. [9] Olgart L. Breakthrough in pain research. Charting of the synaptic network may lead to new analgesics. Nord Med 1998;113:6–12. [10] Kawasaki Y, Kohno T, Zhuang ZY, Brenner GJ, Wang H, Van Der Meer C, et al. Ionotropic and metabotropic receptors, protein kinase A, protein kinase C, and Src contribute to C-fiber-induced ERK activation and CAMP response element-binding protein phosphorylation in dorsal horn neurons, leading to central sensitization. J Neurosci 2004;24:8310–21. [11] Ikeda H, Stark J, Fischer H, Wagner M, Drdla R, Jager T, et al. Synaptic amplifier of inflammatory pain in the spinal dorsal horn. Science 2006;312:1659–62. [12] Dworkin RH. An overview of neuropathic pain: syndromes, symptoms, signs, and several mechanisms. Clin J Pain 2002;18:343–9. [13] Brenner GJ, Ji RR, Shaffer S, Woolf CJ. Peripheral noxious stimulation induces phosphorylation of the NMDA receptor NR1 subunit at the PKC-dependent site, serine-896, in spinal cord dorsal horn neurons. Eur J Neurosci 2004;20:375–84.
[14] vanLoey NE, Maas CJ, Faber AW, Taal LA. Predictors of chronic posttraumatic stress symptoms following burn injury: results of a longitudinal study. J Trauma Stress 2003;16:361–9. [15] Jonsson CE, Holmsten A, Dahlstrom L, Jonsson K. Background pain in burn patients: routine measurement and recording of pain intensity in burn unit. Burns 1998;24(5):448–54. [16] Smeltzer SC, Bare BG, Hinkle JL. 11th ed. Brunner & Suddarth’s textbook of medical-surgical nursing, vol. 1–2, 11th ed. Philadelphia: Lippincott Willams & Wilkins; 2007. [17] Perreault S, Choiniere M, du Souich PB, Bellavance F, Beauregard G. Pharmacokinetics of morphine and its glucuronidated metabolites in burn injuries. Ann Pharmacother 2001;35:1588–92. [18] Herman RA, Veng-Pedersen P, Miotto J, Komorowski J, Kealey GP. Pharmacokinetics of morphine sulfate in patients with burns. J Burn Care Rehabil 1994;15:95–103. [19] Gallagher G, Rae CP, Kinsella J. Treatment of pain in severe burns. Am J Clin Dermatol 2000;1(6):329–35. [20] MacLennan N, Heimbach DM, Cullen BF. Anaesthesia for major thermal injury. Anaesthesiology 1998;89(3): 749–70. [21] Broekmans S, Vanderschueren S, Morlion B, Kumar A, Evers G. Nurses’ attitudes toward pain treatment with opioids: a survey in a Belgian university hospital. Int J Nurs Stud 2004;41(2):183–9. [22] Ferreira M, Verloo H, Mabire C, Margarida MSV, MarquesVidal P. Psychometric evaluation of the French version of the questionnaire attitudes towards morphine use – a cross sectional study in Valais, Switzerland. BMC Nurs 2014;13:1. [23] Gordon DB, Pellino TA, Miaskowski C, McNeil JA, Paice JA, Laferriere P, et al. A 10 year review of quality improvement monitoring in pain management-recommendations for standardized outcome measures. Pain Manag Nurs 2002;3(4):116–30. [24] Verloo H, Mpinga EK, Ferreira M, Rapin CH, Chastonay P. Morphinofobia: the situation among general population and healthcare professionals in north eastern Portugal. BMC Palliat Care 2010;9:15. [25] Komfo Anokye Teaching Hospital. http://www.kathhsp. org/kathnews.php. [26] Opioid. http://en.wikipedia.org/wiki/Opioid. [27] Michaloliakou C, Chung F, Sharma S. Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 1996;82:44–51.
burns 41 (2015) 864–871
[28] Brodner G, Pogatzki E, Van Aken H, Buerkle H, Goeters C, Schulzki C, et al. A multimodal approach to control postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy. Anesth Analg 1998;86:225–7. [29] Richardson P, Mustard L. The management of pain in the burns unit. Burns 2009. http://dx.doi.org/10.1016/ j.burns.2009.03.003.
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[30] Ward SE, Gordon D. Application of the American Pain Society quality assurance standards. Pain 1994;56(3):299–306. [31] Donovan BD. Patient attitudes to postoperative pain relief. Anaesth Intensive Care 1983;11(2):125–9. [32] Kuhn S, Cooke K, Collins M, Jones J, Mucklow J. Perceptions of pain relief after surgery. BMJ 1990;300:1687–90. [33] Melzack R. The tragedy of needless pain. Sci Am 1990;262(2):27–33.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Nurses’ perceptions and experiences regarding Morphine usage in burn pain management J. Bayuo a, P. Agbenorku b,* a
Burns Intensive Care Unit, Reconstructive Plastic Surgery & Burns Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana b Reconstructive Plastic Surgery & Burns Unit, Komfo Anokye Teaching Hospital, School of Medical Sciences, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
article info
abstract
Article history:
Introduction: Morphine, a classical example of opioid has been described as one of the
Accepted 30 October 2014
analgesics of choice for burn pain management but there have been reports of under utilization of the medication and subsequent poor pain management. Nurses have a pivotal
Keywords:
role in successful burn pain management and should therefore possess positive perception
Nurses
as well as strong knowledge base of pain care.
Perception
Aim: In light of this realization, this study sought to investigate the perception and
Experiences
experiences of nurses working in the burns unit possess towards the medication.
Morphine
Methodology: Purposive sampling approach was used to select twenty (20) nurses. Descrip-
Burn pain
tive and themed content analysis approaches were used to analyze data.
Addiction
Results: Mean years in general nursing practice and practice in the burns unit were obtained as 7.4 and 3.4 years respectively. Results indicate that nurses have a clear understanding of the intensity of burn pain but perception towards morphine was mixed and some respondents were unsure about some of the pertinent facts of morphine and thus, would prefer other medications such as paracetamol, diclofenac and pethidine. Addiction to the medication and morphine causing death were major themes identified. Conclusion: The resultant effect of these perception and experiences imply and confirm the under usage of morphine. It is therefore recommended that nurses within the burn unit be taken through training modules on the suitability of morphine in burn pain management. # 2014 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Unrelieved pain in the burn injured client has been described as a significant public health problem [1–7]. Burn pain has also been described as a major clinical problem over two decades ago and several studies have confirmed the under treatment of burns associated pain [1–7]. This is of major concern as poorly managed pain contributes to
long term sensory problems such as chronic pain, paresthesis [8–13] etc. as well as debilitating psychological conditions [14]. Pain in the burned patient has been described as a tormenting consequence of burn and wound healing [15]. Burn pain is thought to have both nonciceptive and neuropathic pain components [16]. If pain is not handled well, the physiological perturbations it leads to further contributes to the already established deleterious hypermetabolic status of the patient.
* Corresponding author at: University PO Box 448, KNUST, Kumasi, Ghana. Tel.: +233 24 459 9448; fax: +233 32 207 4222. E-mail address: [email protected] (P. Agbenorku). http://dx.doi.org/10.1016/j.burns.2014.10.031 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
burns 41 (2015) 864–871
The primary pain from burn itself is intense in the initial acute post burn phase. In the next few weeks thereafter, until the skin heals, the pain intensity remains high because of treatment induced pain [16]. Wound cleaning, dressing change, physical therapy etc. can all cause intense pain. Discomfort related to tissue healing such as itching, tingling and tightness of contracting skin and joints adds to the duration, if not the intensity [16]. Opioids are among the world’s oldest known drugs used chiefly as analgesic. Besides been used in managing pain, opioids have proved competent in managing dyspnoea and will also reduce distressing cough and diarrhea. Morphine sulphate which is a classical example of an opioid has been described as one of the analgesic of choice in managing burn pain. There is evidence that despite the varied physiological changes associated with burn, the kinetics of morphine is not impaired and that systemic clearance may actually be enhanced in larger burns [17,18]. Apart from been useful in managing burn associated pain, morphine has been cited as decreasing cardiac work load. Alternative opioids such as methadone and pethidine have been used but long term use of pethidine is contraindicated because of the accumulation of toxic metabolites and methadone has been cited as been expensive [19,20]. Despite these benefits, usage of morphine in the burns unit appears to be a challenge and paucity of research is available on the actual perception that nurses within the unit possess towards the medication. Nurses have a pivotal role in burn pain management and must therefore possess a strong foundation and positive attitude towards pain care. A study that investigated nurses’ attitudes towards pain management with opioids revealed they possessed negative attitudes towards the usage of the medication and fear of possible addiction [21]. However, although the development of opioid addiction is a potential concern, there is no evidence that it is a problem in patients with burn [19]. In Switzerland, nurses are allowed to prescribe and administer morphine in emergency situations but studies indicate they are often reluctant to do so for pain management in patients [22]. Despite the fact that several evidence-based guidelines have been developed [23], inadequate attitude towards morphine administration for pain relief is still been observed among health professionals [24]. Research suggests that procedural, background and breakthrough pain can be treated with the use of rapid release oral morphine. Similarly, morphine sulphate sustainedrelease formulations are a good choice in the management of background pain. In the Komfo Anokye Teaching Hospital, pain assessments are routinely performed with pain rating scales prior and after pain medication administration. Furthermore, morphine sulphate is readily available in the oral and parenteral forms. Despite this, there are still complaints of pain from burned patients prior to wound care procedures and pain scores reported represent only a slight reduction in pain. It is thus in light of this realization that this study was designed to investigate the perception and experiences nurses’ within the burns unit possess towards morphine usage.
2.
Methodology
2.1.
Setting
865
The Komfo Anokye Teaching Hospital (KATH) in Kumasi is the second-largest hospital in Ghana and the only tertiary health institution in the middle belt of the country. It is the main referral hospital for the Ashanti, Brong Ahafo, the Northern, Upper West and Upper East regions of the country. The hospital was built in 1954 and affiliated to the School of Medical Sciences (SMS) of the Kwame Nkrumah University of Science and Technology (KNUST). The hospital currently has 1000 beds, with an annual hospital attendance of about 679,050 patients made up of both out- and in-patients [25].
2.2.
Data collection
A cross-sectional descriptive approach was utilized. Ten (10) nurses were selected each from the two burn units namely Burns Intensive Care Unit (BICU) and Burns Ward–Ward D2C using purposive sampling method within the period March to April 2014. A structured questionnaire was used to collect data using a survey approach. Data analysis took the form of themed content analysis and descriptive statistics. All questionnaires were completed and returned. No missing answers were also identified. Prior to the actual study a pilot project was carried out with five nurses selected at convenience from the surgical units. Amendments were made to the instrument before the actual study took off.
2.3.
Data analysis
The data was entered in to excel as well as a graph drawn using excel.
2.4.
Ethical clearance
Ethical approval for the study was obtained from the Committee on Human Research, Publications and Ethics of the School of Medical Sciences, Kwame Nkrumah University of Science and Technology and Komfo Anokye Teaching Hospital.
2.5.
Limitations
This study used respondents from the burn units and therefore findings are specific to that setting.
3.
Results
3.1.
Characteristics of respondents
Table 1 shows the professional distribution of the respondents based on their grades, years in general nursing practice, years worked in the burns unit and whether they have attended any pain management workshop.
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Table 1 – Characteristics of respondents. Characteristic
Frequency
Professional grade 3 Principal nursing officers Nursing officers 2 6 Senior staff nurses 5 Staff nurses Enrolled nurses 4 20 Total Years in general nursing practice 17 1–10 years 11–20 years 1 1 21–30 years 1 31–40 years 20 Total Years worked in the burns unit 17 1–5 years 2 6–10 years 11–15 years 1 20 Total Attended training on pain management 6 Yes No 14 20 Total
Percentage 15 10 30 25 20 100 85 5 5 5 100 85 10 5 100 30 70 100
3.2. Perception towards Morphine usage in burns pain management All nurses described burn pain using adjectives such as excruciating, severe and some even indicated it had been worse than labor pains. In terms of managing the pain satisfactorily, 9 (45%) indicated they perceived they managed both background and procedural pain well as evidenced by patients verbalizing reduction in pain whilst the remaining 11 (55%) indicated they could not manage the pain well. The former stated using approaches such as diversion, reassurance, fluids and prescribed analgesics to manage the pain. Analgesics of choice include diclofenac-8, pethidine-5, paracetamol-8 and morphine-3; the latter indicated they faced some barriers such as not having access to potent but less addictive analgesics and fear of addiction to opioids. In terms of morphine administration, if added to the treatment plan of clients, 10 (50%) indicated giving the medication whilst one respondent stated not having the opportunity to administer it and the remaining 9(45%) would not administer it due to reasons such as prevention of addiction and total dependence or tolerance to the medication. If it had to be prescribed, 19 (95%) would however prefer the oral route or give in limited doses if oral type is unavailable and 7 (35%) would opt for the intravenous route. Reasons for such preferences were however not provided. Four (20%) respondents gave the medication prior to wound care and 16 (80%) stated that if administered prior to dressing change, it made the patient drowsy and as such wound care procedures became difficult; 10 (50%) gave it after wound care procedures; 3 (15%) gave it prior to physiotherapy; 8 (40%) gave it only when the patient complained of pain and 12 (60%) administered the medication when the client complained of difficulty in sleeping to achieve the sedative effect.
Furthermore, 13 (65%) respondents indicated morphine caused addiction and would prefer other analgesics but 4 (20%) were unsure it could result in addiction; 10 (50%) indicated it could hasten the death of a burn patient whilst 6 (30%) were uncertain. In addition, 12 (60%) respondents cited that patients developed tolerance to the medication but 6 (30%) respondents indicated not been certain about this.
3.3.
Experiences with Morphine usage
Five themes were identified from the data collected. These are as follows: patients became addicted to the medication (13 responses); best analgesic ever for burn pain management (3 responses); caused immediate death in some clients (10 responses); patients developed tolerance and became dependent on the medication (5 responses); discharged clients abused the medication if added to discharge medications (1 response).
4.
Discussion
4.1.
Perception towards Morphine usage
Generally, mixed perceptions towards morphine as well as uncertainties have been identified among respondents. Though all respondents identified burn pain to be intense and highly incapacitating, 9 (45%) respondents indicated been able to manage both procedural and background pain satisfactorily as evidenced by patients’ reports of reduction in pain with approaches such as diversion, reassurance and use of analgesics (morphine was however the least mentioned: 15%). Seventeen (85%) respondents would however prefer analgesics such as paracetamol, diclofenac injection and pethidine to morphine citing absence of addiction and prevention of tolerance as the main reasons. The effectiveness of diclofenac and paracetamol is however limited to mild and moderate pain but pethidine whose usage in burn pain management have been reported has toxic effects in case of prolonged use. The non pharmacological approaches reported by respondents have limited benefit to burn pain management. This therefore poses a question as to how effective the pain is managed in light of morphine under utilization. In cases when morphine was prescribed, 19 (95%) would prefer the oral route whilst 7 (35%) would go for the intravenous route. In relation, 13 (65%) respondents cited fear of addiction as a reason to administer in limited doses whilst 10 (50%) indicated morphine hastened a patient’s death even as 6 (30%) were unsure. In addition, 12 (60%) respondents cited that patients developed tolerance to the medication and these perceptions may account for the reason why most respondents would prefer to give the medication orally. Though majority affirm the complete treatment of burn pain, practitioners seem to possess some fears and uncertainties which hinders them from fully utilizing morphine in managing burn associated pain though it is the most readily available opioid within the hospital. Nevertheless, 4 (20%) respondents indicated administering morphine prior to wound care, 16 (80%) respondents also
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indicated that the medication made the patient drowsy and as such end up making the wound care procedure very difficult as well as causing death even in some instances. This is a matter of consideration as if this is the case, then it implies that the pain is not well managed prior to wound care and as such the patient has to endure both background and procedural pain and will require higher doses of the medication afterwards. It may be this issue that makes respondents believe patients get addicted to the medication as they may require higher than usual doses. Fear of addiction is a major barrier identified but it is however worth noting that no evidence currently supports the development of addiction to morphine by burns patients as well as hastening death of a client. It is however surprising that 12 (60%) respondents would administer morphine if a patient complained of not been able to sleep but 8 (40%) respondents would serve it only when the burned victim complained of pain. It could therefore be deduced that nurses preferred the sedative effect of the medication rather than its analgesic effect. Adverse effects such as nausea, vomiting, urine retention, pruritus, respiratory depression are common from morphine usage [26]. Due to the related side effects of opioids, non-opioids analgesics have been used in order to lessen the morphine side-effects [27,28]. It is important for the nurse to know the mechanism of action of drugs so that they would know how long it takes for some drugs to be cleared from the body to reduce side effects. When a nurse has adequate knowledge about a particular pain reliever, it would help to reduce pain and anxiety of the patient. The need to control pain helps to reduce hospital stay as well as reduction in wound care and other therapies the patient may have to undergo [29]. When a patient is given assurance by hospital staff, their pain can be managed as it provides them with much relief even if nothing is actually done about their pain since most patients do not know what pain management is all about or what to expect or not [30]. Most commonly opioids are used in the management of pain. However, inability of hospital staff to assess and estimate the severity of pain has been reported as well as misinterpretation of other behaviour such as anxiety in which case may require an anxiolytic; but because of the misinterpretation, the patient may be given opioids resulting in overdose [30]. Studies by Donovan and Kuhn revealed patients have low prospect concerning pain relief [31,32]. The issue of patient’s low expectation may negatively impact on pain management and if staff is not able to understand the patient behaviour, it could also lead to under medication [30]. Most of the fears, uncertainties and perception respondents possess are uncorroborated but confirms previous studies [30] and will require training to relieve them of such since most respondents certified that it was better to treat the pain entirely. As 14 (70%)
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respondents indicated not having attended any workshop on pain management, it may be necessary to develop such programs to help strengthen their knowledge base which will definitely impact their attitudes and perception positively.
4.2.
Analysis and impact of nurses’ experiences
The major theme identified from the experiences of respondents was that of patient addiction. Other noted themes of much importance include morphine causing immediate death in some patients, development of tolerance and total dependence on the medication. However, some indicated that morphine was the best analgesic for burn pain management. In some situations, the usual dosage of morphine given to the patient may not bring much relief and may require an excess dose. This result in constant struggle between the patient and the nurse as when the drug is not administered in the greater dose, the patient will still continue to be in pain. Administration of large dose may result in side effects such as nausea and mental clouding and may lead to addiction [33]. Another method to reduce or prevent addiction is to give the patient regular medication which will control the pain so as not to allow the patient to continuously request for medication but that the dosage given to the patient could provide relief for a period before the next dosage is administered; thus, addiction could be prevented as well as side effects and frequent reporting of pain by the patient [33].
5.
Conclusion
Generally, unwarranted fears as well as uncertainties have been recognized as existing among nurses working in the burn units. Perception towards morphine is mixed. Though morphine is readily available, there is under utilization and high possibility of pain under management. It is therefore recommended that training programs be developed and executed to improve their knowledge base which in turn will impact attitudinal change.
Conflict of interest None declared.
Acknowledgement The authors sincerely thank the participants of this study whose responses formed the basis of this article.
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Appendix
RESEARCH QUESTIONNAIRE To the respondent, This study aims to understand the attitude and experiences of nurses regarding opioid usage and the impact of these on the medication usage in the burns unit. It is not compulsory to participate in this study though your participation will be highly appreciated. Information provided will be treated with utmost confidentiality and not disclosed to anyone. If you accept to participate in this study, please do affirm that by appending your signature in the space provided below Thank You Signature ……………………………………….. SECTION A
1. Rank………………………………………………………………………………. 2. Number of years/ months in practice………………………………………………. 3. Number of years/ months working in the burns unit………………………………..
SECTION B: KNOWLEDGE AND ATTITUDES 4. Have you ever attended a workshop on pain management
yes
[ ]
No
[ ]
5. If yes, please state year attended………………………… 6. How best can you describe the pain experienced by burn patients………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… …………… 7. Are you able to manage the background/ pain during a procedure very well Yes
[ ]
No
[ ]
8. If yes, please state how you manage
it and possible pain results
achieved……………………………….…………………………………………………... ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… 9. If no, please state your reasons……………...……………………………………………... ……………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………………………
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10. Have you ever administered morphine to any of your clients in the management of background pain or pain during a procedure? Yes [ ]
No
[
]
11. Which route was the medication administered…………………………………………… 12. In which of the following circumstances did you administer the medication (select all that apply) a. Before wound care procedure
[
]
b. After wound care procedure
[
]
c. Before physiotherapy
[
]
d. Client complaints of pain
[
]
e. Client complaints of inability to sleep
[
]
13. Any other circumstance, please specify……………………………………………….. 14. Would you prefer to use another medication in place of morphine? Yes
[
]
No[
]
15. If yes, please state the preferred medication and reasons………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………..
Please select the most suitable response in your opinion to the following questions: 16. Morphine used in burns patients can cause them to be addicted to the medication
17. Morphine can hasten the death of a burn patient
18. It is better to treat the pain partially than entirely
Yes
[
]
No
[
]
Unsure [
]
Yes
[
]
No
[
]
Unsure [
]
Yes
[
]
No
[
]
Unsure [
]
19. Morphine administered prior to dressing change makes the patient drowsy and as such makes the procedure difficult
yes
[
]
No
[
]
Unsure [
]
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SECTION C: EXPERIENCES WITH USAGE OF OPIOID Please describe your experience with using morphine in the management of background/ procedural pain in burns……………………………….…………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………
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