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Fear of engendering addiction is frequently reported as both a provider and a patient barrier to effective pain
management. In this study, a clinical scenario ascertained nursing staff members' usual practice in addressing
addiction fears for patients with concerns about the addictive potential of pain medication. One hundred forty-
five Veterans Health Administration nursing staff members from eight ambulatory care sites were queried to
identify variables associated with proclivity to address patient fears about addiction risks in a population where
pain is prevalent and the risk for substance abuse is high. Regarding addressing addiction concerns, 66% of
nursing staff were very likely, 16% somewhat likely, 9% unsure, 6% somewhat unlikely, and 2% very unlikely
to take action. Health technicians were less likely to address addiction concerns than registered or licensed
vocational nurses (odds ratio [OR] 0.116; ’ = .004). Nursing staff with more years' experience (OR 1.070; ’ =
.005) and higher levels of self-efficacy/confidence (OR 1.380; ’ = .001) were more likely to engage in
discussions related to addiction risks. Targeted efforts to improve pain management activities should focus on
retaining experienced nursing staff in initial assessment positions and improving the skills and confidence of
less experienced and less skilled staff.

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Fear of engendering addiction is frequently reported as both a provider and a patient barrier to effective pain
management (McCaffery and Pasero, 1999, Randall±David et al., 2003, Sullivan and Ferrell, 2005). The
prevalence of substance abuse may be as high as 10% in outpatient settings where many patients in late life
receive their care, and both providers and patients may fear that opioid medications could exacerbate an
underlying substance abuse disorder or even initiate one (Fleming, Balousek, Klessig, Mundt, & Brown, 2007).
This risk, while real, is generally associated with selected patient characteristics, including a diagnosis of
nonopioid substance abuse, male gender, younger age, and mental health disorders (Edlund et al., 2007, Ives et
al., 2006, Manchikanti et al., 2007).

Clinical experts regard addressing patient concerns as an important attribute of high quality pain management
practice (Ñ
  
 


 
   , 2009). Indeed, clarification, inquiry, and
education are important ways for providers to respond when patients express fears about addiction related to
treatment (Fishman, 2005). These issues are particularly germane to efforts to improve palliative care delivery
in outpatient settings, for which pain management is a major focus (Higginson et al., 2007). Because nursing
staff may provide the first contact with patients and pain assessment is a key nursing role, it is important to
understand what influences this crucial service for patients.

To examine these clinical issues, we used social cognitive theory (SCT), which provides certain advantages
over past investigations of provider pain management, which have not emphasized explicit behavioral
frameworks. SCT is a theory previously used to examine provider performance for depression management,
antibiotic prescribing, and other behaviors (Eccles et al., 2007, Meredith et al., 2000). SCT identifies important
environmental/contextual and personal (cognitive and affective) domains that might be associated with pain
management practices (Bandura, 1994).

Accordingly, we evaluated the influence of environmental/contextual factors (peer attitudes toward pain
management) and personal variables (negative pain beliefs and perceived self-efficacy, or confidence, in
managing pain) as well as professional characteristics (experience, education, and credentials) on nursing staff
predisposition to address patient concerns about addiction risk and opioid therapy. We hypothesized that these
variables might be associated with nursing practices for a number of reasons.
First, evidence from earlier studies suggests that contextual/environmental variables influence provider
performance (Dudley and Holm, 1984, Manias et al., 2005). Values such as willingness to expend time and
energy managing pain in specific patient groups (oncology or substance abuse populations) may be acquired
during acculturation into professional practice (Brockopp, Ryan, & Warden, 2003). These values may influence
nurses' inferences of physical pain and psychologic suffering (Brockopp et al., 2003, Wilson and McSherry,
2006) and proclivity to address addiction concerns with patients. Second, professional attitudes, such as
negative regard for patients' pain, may be an obstacle to achieving optimal pain management (Brockopp et al.,
2003, Glajchen, 2001, McCaffery and Pasero, 1999, Morgan, 2006, Wilson and McSherry, 2006). Treatment
efforts may be lacking in nurses who doubt the validity of pain in substance abusers (Morgan, 2006). Other
nurses may struggle with treating patients with chronic nonmalignant pain which frequently is disproportional
to objective disease severity (Sullivan & Ferrell, 2005) Studies of provider education suggest heightened
awareness of and motivation for pain management after participation in pain and palliative care education
(Brockopp et al., 2004, McCaffrey and Ferrell, 1997). Additionally, clinically confident nurses may be more
likely to serve as strong patient advocates (Glajchen & Bookbinder, 2001). Finally, these issues are relevant in
light of the nursing shortage and the shrinking pool of experienced nurses (Hatcher et al., 2006).

Assessing interpersonal interactions poses special methodologic challenges. Like other providers, nurses do not
always completely document such activities, making chart reviews potentially infeasible. Clinical vignettes are
brief scenarios related to a realistic clinical situation that have been found to be more accurate than chart
abstraction in measuring certain aspects of clinician performance. The vignette approach is especially helpful in
studying interpersonal and similar aspects of care that are less likely to be documented (Peabody et al., 2000,
Peabody et al., 2004). Therefore, a clinical vignette was used to evaluate proclivity to respond to a patient
whose addiction concerns impeded effective pain management.


 

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The Helping Veterans Experience Less Pain study (HELP-VETS) is a Veterans Administration (VA) funded
cross-sectional visit-based cohort study of routine outpatient pain management. Data for this study were
collected from veteran patients and multiple levels of health care providers. Licensed nurses and health
technicians (nonlicensed direct care providers) who conduct routine pain assessments at eight VA-owned or
contract sites were surveyed from March 2006 to June 2007. Two sites were large academic medical centers,
two were medium-sized outpatient facilities, and four were smaller community-based outpatient clinics. To
assure that the study addressed the care of seriously ill patients broadly, we included outpatient clinics serving
primary care, urgent care, women's health, cardiology, and oncology patients. Informed consents were obtained
from all participants included in this study. Approvals for the study were obtained from Institutional Review
Boards of VA Greater Los Angeles Healthcare System and VA Long Beach Healthcare System.



  · 

The 63-item self-administered nursing staff survey was developed by a team of pain experts at the VA Greater
Los Angeles Healthcare System (A copy of the survey is available upon request from corresponding author).
The tool was based on theoretic constructs and empiric qualitative preparatory work. Survey items reflect a
review of existing pain instruments (Ferrell & McCaffery, 2005) and are consistent with the Agency for
Healthcare Research and Quality (Timming et al., 2008) and World Health Organization pain guidelines
(Kumar, 2007). Informal cognitive testing ensured individual item comprehension. Survey items were mapped
to domains of SCT to provide a conceptual basis to examine the influence of the variables on provider
performance. After conducting the pilot study, the final survey was administered to all nurses working in
outpatient clinics at staff meetings and after scheduled shifts. One hundred forty-five of the 155 surveys
distributed were returned (94% response rate). After data cleaning and correlational analysis, scales were
constructed from individual survey items.
The dependent variable, provider behavior, was measured as the propensity of nurses to address patient
addiction concerns related to pain medication. A team-derived clinical vignette posed the case of "a 74-year-old
frail man with a history of CHF and spinal fractures from osteoporosis [who] comes into [the] clinic in a
wheelchair with his eyes closed. When asked to rate his pain from 0±10, he appears quite uncomfortable but
says 'I'm fine.' His wife adds, 'He's been hurting a little, but neither of us want him to get addicted.'" The
scenario poses the issue of how to address a patient who minimizes his report of pain and who (through a family
member) also expresses fears of addiction. Respondents were asked how likely they were to "educate the patient
and his wife about addiction risk and pain medication" (5-point scale from very likely to very unlikely). Factors
associated with the response of "very likely" were compared with other categories.

Independent variables represented conceptual domains supported by SCT. Personal variables included cognitive
attributes (years of clinical experience, level of licensure, and provider continuing education in pain/palliative
care) and affective attributes (negative pain beliefs and self-efficacy/confidence). Nursing staff were asked
directly about their cumulative years of work experience (range 1±48 years). Level of licensure was self-
reported as registered, licensed vocational (LVN), or health technician. Five nursing staff members identified
themselves as student nurses and were categorized as LVN for the purposes of analysis; sensitivity tests deleting
these participants did not affect study findings. The Pain and Palliative Care Education Scale summed the
number of educational encounters reported by nursing staff in the last year. These included attending lectures,
reading journals/books, or searching for electronic information related to pain and palliative care (range 0±28;
Cronbach Į = 0.658).

Regarding affective measures, a Confidence in Pain Management Scale was constructed to assess self-efficacy
with four items addressing confidence in determining pain presence and severity, detecting depression among
patients in pain, and evaluating pain in patients with substance abuse. The items were ranked by very confident,
somewhat confident, neither confident nor unconfident, and somewhat unconfident (range 0±16; Cronbach Į =
0.82). A Negative Pain Belief Scale included four items assessing attitudes/beliefs about patients in pain (5-
point Likert scale from strongly agree to strongly disagree): "Alcohol and drug abusers often exaggerate their
pain," "Patients don't report their pain accurately," "Patients cannot distinguish between acute and chronic
pain," and "The cause of pain is usually not clear" (range 0±16; Cronbach Į = 0.79).

The environmental/contextual domain was measured by asking nurses to rank their agreement with the
statement, "My peers regard pain assessment as an important skill" (5-point Likert scale from strongly agree to
strongly disagree). Responses with the statement were dichotomized as strongly agree/agree or not (0, 1).

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After descriptive analysis, multivariate logistic regression models evaluated the associations between
environmental/contextual domains (peer support for assessment), cognitive domains (years' experience,
licensure level, and educational activities), and affective domains (self-efficacy/confidence, negative pain
beliefs), and the outcome (vignette performance, i.e., propensity to address concerns about addiction risks). For
independent variables where missing data was low, mean substitution techniques were used;(Pearson, 2005)
sensitivity tests deleting the few participants with missing data found similar results. Statistical significance was
established at ’ ” .05 for all analyses. Analyses were conducted using SPSS version 15.0.




Out of the nursing staff respondents, 13% were male. Ages of respondents ranged from 21 to 67 years (median
49 years). Thirty-one percent of the sample was African American (n = 45), 18.6% caucasian/white (n = 27),
17.2% Hispanic (n = 25), 17.2% Asian (n = 25), and 15.8% self-identified as other (n = 5). Thirty-three percent
reported speaking a second language.
Regarding the vignette outcome, 66% of nursing staff were very likely, 16% somewhat likely, 9% unsure, 6%
somewhat unlikely, and 2% were very unlikely to address the patient's concerns about addiction risks. Seventy-
four percent of registered nurses were very likely to provide some patient education around the risk of
addiction, compared with 70% of LVNs and 20% of health technicians (Ȥ2 = 16.063; ’ .001). Eighty-three
percent of nursing staff strongly agreed or agreed with the statement, "Peers regard pain assessment as
important." Overall confidence levels were high (range 5±16, mean 12.9); the majority of nursing staff reported
being very confident or somewhat confident in detecting pain in a number of clinical conditions (Table 1). In
general, nurse respondents reflected more positive beliefs (range 0±16, mean 8.9) to patient pain reports (Table
2). Participation in pain and palliative care educational activities (Table 3) was generally low and varied
substantially (range 0±28, mean 5). Descriptive characteristics for the independent variables are provided in
Table 4.

Multivariate logistic regression models supported the influence of licensure status, years of experience, and self-
efficacy/confidence on the likelihood to address patient concerns about addiction risks (Table 5). Compared
with licensed nurses, health technicians were less likely to address addiction concerns (odds ratio [OR] = 0.116;
’ = .004). Furthermore, nursing staff with more clinical experience (OR = 1.070; ’ = .002) and higher levels of
confidence (OR = 1.380; ’ = .001), were more likely to engage in discussions of addiction risk and pain
management.

  

We evaluated the independent association of nursing staff attributes with the likelihood of taking appropriate
action to address the apprehension of a patient minimizing their pain report due to concerns about addiction. We
found that nursing staff with more years of clinical experience, higher levels of education (registered nurses and
LVNs compared with health technicians), and higher levels of self-efficacy/confidence were most likely to
report their intention to address such concerns.

Limitations include the inability to assess the specific content of discussions that nurses might pursue; however,
assessing the intent to address such concerns is a crucial step to evaluating nursing practice related to a
commonly identified barrier to effective pain management. Furthermore, clinical vignettes are a valid way to
assess such interpersonal practices (Peabody et al., 2000, Peabody et al., 2004). The variables used to represent
domains of the SCT may have incompletely captured dimensions of the model, although we were still able to
identify actionable targets for improving pain management. The VA Healthcare System may be unique in its
provider culture and the patient population it serves, although the variables we identified as significant are
relevant to improving care in most systems.

Our finding that more experienced nursing staff responded to the vignette most appropriately underscores the
value of retaining experienced staff in clinical positions. The critical role of clinical experience to quality
patient care was also stressed by a recent white paper commissioned by the Robert Wood Johnson Foundation,
o
o ’
 
   ’   Ñ
 
 o’  (Hatcher et al., 2006).
The average age of a registered nurse in 2004 was 47 years and the average age of a LVN in 2001 was 43 years,
but by 2010, 40% of registered nurses will be >50 years (Stieger, D.M. et al, 2006, Seago JA, et al, 2004). As
bedside providers age, they often retire or move into nonclinical roles, leaving less experienced younger
clinicians in direct patient care (Hatcher et al., 2006). To fill the gap created by retiring nurses and to economize
on labor costs, outpatient settings tend to employ health technicians to perform initial pain and vital sign
assessments. Many of these individuals may have limited years of experience or lack confidence in clinical
practice.

These findings also emphasize the value of formal or informal mentoring programs. In one program, 65 senior
clinical mentors who met strict competence criteria scheduled shorter and more flexible shifts to meet the
mentoring needs of junior staff. The program demonstrated improvements in two national quality nursing
outcome measures: failure to rescue (when complications such as death may have been prevented if a nurse had
been available for early identification and intervention) and pressure ulcer incidence (Hatcher et al., 2006). In
another mentoring program, financial incentives successfully promoted experienced nurses' mentoring of more
junior staff (Russell, Rix, & Brown, 2004).

Staff with low self-efficacy/confidence may be more open to interventions which address both knowledge and
skill-based learning (Glajchen & Bookbinder, 2001). For example, a comprehensive program to improve pain
management at Memorial Sloan-Kettering included cognitive and behavioral interventions, feedback, and
quality improvement. Experienced clinicians engaged in a "see one, do one, teach one" train-the-trainer model.
Following implementation of the program, formal processes evaluated adherence to pain management
standards. In this program, experiential learning by observing actual practice and receiving feedback improved
pain management activities (Bookbinder et al., 1996, Glajchen and Bookbinder, 2001).

  

Patients and providers cite concerns with substance abuse as a major barrier to effective pain
management.(Glajchen, 2001, McCaffery and Pasero, 1999, McCaffrey and Ferrell, 1997, Vallerand et al.,
2004, Weiner and Rudy, 2002) However, our findings support the need for improving nursing practice to
advance the management of pain for patients, especially those with concerns related to opioid use. Previous
research suggests that physicians may not act on routinely obtained pain ratings (e.g., the fifth vital sign
(Mularski et al., 2006)) and that routine nurse assessments may underestimate the patient's pain (Florin,
Ehrenberg, & Ehnfors, 2005). If accurate education about addiction risks are lacking, the problem of providers
not attending to patients' pain ratings will be compounded. Our findings suggest that retention of experienced
licensed nursing staff in initial assessment roles to improve the confidence and skills of less experienced staff is
an important part of the solution.