Predictors of nurses intentions to administer PRN opioid analgesics for pain relief to postoperative

211 Pages·2015·3.23 MB·English

by  Taylor, Colleen Y.

A Dissertation
entitled
Predictors of Nurses’ Intentions to Administer PRN Opioid Analgesics for Pain
Relief to Postoperative Orthopedic Patients in the Acute Care Setting
By
Colleen Y. Taylor
Submitted to the Graduate Faculty as partial fulfillment of the requirements for the
Doctor of Philosophy Degree in Health Education

___________________________________________________
Jiunn-Jye Sheu, PhD, MCHES, Committee Chair

______________________________________________
Tavis Glassman, PhD, MCHES, Committee Member

______________________________________________
Joseph Dake, PhD, MPH. Committee Member

______________________________________________
Huey-Shys Chen, PhD, RN, FAAN Committee Member

The University of Toledo
May, 2015
Colleen Y. Taylor

This document is copyrighted material. Under copyright law, no parts of this document
may be reproduced without the expressed permission of the author.
An Abstract of

Predictors of Nurses’ Intentions to Administer PRN Opioid Analgesics for Pain
Relief to Postoperative Orthopedic Patients in the Acute Care Setting
by
Colleen Y. Taylor
Submitted to the Graduate Faculty as partial fulfillment of the
Requirements for the Doctor of Philosophy Degree in Health Education
The University of Toledo
May 2015

Patients undergoing orthopedic surgery experience severe postoperative pain that
is frequently undertreated. Nurses play an important role in the management of
postoperative pain in hospitalized patients because they perform pain assessments on
patients, administer pain medications and inform physicians when patients experience
inadequate pain relief from prescribed medications. The objective of this study was to
determine what constructs from the Integrated Behavioral Model (IBM) are predictors for
intentions to administer PRN opioid analgesics for pain relief to hospitalized
postoperative orthopedic patients.
This study utilized a non-experimental quantitative format. A representative
national random sample of nurses who regularly provide care for postoperative
orthopedic patients who are hospitalized were selected to participate in the study. There
were 420 surveys returned for a 53% response rate, with the majority of participants
being female (92.3%), Caucasian (86.8%), and having earned a bachelor’s degree
(55.7%).
A statistically significant association was found with the demographic
characteristics of age, level of education, hospital type and having orthopedic surgery and
staying in the hospital and nurses’ intentions to administer PRN opioid analgesics for
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pain. A statistically significant association was found with nurses’ self-efficacy and their
intentions to administer PRN opioid analgesics when there were time and dosage
stipulations. Other constructs from the IBM that were found to have statistically
significant associations with nurses’ intentions to administer PRN opioids included
nurses’ normative beliefs and its factors, perceived control, and instrumental attitude. No
statistically significant association was found between nurses’ knowledge or their
underlying beliefs and their intentions to administer PRN opioid analgesics.
The significant predictors for nurses’ intentions to administer opioid analgesics
included self-efficacy, perceived control, normative beliefs total score, and behavioral
beliefs (instrumental attitude). Salience of the behavior, knowledge, education, number
of years caring for postoperative orthopedic patients, and orthopedic surgery requiring an
overnight stay in the hospital were also significant predictors of nurses’ intentions in this
study.
Path analysis was done separately for each intention item (intention to administer
PRN opioids, intention to administer PRN opioids with a dosage stipulation and intention
to administer PRN opioid with a timing stipulation). The significant predictors for nurses’
intention to administer opioid analgesics without a time or dosage stipulation include
self-efficacy (β=0.15), normative beliefs (β=0.21) and salience of the behavior (β=0.25).
The significant predictors for nurses’ intentions to administer opioids when there was a
dosage stipulation include salience (β=0.12) and normative beliefs (β=0.19). Finally, the
significant predictors that had a direct effect on intention when there was a time
stipulation are salience (β=0.11) and self-efficacy (β=0.12.)
Results from this study showed that while nearly all nurses intended to administer
PRN opioids for pain relief, the predictors of their intentions varied when there were time
and dosage stipulations. The study showed that the IBM constructs are useful for
predicting intentions towards performance of a professional behavior. The inclusion of
self-efficacy, underlying beliefs, and salience of the behavior were new and unique
contributions for this study to the existing body of knowledge.
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Dedication
This dissertation is dedicated to my friends and family, especially Wayne, Mariska, and
Benjamin. Thank you for your prayers and loving support throughout this process.

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Acknowledgments
I would like to express my sincere gratitude to my dissertation chair, Dr. Jiunn-
Jye Sheu, for your assistance and guidance with this dissertation. I appreciate the
countless hours that Dr. Sheu spent meeting with me sharing his knowledge and
expertise. I am extremely grateful for the time and effort you expended in order to get
this dissertation completed. Your patience and calmness served as motivators and
encouragement to persist to the finish line.
Thank you, Dr. Dake for your support throughout this journey. I am grateful for
the opportunity to learn from you, and for the excellent feedback that you provided
throughout this process.
Thank you, Dr. Glassman for sharing your expertise and knowledge about the
Integrated Behavioral Model for this study. Thanks for your revisions and comments,
which made this dissertation stronger.
Thank you, Dr. Chen for sharing your knowledge of nursing and nursing research
for this project. I grew from your insight and experience as a nurse researcher. This
study was strengthened by your thoughtful input.
Thanks to the faculty in the Department of Health and Recreation professions for
your knowledge and enthusiasm about health education. Thank you, Dr. Jordan for
always encouraging me and for sharing your knowledge of health behavior theories so
freely. Thanks to my colleagues in the College of Nursing for your support, and for
making nursing research a priority. Thanks Roni, Mariska, Wayne and others for all the
technical assistance that you provided to me. I would not have been able to complete this
dissertation without your help.
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Table of Contents

Abstract ..........................................................................................................iii
Dedication ………………………………………………………………….v
Acknowledgments..........................................................................................vi
Table of Contents ...........................................................................................vii
List of Tables .................................................................................................xi
List of Figures ................................................................................................xiii
1 Introduction .......................................................................................... 1
1.1 Theoretical Framework ................................................................. 7
1.2 Statement of the Purpose .............................................................. 8
1.3 Research Questions and Hypotheses .................................................8
1.4 Definition of Terms..................................................................... 12
1.5 Delimitations ............................................................................... 14
1.6 Limitations .................................................................................. 15
1.7 Summary ..................................................................................... 15
2 Literature Review............................................................................... 16
2.1 Overview of Pain ......................................................................... 16
2.2 Classification of Pain .................................................................. 17
2.3 Prevalence of Pain ....................................................................... 20
2.4 Prevalence of Musculoskeletal Disease and Musculoskeletal
Pain ................................................................................................... 23
2.5 Impact of Pain on Society and Individuals .................................. 27
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2.5 Impact of Musculoskeletal Conditions on Society ..................... 27
2.6 Orthopedic Surgery ..................................................................... 30
2.7 Postoperative Pain Control for Hospitalized Orthopedic
Patients ......................................................................................... 31
2.8 Barriers to Pain Control in the Acute Care Setting ..................... 34
2.9 Patient Related Barriers to Pain Management ............................. 34
2.10 Provider Related Barriers to Pain Management....................... 36
2.11 Institutional Related Barriers to Pain Management…………..37
2.12 The Integrated Behavioral Model .............................................. 40
2.12 Nurses’ Intention to Administer Opioid Medications for Pain .. 44
2.13 Nurses’ Self-Efficacy Studies .................................................... 47
3 Methods ............................................................................................. 52
3.1 Research Design .......................................................................... 52
3.2 Participants .................................................................................. 52
3.3 Research Instruments .................................................................. 54
3.4 Protection of Human Rights ........................................................ 59
3.5 Data Collection ........................................................................... 60
3.6 Data Analysis .............................................................................. 61
3.7 Summary ..................................................................................... 61
4 Results ............................................................................................... 63
4.1 Sample.......................................................................................... 63
4.2 Research Question 1 .................................................................... 63
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4.3 Descriptive statistics .................................................................... 63
4.4 Validity ........................................................................................ 69
4.5 Reliability ..................................................................................... 75
4.6 Research Question 2 .................................................................. 104
4.7 Research Question 3 .................................................................. 107
4.8 Research Question 4 .................................................................. 108
4.9 Research Question 5 .................................................................. 110
4.10 Research Question 6 ................................................................ 111
4.11 Research Question 7 ................................................................ 112
4.12 Research Question 8 ................................................................ 113
4.13 Research Question 9 ................................................................ 115
4.14 Research Question 10 .............................................................. 120
4.15 Summary .................................................................................. 126
5 Discussion, Recommendations & Conclusions ............................... 130
5.1 Overview of the Study ............................................................... 130
5.2 Discussion of findings................................................................ 148
5.3 Summary of Limitations ............................................................ 156
5.4 Implications for Nursing Research ............................................ 158
5.5 Implications for Health Behavior Research ............................... 159
5.6 Implications for Health Education ............................................. 161
5.7 Recommendations for Future Research ..................................... 162
References .................................................................................................... 164
Appendices ................................................................................................... 176
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A Permission letter to use Nursing Self-efficacy Scale .......................... 176
B. Permission to use Pain Management Survey ..................................... 177
C. Original Nursing Self-efficacy Scale ................................................. 178
D. Original Pain Management Survey .................................................... 179
E. The first IRB approval letter............................................................... 183
F. The second IRB approval letter .......................................................... 184
G. The third IRB approval letter ............................................................. 185
H. The first IRB approved research instrument ...................................... 186
I. The second and final IRB approved research instrument ................... 190
J. IRB approved cover letter to nurses in the pilot testing ..................... 194
K. IRB approved cover letter to nurses in the main study ...................... 195
L. IRB approved post card notification to participants ........................... 197

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