Στάσεις και Γνώσεις Νοσηλευτών και Γιατρών ως προς τη διαχείριση του πόνου

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1 ιεπιστηµονική Φροντίδα Υγείας (2010) Τόµος 2, Τεύχος 1, Στάσεις και Γνώσεις Νοσηλευτών και Γιατρών ως προς τη διαχείριση του πόνου Κωνσταντή Ζ., 1 Γκούβα Μ. 2, Μαντζούκας Σ. 3, Πετρίδης Α. 4, Ευτυχίδου Ε. 5, Μαυρέας Β. 6, αµίγος. 7 1 Εργαστηριακός Συνεργάτης Τµήµατος Νοσηλευτικής Τ.Ε.Ι. Ηπείρου 2 Επίκουρος Καθηγήτρια Τµήµατος Νοσηλευτικής Τ.Ε.Ι. Ηπείρου 3 Επιστηµονικός Συνεργάτης Τµήµατος Νοσηλευτικής Τ.Ε.Ι. Ηπείρου 4 Καθηγητής Τ.Ε.Ι. Αθηνών 5 Καθηγήτρια Τ.Ε.Ι. Αθηνών 6 Καθηγητής Ψυχιατρικής Ιατρικής Σχολής Παν/µίου Ιωαννίνων 7 Επίκουρος Καθηγητής Τµήµατος Ιατρικής Παν/µίου Ιωαννίνων ΠΕΡΙΛΗΨΗ Η παρούσα µελέτη διερευνά τις στάσεις και τις γνώσεις των Ελλήνων επαγγελµατιών υγείας (νοσηλευτές και γιατροί) στη διαχείριση του πόνου. Για τη µελέτη των παραγόντων χρησιµοποιήθηκε το ερωτηµατολόγιο της M. McCaffery για τις στάσεις των νοσηλευτών σχετικά µε τη διαχείριση του πόνου. Η έρευνα πραγµατοποιήθηκε στα Ιωάννινα, στο Εργαστήριο Ιατρικής Ψυχολογίας του Πανεπιστηµίου Ιωαννίνων από τον Ιανουάριο του 2006 έως τον Ιούλιο του Καθορίστηκε το δείγµα να αποτελέσουν οι νοσηλευτές και οι γιατροί που θα ανταποκρίνονταν στις προϋποθέσεις της µελέτης. Ο αριθµός των νοσηλευτών και γιατρών που πληρούσαν τις προϋποθέσεις και αποτέλεσαν το δείγµα ήταν 422 άτοµα. Από τα αποτελέσµατα διαπιστώθηκε ανεπαρκής γνώση ως προς τη διαχείριση του πόνου των Ελλήνων επαγγελµατιών υγείας του δείγµατος και επίδραση αυτής της ανεπάρκειας στη στάση τους στην αποτελεσµατική αντιµετώπιση του πόνου. Τα συγκεκριµένα ευρήµατα έδειξαν αναποτελεσµατική διαχείριση του πόνου και φαίνεται να κρούουν τον κώδωνα του κινδύνου, και επιτείνουν την αναγκαιότητα περαιτέρω εκπαίδευσης για τη διαχείριση του πόνου στους Έλληνες Επαγγελµατίες Υγείας. Λέξεις-Κλειδιά: Πόνος, ιαχείριση του Πόνου, Αξιολόγηση του Πόνου, Νοσηλευτική, Επαγγελµατίες Υγείας. Υπεύθυνος Αλληλογραφίας: Γκούβα M., TEI ΗΠΕΙΡΟΥ, 4 ο χλµ Εθνικής οδού Ιωαννίνων Αθηνών, 45500, Ιωάννινα gouva@ioa.teiep.gr 37

2 Interscientific Health Care (2010) Vol 2, Issue 1, An exploratory study on nurses and doctors attitudes and knowledge of pain management in a Greek hospital Konstanti Z., 1 Gouva M. 2, Mantzoukas S. 3, Petridis A. 4, Eftixidou E. 5, Mavreas V. 6, Damigos D. 7 1 RN, BSc (Nursing), Msc «pain management» Laboratory Collaborator/ Department of Nursing, Highest Technological Educational Institute of Epirus, Lecturer nursing of secondary education, Greece 2 BScPsych, Msc, PhD, Assistant Professor of Nursing Department, Higher Technological Educational Institution of Epirus, Greece 3 RN, BSc (Nursing), BSc (Health Studies), PgCert, PgDip, MSc, PhD Scientific Collaborator/ Assistant Professor, Department of Nursing, Highest Technological Educational Institute of Epirus, Greece 4 Professor, Technology Education Institute of Athens, Greece 5 Associate Professor, Technology Education Institute of Athens, Greece 6 Professor of Psychiatric Department, Medical School, University of Ioannina, Greece 7 Assistant Professor of Medical Psychology University of Ioannina, Greece ABSTRACT The current study explores the attitudes and knowledge of Greek health professionals (nurses and doctors) in the management of pain. Quantitative non-experimental methodology was implemented based on McCaffery s questionnaire with regards nurses attitudes of pain management to conduct the study. The study was carried out in Greece at the city of Ioannina in the laboratory of Medical Psychology of the University of Ioannina. The data collection commenced in January 2006 and lasted until July A total of 422 doctors and nurses all of Greek background constituted the sample. The results of the survey revealed that the Greek health professionals demonstrated insufficient knowledge of pain management, which consequently influenced their attitude of effectively treating pain. Hence, leading to ineffective pain management and consequently indicating the need for continuous professional development and knowledge enhancement of Greek health professionals with regards the management of pain. Keywords: pain, pain management, pain assessment, nursing care, nursing knowledge. INTRODUCTION Pain is one of the most frequent and most daunting of problems that health professionals have to counter in their daily clinical practice. Pain causes problems both to patients and to their loved ones. Moreover, pain brings about financial, social and personal problem. In the mid 1990s the American Pain Society recognized pain as the 5 th vital sign demonstrating in this way the necessity and significance for developing a scale as to properly measure and assess pain. 6 For effective pain evaluation health professionals need to use the knowledge they have acquired through several sources, including any relevant theoretical or searching instructions. Health professionals should also be aware of the 38 philosophical dimensions of pain. The underlying philosophy for effective evaluation and treatment of pain is the attempt to completely alleviate pain whenever it is possible. However, it appears in most cases that total alleviation is a great if not impossible task for health professionals and in these cases the main purpose is to provide patients with the best possible treatment as to minimize the effects of pain. 38 Effective pain management is a serious challenge for both nurses and doctors. Relevant studies have demonstrated that patients pain is treated and controlled in conflicting and unsuccessful ways. 2,5,32,33,37 Also, a set of other studies on pain management suggest that the systematic estimation of pain from both health professionals and patients Corresponding Author: Gouva M., TEI of Epirus,45500, Ioanina Greece gouva@ioa.teiep.gr

3 is inadequate and that health professionals demonstrate inefficient knowledge of dealing with pain. 12,15,24,30,31 Furthermore, a set of other surveys examining the factors that influence nurses perceptions of pain concluded that nurses in an attempt to choose the right analgesic chose those with the least sideeffects. 27,36 Also, studies that examined the relationship between estimation of pain, and nurse s age and professional experience concluded that there were not any statistically important differences between those attributes and the estimation of pain. 3 Lastly, studies on the management of pain suggest the systematic estimation of pain is inadequate due to the inefficient knowledge of health professionals about pain and the ways to deal with it. 12,23,24 The relevant absence of research studies on the management of pain in Greece and the set of international studies that demonstrate inadequate assessment and management of pain by health professionals triggered our interest and the need to develop a study that would explore the attitudes and knowledge of Greek health professionals in the assessment and management of pain. METHOD The aim of the present study is the exploration of the attitude that Greek health professionals have towards the management of pain, as well as the exploration of their knowledge on the appropriate treatment of pain. This study took place in Greece at the city of Ioannina in the laboratory of Medical Psychology of the University of Ioannina. It commenced in January 2006 and was completed July The total sample size was 422 nurses and doctors employed in a Greek Hospital. Participation in the study was voluntary and all participants were full informed about the aims and method of the study. The study acquired relevant ethical approval and all participants in the study signed an informed consent For the recording of the socio-demographic characteristics of the sample a relevant questionnaire was provided which included elements relating to sex, age, marital status, educational level, place of residence and vocational status. For exploring the attitudes and knowledge of Greek health professional on the topic of pain management McCaffery s and Ferrell s questionnaire on nurses knowledge and attitudes survey regarding pain were used. 21 McCaffery and Ferrell s (1995) initially developed their survey questionnaire to address nurses knowledge and attitudes about patients reports of pain and the management of their pain. In 2002 McCaffery presented an updated version of the questionnaire consisting of 24 questions. The first 12 question have a right/ wrong answer and refer nurses general knowledge of pain management. The following 3 questions refer to addictions on opium medication for pain management. The 16 th question asks participants to indicate in a likert scale from 1 to 5 how sure are they that they have correctly completed the questionnaire. The following 8 questions refer to demographic characteristics of the participants. Finally, there is space for further comments on specific pain management techniques or methods. The extensive use of McCaffery and Ferrell s questionnaire is an indication that it is a valid measurement tool of knowledge on pain. Furthermore, the survey questionnaire used in the current study has previously been used by the American Society of Pain and the World Health Organisation. McCaffery and Ferrell s questionnaire has been established as a valid tool as it has been widely used by researchers, pain experts, academics and clinicians to assess pain management skills. 35,36 The test-retest validity of the questionnaire with a group of nurses (N= 60) undertaking a continuing professional development course was r>.80 and the internal consistency was r>.70. The questionnaire was initially translated in the Greek language and sequentially back translated in the English language by a set of bilingual translators as to maintain equivalence between the original and the translated versions. 4 Eventually, the two versions were compared for concept equivalence until the bilingual translators came to an agreement that the two versions were identical. 7 From the above process the translators on question nine of McCaffery s questionnaire that refers to the analgesic Vicodin agreed that it should be replaced by Lonalgal since Vicodin is not available in Greece. The choice of Lonalgal was due to the fact that it was the most known analgesic that had similar chemical composition to the one of Vicodin and it is widely used by Greek doctors and nurses. The questionnaire in spite being widely used in the international literature to study nurses pain management knowledge, nonetheless the current study used a mixed sample of nurses and doctors as to study and compare the pain management knowledge of nurses and doctors, since both professions do not receive any formal training in pain management at undergraduate level. The data analysis was completed by using the statistical package S.P.S.S. (Base 13.0, 2005). The analysis of the was done by using descriptive distribution elements, such as average, mean standard deviation, typical error of mean (rate), as well as histograms. Consequentially, a comparison of the mean (rate) of the results of several parameters between the two groups was made. For the comparison of the mean-rates of the two distributions i.e. the nurses and doctors answers which concerned quantitative variants, T-test was used since the standard deviations of these two distributions were not unequal and none of the distributions compared was clearly asymmetric. In the cases of comparison of distributional data the testing x 2, Fisher s Exact Test and Likelihood Ratio (LR) were used. More specifically, the following were used: Pearson s x 2 for tables 3x2 for cases where less than 25% of the expected rates was <5, none of the expected rates was <1 and the total of the observations was >

4 Pearson s x 2 for tables 2x2 in cases where all the expected rates were > Yates x 2 for tables 2x2 in cases where at least one of the expected rates was between 5 and In cases where at least one of the expected rates was <1 or the requirements were not met for the application of x 2 Fisher s exact test was used (Fisher s Exact Test). The calculating forms of this test are complicated, but the testing is not easy to be applied statistic software programs. 17 The mean rate of the Health Professionals (nurses and doctors) experience was 7.71±7.84 with amplitude Specifically the mean rate of the men s experience of the sample was 8.90± 8.49 with amplitude 0-26 and statistically the difference (P=0.211) from the mean rate of the women s experience of the sample which was 6.80±7.25 with amplitude, was not of great importance. RESULTS Socio-demographic profile of the sample The socio-demographic profile of the participants from both groups (nurses and doctors) is shown in details in tables 1. The nurses who took part in the research were 267 (63.3%) and the doctors were 155 (36.7%) in total 422 health professionals. The average age of the sample was ± 7.89 with amplitude More specifically, the nurses average age was ± 7.72 with amplitude and the difference from the doctors average age which was ± 8.03 with amplitude 21-60, was very important from a statistic point of view (Table 1). Regarding the gender of the participants of the study the percentage of women was 64%, a percentage almost twice that of the number of men 36%. More particularly, the women participating in the study were 221 nurses (82.8%) and 49 doctors (31.6%). As for the men in the study, there was not observed a serious statistical difference between the two groups when they were compared with Likelihood Ratio (P=0.000) (Table 1). In relation to the marital status of the participants, the percentages not only for the married ones but for the unmarried as well were shared almost equal in amount (44.1% and 52.6%). (Table 1). The two groups were also compared as to their place of residence, as it is shown by the distribution of the table 1. As to the place of residence when both groups were compared with Fishers Exact Test many differences of a statistic point of view were observed between them (P=0.000). (table 1) The Vocational Profile of both groups (nurses and doctors) as it is shown from their professional status, their position at work and the years of their experience in the field of health are shown in details in table 1. The vocational status of participants denotes that 19.1% of the whole sample are unemployed (25.6% male and 13.7% female) in other words one out of four men is unemployed. In relation to the position they have both groups were compared with Fishers Exact Test and great statistic differences (P=0.107) were not observed between them. The 52.2% of the sample have a leading role and have a responsible position in their occupational environment (12.7% managers, 12.7% head of departments and 26.8% in charge). Regarding the type of work undertaken in the clinical environment by both groups were compared with Fishers Exact Test and they did not have serious statistic differences (P=0.422). A significant percentage (38.2%) of the sample are educators/teachers in tertiary education. (table 1) Vital signs and acute pain Question: Observable changes in vital signs must be relied upon to verify a patient s report of severe pain? The overwhelming majority (84.8%) of our sample (84.6% nurses and 85.2% doctors) answered this question wrong unlike the 88.4% of McCaffery and Robinson s (2002) study that answered correctly. Also, 80% in D Arky s sample answered wrongly in the above question. 10 (Table 2). The majority health professionals have been taught the evaluation of pain and the importance of alterations in the readings of vital signs. However, the research shows that the high rates of the vital signs appear only for a short period of time after the sudden and severe onset of pain. After this initial increase the body seeks to balance these changes. In less than an hour the vital signs return to their previous state, even if the patient is continues to undergo severe pain. The persistence of severe pain can make the vital signs increase again from time to time, but they rarely remain high in levels. 20 Estimation of the intensity of pain Question: Pain intensity should be rated by the clinician not the patient A total of 64.2% of our sample (58.4% nurses and 74.2% doctors) answered correctly to this question. This contrasted the percentage of the nurses that answered correctly in McCaffery and Robinson s (2002) study, which was 99.1% (Table 2). Patients subjective perceptions and estimation about pain constitute the most reliable indicator of the existence of pain. Previous studies that researched the effectiveness of analgesics relied on the patient s subjective perception for the estimation of pain. Furthermore, they indicated that inadequate evaluation of pain leads to an inadequate alleviation of pain and that the doctors who work in hospitals tend to underestimate patients acute pain. 20 The results of our research do not agree with the above studies since the doctors of our sample, with a great difference from a statistic point of view, consider that the intensity of pain is better to be estimated by the patient. So, from the present findings it seems that the Greek nurses of our sample are medical-centered, situation which agrees with our experiential clinical experience. 40

5 Table 1. Socio-demographic profile of the sample Nurse s Doctors Total Difference between nurses and doctors Total 267 (63. 3) 155 (36.7) 422 (100.0) Age Minimum-maximum age 85 (31. 8) 63 (40. 6) 148 (35. 1) age 123 (46. 1) 67 (43. 2) 190 (45. 0) age 56 (20. 9) 19 (12. 2) 75 (17. 8) age 2 (0. 8) 4 (2. 4) 6 (1. 5) age 1 (0. 4) 1 (0.6) 2 (0.6) 35 ετών 132 (49.4) 114 (74.0) 246 (58.4) LR= >35 ετών 135 (50.6) 40 (26.0) 175 (41.6) P=0.000 Mean rate (x ± SD) ± ± ± 7.89 t= P= Sex Male 46 (17.2) 106 (68.4) 152 (36.0) LR= Female 221 (82.8) 49 (31.6) 270 (64.0) P=0.000 Marital status Unmarried 112 (41.9) 110 (71.0) 222 (52.6) Married 144 (53.9) 42 (27.1) 186 (44.1) Fisher's Exact Test = Divorced 10 (3.7) 2 (1.3) 12 (2.8) P= Widowed 1 (0.5) 1 (0.6) 2 (0.5) Residence Village/small town 63 (23.6) 16 (10.3) 79 (18.7) City< (43.8) 113 (72.9) 230 (54.5) Fisher's Exact Test= City > (32.6) 26 (16.8) 113 (26.8) P= Urban centres 204 (76.4) 139 (89.7) 343 (81.3) X 2 p = Non urban centres 63 (23.6) 16 (10.3) 79 (18.7) P= Vocational status Under specialty doctor 0 (0. 0) 74 (48.7) 74 (17.7) Doctor-lecturer A 0 (0. 0) 14 (9.2) 14 (3.3) Doctor-lecturer B 0 (0. 0) 13 (8.6) 13 (3.2) Clinical Nurse 96 (36. 1) 0 (0.0) 96 (23.0) Nurse in Charge 6 (2. 3) 0 (0.0) 6 (1.4) Chief nurse 5 (1. 9) 0 (0.0) 5 (1.2) Nurse assistant 104 (39. 1) 0 (0.0) 104 (24.8) Nurse professor 5 (1. 9) 0 (0.0) 5 (1.2) Student 50 (18. 8) 50 (32.9) 100 (24.0) Under PhD 0 (0. 0) 1 (0.7) 1 (0.2) Clinical where they work Pathological 78 (30.8) 50 (32.9) 128 (31.6) Chirurgical 71 (28.1) 73 (48.0) 144 (35.6) Orthopaedic 19 (7.5) 8 (5.3) 27 (6.7) Oncology 13 (5.1) 10 (6.6) 23 (5.7) Emergency 32 (12.6) 0 (0.0) 32 (7.9) Intensive 14 (5.5) 3 (2.0) 17 (4.2) Paediatric 9 (3.6) 0 (0.0) 9 (2.2) Aimatological 5 (2.0) 1 (0.7) 6 (1.5) Anaesthesiological 2 (0.8) 5 (3.3) 7 (1.7) Re-establishment 3 (1.2) 0 (0.0) 3 (0.7) Help in the House 7 (2.8) 1 (0.7) 8 (2.0) Psychiatry 0 (0.0) 1 (0.2) 1 (0.2) Hospital where they work Hospital of Ioannina 157 (59.0) 111 (72.5) 268 (64.0) Hospital Hagikosta 59 (22.2) 36 (23.5) 95 (22.7) Fisher's Exact Test = Hospital of Macedonia 3 (1.1) 0 (0.0) 3 (0.7) P= Old men Centres 7 (2.6) 1 (0.7) 8 (1.9) Health centres 14 (5.3) 3 (2.0) 17 (4.1) Hospital of Attica 7 (2.6) 2 (1.3) 9 (2.1) Hospital of Epirous 9 (3.4) 0 (0.0) 9 (2.1) Hospital of Peloponnesus 1 (0.4) 0 (0.0) 1 (0.2) Hospital of Larissa 4 (1.5) 0 (0.0) 4 (1.0) Technological Institute Of Epirous 5 (1.9) 5 (0.0) 5 (1.2) Area of work Urban area 208 (77.9) 139 (89.7) 347 (82.2) Suburb 8 (3.0) 2 (1.3) 10 (2.4) Fisher's Exact Test =9.529 Small town 43 (16.1) 13 (8.4) 56 (13.3) P= Rural area 8 (3.0) 1 (0.6) 9 (2.1) Years of experience in the field of Health Minimum-maximum <1 - >15 < 1 60 (22.5) 67 (43.2) 127 (30.1) (13.1) 43 (27.7) 78 (18.5) Fisher's Exact Test = (13.9) 27 (17.4) 64 (15.2) P= (16.9) 9 (5.8) 54 (12.8) > (33.7) 9 (5.8) 99 (23.5) Mean rate (x ± SD) 3.26 ± ± ± 1.56 t= P= Fisher's Exact Test= it is about the rate of the test as it is given by S.P.S.S., LR=Likelihood Ratio, X 2 P= X 2 του Pearson., X 2 Υ= X 2 του Yates, t = T-Test. 41

6 Pain effect during sleep Question: A patient may sleep in spite of moderate or severe pain Answer: True More than half of our sample (60.7% of the nurses and 60.6% of the doctors) gave a wrong answer to the question, unlike 90.6% that answered correctly in McCaffery and Robinson s (2002) study and 94% answered correctly in D Arky s (2008) study (table 2). Previous studies advocate that patients are able to sleep despite pain. A double-blind study for the effectiveness of the analgesics concluded that sleep is not equivalent to a non-pain situation and a study on patient s management of pain indicated that patients tried to manage pain by sleeping. 20,39 Hence, when a patient is asleep we can not assume that he is pain free. In order to estimate the pain we need to wake him up. (table 2) The results of various studies conclude that taking medicine, which contains opium, for the alleviation of pain rarely causes addiction and that tolerance is a problem which can be faced through the increase of the dose. The pain has also harmful effects like increasing oxygen demand, breathing malfunction and vexation as well as emotional effects like anxiety, depression, irritation and an effect on the quality of life. So, patients who need help to manage their pain understand that it is not worth obscuring the signs of pain without taking analgesics until the pain becomes unbearable. They not only spend time aching but they might also need bigger doses of medicine to alleviate pain. 20 (table 2) Respiratory depression and Analgesics with opium Question: Respiratory depression (less than seven breaths/minute for an adult) probably occurs in at least 10% of patient who receive one or more doses of an opioid for relief of severe pain: In the above question more than half of our sample (64.4% nurses and 60.6% doctors) gave a wrong answer to this question. In McCaffery and Robinson s (2002) research 60.5 % answered correctly to this question (Table 2). Health professionals seem to exaggerate with their fear for respiratory depression, probably because many of them have not been taught which patients are in danger from respiratory depression and how to prevent it. Estimates on intramuscular, intravenous and superdural administration indicate that the possibility of a respiratory depression caused by the administered opium based medicine is less than 1%. These percentages regarding respiratory depression are even lesser when opium based medicine is administered in the ward setting e.g. through superdural injection (0.07% - 0.4%) or through intravenous injection (0.1% %) and intramuscular injection (0.9%). The frequency of a respiratory repression caused by medicine with opium can be high when the patients are not checked for the level or analgesia. 20. (table 2) Lonalgal rs meperidine Question: Lonalgal (Hydrocodone 30 mg και 500 mg acetaminophen) is approximately equal to the analgesics of half of a dose of meperidine 75 mgr im. In the above question less than half (42.2%) of our sample (42.3% nurses and 41.9% doctors) answered correctly to this question concurring with the 48.3% of the nurses who answered correctly in McCaffery and Robinson s (2002) study. (table 2) Placebo and Pain Question: If a patient s pain is by a placebo the pain is not real: In the above question 60.0% of our sample (67.4% nurses and 47.1% doctors) gave a wrong answer, unlike the 86.1% who answered correctly in McCaffery and Robinson s (2002) study and 92% answered correctly in D Arky s (2008) study (Tables 2). To give a patient a placebo without informed consent is deceptive and unethical and can destroy her trust in her caregivers. The only time a placebo can be ethically used is in research setting where the patient is informed that she may receive a placebo as part of the research protocol. 10 Many patients who have an easily defined cause for the pain they feel as in the case of ventral operation a placebo may be administered for pain management. This does not indicate that the pain is psychological or that the patient does not ache. Hence, the results of the studies for pain handling can be questioned. 20 (table 2) Doses of opium medicine and Pain alleviation Question: Beyond a certain dose increasing the dosage of an opioid such as morphine won t increase pain relief In the above question 64.7% of our sample (58.4% nurses and 75.5% doctors) gave a wrong answer, unlike the 57.2% who answered correctly in McCaffery and Robinson s (2002) study (Table 2). Out of the three categories of analgesics with opium, those, which do not contain opium, and those with opium such as morphine do not have a maximum level of analgesia. In other words the appropriate rise of the doses is 25%, 50% and 100% as to provide further analgesia. Only the undesirable reactions contraindicate the rise of the dose. The rise of the dose of a suitable medicine with opium is important until the patient reaches the desirable level of pain alleviation or until the undesirable reactions are controlled or tolerated

7 Table 2 Percent of correct and incorrect responses to each question on Nurses Knowledge and Attitudes Survey Regarding Pain Questionnaire Nurse s Doctors Total Difference between nurses and doctors Total 267 (63. 3) 155 (36.7) 422 (100.0) Observable changes in vital signs must be relied upon to verify a patient s report of severe pain? True 226 (84.6) 132 (85.2) 358 (84.8) X 2 Ρ=0.020 False 41 (15.4) 23 (14.8) 64 (15.2) P=0.886 Pain intensity should be rated by the clinician not the patient: True 111 (41.6) 40 (25.8) 151 (35.8) X 2 Ρ = False 156 (58.4) 115 (74.2) 271 (64.2) P=0.001 A patient may sleep in spite of moderate or severe pain True 105 (39.3) 61 (39.4) 166 (39.3) X 2 Ρ =3.450 False 162 (60.7) 94 (60.6) 256 (60.7) P=0.995 Intramuscular (IM) meperidine is the drug of choice for prolonged pain: True 168 (62.9) 62 (40.0) 230 (54.5) LR= False 99 (37.1) 93 (60.0) 192 (45.5) P=0.000 Analgesics for chronic pain are more effective when administered p.r.n rather than around the clock: True 150 (56.2) 76 (49.0) 226 (53.6) X 2 Ρ =2.014 False 117 (43.8) 79 (51.0) 196 (46.4) P=0.156 If the patient can be distracted from pain. this means he does not have as high an intensity of pain as he reports: True 187 (70.0) 96 (61.9) 283 (67.1) X 2 Ρ =2.914 False 80 (30.0) 59 (38.1) 139 (32.9) P= The patient with pain should be encouraged to endure as much pain as possible before resorting to a pain relief measure: True 148 (55.4) 54 (34.8) 202 (47.9) LR = False 119 (44.6) 101 (65.2) 220 (52.1) P= Respiratory depression (less than seven breaths/minute for an adult) probably occurs in at least 10% of patient who receive one or more doses of an opioid for relief of severe pain: True 172 (64.4) 94 (60.6) 266 (63.0) X 2 Ρ =0.599 False 95 (35.6) 61 (39.4) 156 (37.0) P= Lonalgal (Hydrocodone 30 mg και 500 mg acetaminophen) is approximately equal to the analgesics of half of a dose of meperidine 75 mgr im. True 154 (57.7) 90 (58.1) 244 (57.8) X 2 Ρ =0.006 False 113 (42.3) 65 (41.9) 178 (42.2) P= If a patient s pain is by a placebo the pain is not real: True 180 (67.4) 73 (47.1) 253 (60.0) LR = False 87 (32.6) 82 (52.9) 169 (40.0) P= Beyond a certain dose increasing the dosage of an opioid such as morphine won t increase pain relief: True 156 (58.4) 117 (75.5) 273 (64.7) X 2 Ρ = False 111 (41.6) 38 (24.5) 149 (35.3) P= Research shows that promethazine HCL (Phenergan) reliably potentates opioid analgesics: True 176 (65.9) 115 (74.2) 291 (69.0) X 2 Ρ=3.138 False 91 (21.6) 40 (25.8) 131 (31.0) P= Percentance of the patients who are likely to become addicted after taking opioid for 1-3 days: Less than 1% 136 (50.9) 113 (72.9) 249 (59.0) Less than 5% 66 (24.7) 29 (18.7) 95 (22.5) Less than 25% 34 (12.7) 8 (5.2) 42 (10.0) Fisher's Exact Test= Less than 50% 17 (4.0) 3 (1.9) 20 (4.7) P=0.000 Less than 75% 13 (4.9) 2 (1.3) 15 (3.6) Less than 100% 1 (0.4) 0 (0.0) 1 (0.2) Percentance of the patients who are likely to become addicted after taking opioid for 3-6 months: Less than 1% 30 (11.2) 31 (20.0) 61 (14.5) Less than 5% 81 (30.3) 62 (40.0) 143 (33.9) Less than 25% 78 (29.2) 36 (23.2) 114 (27.0) Fisher's Exact Test= Less than 50% 43 (16.1) 12 (7.7) 55 (13.0) P=0.007 Less than 75% 21 (7.9) 8 (5.2) 29 (6.9) Less than 100% 14 (5.2) 6 (3.9) 20 (4.7) Percentance of the patients who are likely to become addicted after taking opioid for 1 day -6 months: Less than 1% 37 (13.9) 44 (28.4) 81 (19.2) Less than 5% 66 (24.7) 51 (32.9) 117 (27.7) Less than 25% 83 (31.1) 39 (25.2) 122 (28.9) Fisher's Exact Test= Less than 50% 59 (22.1) 18 (11.6) 77 (18.2) P=0.000 Less than 75% 13 (4.9) 2 (1.3) 15 (3.6) Less than 100% 9 (3.4) 1 (0.6) 10 (2.4) In a climax 1 (not sure) to 5 (sure). how certain are you that they have answered most of the questions correctly: Degree of certainly 1 13 (5.1) 8 (5.2) 21 (5.1) Degree of certainly 2 55 (21.4) 40 (26.0) 95 (23.1) Degree of certainly (45.1) 66 (42.9) 182 (44.3) Fisher's Exact Test=9.104 Degree of certainly 4 46 (17.9) 35 (22.7) 81 (19.7) P=0.057 Degree of certainly 5 27 (10.5) 5 (3.2) 32 (7.8) Correct answers: 1 Correct answer 6 (2.2) 0 (0.0) 6 (1.4) 2 Correct answers 14 (5.2) 6 (3.9) 20 (4.7) 3 Correct answers 35 (13.1) 10 (6.5) 45 (10.7) 4 Correct answers 48 (18.0) 14 (9.0) 62 (14.7) 5 Correct answers 46 (17.2) 27 (17.4) 73 (17.3) 6 Correct answers 38 (14.2) 24 (15.5) 62 (14.7) 7 Correct answers 40 (15.0) 25 (16.1) 65 (15.4) 8 Correct answers 25 (9.4) 26 (16.8) 51 (12.1) 9 Correct answers 8 (3.0) 8 (5.2) 16 (3.8) 10 Correct answers 4 (1.5) 4 (2.6) 8 (1.9) 11 Correct answers 2 (0.7) 3 (1.9) 5 (1.2) 12 Correct answers 1 (0.4) 5 (3.2) 6 (1.4) 13 Correct answers 0 (0.0) 2 (1.3) 2 (0.5) 14 Correct answers 0 (0.0) 1 (0.6) 1 (0.2) 15 Correct answers 0 (0.0) 0 (0.0) 0 (0.0) Mean rate(x ± SD) 5.30 ± ± ± 2.29 t= P= Fisher's Exact Test= it is about the rate of the test as it is given by S.P.S.S., LR=Likelihood Ratio, X 2 P= X 2 του Pearson., t = T-Test. 43

8 The combined action of promethazine and medicine with opium Question: Research shows that promethazine HCL (Phenergan) reliably potentates opioid analgesics In the above question 31% of the our sample (21.6% nurses and 25.8% doctors) answered correctly, almost the same percentage of the nurses who answered correctly in McCaffery and Robinson s (2002) study (Table 2). Promethazine neither alleviates pain nor strengthens the analgesia of medicine with opium. As a matter of fact McCaffery and Pasero (1999), and Ernest et al. (2000) studies showed that promethazine increases the sensitivity to pain and requires an increased dose in order to have satisfactory pain alleviation. Also the American Pain Society (1999) has opposed the use of promethazine. Addiction during administration of medicine with opium I Question: Percentance of the patients who are likely to become addicted after taking opioid for 1-3 days Answer: Less than 1% In the above question more than half (59%) of our sample (50.9% nurses and 72.9% doctors) gave a correct answer. More specifically, the correct answers of the nurses in the our sample show a statistical difference (P=0,000) from those of the doctors, which almost agrees with 53.9% of the nurses who answered correctly in McCaffery and Robinson s (2002) study and 89% answered correctly in D Arky s (2008) study (Table 2). II Question: Percentance of the patients who are likely to become addicted after taking opioid for 3-6 months: Answer: Less than 1% In the above question 14.5% of our sample (11.2% nurses and 20% doctors) answered correctly (Tables 2). The correct answers from nurses in our sample appear important with difference P=0,007 from those of the doctors in the sample which are more but both groups significantly differ from the nurses who gave a correct answer in McCaffery and Robinson s (2002) study (82.8%).in a study of 800 patient in primary care practices, the rate of addiction among patient with chronic pain who d been prescribed opioids by primary care physicians was roughly 4%.this is within the 4% to 6% range estimated in other research. 14 III Question: Percentance of the patients who are likely to become addicted after taking opioid for 1 day - 6 months: Answer: Less than 1% In the above question a small percentage (19.2%) of our sample (13.9% nurses and 28.4% doctors) answered correctly. The nurses that answered correctly in our sample show statistical difference (P=0,000) from those of the doctors of the sample, which are more, but they agree (the Greek doctors of the sample) with the 26.7% nurses who answered 44 correctly in McCaffery and Robinson s (2002) study (Table 2). The small percentage of correct answers to this question reveals the fear of potential addiction and this fear increases according to the period of time that the patient takes opium based medicine. Recent studies have shown that addiction from taking an opium based medicine for pain alleviation, even during a long period of time, is rare and less than 1%. The result shows that the medical use of medicine with opium for pain alleviation is rarely linked to addiction. There is no study to show that the possibility of addiction is increased with the period of time that the patient takes medicine with opium to treat pain. The physical tolerance and addiction are found in many patients after 1 to 4 weeks of normal administration of the dose of the medicine with opium but these results cannot be equated with addiction. 20 Degree of certainty for the accuracy of the results Question: In a climax 1 (not sure) to 5 (sure), how certain are you that they have answered most of the questions correctly In the above question 26.8% of our sample gave a level of certainty for their answers 4 to 5 (sure), but 94.7% of the participants had an unsuccessful result under 80% (i.e. less than 12 correct answers). Only 6 participants (5.3%) from those who gave an answer of 4 or 5 had a result over 80. From these six participants one was a female nurse and the other five were male doctors. Out of those who gave a level 4 to 5, thirty (26.6%) had under four correct answered questions (Tables 2). Three health professionals (doctors) who had 80% successful results did not feel sure that they answered correctly to questions and scored themselves with a 2 or 3. Those who gave a degree of certainty 1 or 2 had answered correctly to nine questions. The overwhelming majority (71.1%) of our sample had high levels of certainty (degree of certainty 3 to 5) for the answers they gave, even though a percentage of 95% of the sample did not answer correctly to less than 10 questions. This signals that health professionals feel sure enough about their knowledge as far as it concerns the patients pain management. This was interpreted as an indication of a low level of self-knowledge and disproportionate levels of selfconfidence and actual knowledge of pain management. This lack of knowledge agrees with the results of other research studies, such as Aslan et al. (2005) in Turkey, Visentin et al. (2005) in Italy and Coulling et al. (2005) who also used the short edition of McCaffery and Ferell s questionnaire. DISCUSSION The results of the present survey display significant variations from McCaffery and Robinson s (2002) findings signaling that perceptions and knowledge of health professionals in the Greek health context differ from USA health context. Two out of three health professionals who were studied were females, they were younger than 35 years old percent and one out of them was never

9 married. This specific find recently came to strengthen the statistic data of the West, which support that the creation of a family nowadays starts in an older age as the priority is given to career 25 despite the fact that in 99.1 and 95.3 percent they haven t taken any master or PhD respectively. Almost 8 out of 10 work and live in an urban area. For discursive reasons we took the 80 percent (12 correct answers) as a limit for a successful result, a limit that M. McCaffery and E.S. Robinson (2002) used in the discussion of their survey, as they considered that if a nurse does not answer correctly in more than three questions, his ability to take care of a patient who aches is seriously decreased. None of the health professionals that participated in the study answered correctly in all 15 questions. Only 9 participants (2.1 %) of the whole sample 1 nurse and 8 doctors had a result of 80% (12 correct answers) which is considered as a successful result. This indicates that the overwhelming majority of 97.9% of health professionals did not have a successful result, something that shows serious lack of knowledge on managing patients in pain. The results of the present study confirmed that health professionals have minimal knowledge about the problem of pain management or misconceptions about ease of addiction to opium based medication and the side-effects from the administration of medicine like respiratory depression. Kaasalainen et al. (2007) and Akbas and Oztuck studies also concur with the above findings. This knowledge deficit in pain management is not present in other studies as McCaffery and Robinsons (2002) study demonstrates. However, there are also similarities with health professionals outside Greece, when the lack of knowledge for the right pain management is considered as the studies of Visentin et al (2005), Aslan et al (2005) and Coullings et al (2005) demonstrate. 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