| | Addressing Patients' Concerns about Pain Management and Addiction RisksReceived 2 June 2008; received in revised form 22 February 2009; accepted 31 March 2009. published online 14 September 2009. 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 (National Consensus Project for Quality Palliative Care, 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. Methods  Study Sites and Participants 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. Design and Survey 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 α = 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 α =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 α =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). Analysis 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 p ≤ .05 for all analyses. Analyses were conducted using SPSS version 15.0. Results 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 (χ2=16.063; p < .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.  | Environmental Variable | | | “Peers regard pain assessment as important” | | | Strongly agree or agree | 121 (83.4%) | | | Neutral or disagree | 24 (16.6%) | | | Personal Variables | | | Confidence Scale | 12.9 (2.3, 5-16)∗ | | | Negative Pain Belief Scale | 8.9 (3.3, 0-16)∗ | | | Pain/Palliative Care Educational Scale | 6.0 (5.3, 0-28)∗ | | | Years' experience | 18.9 (11.3, 1-48)∗ | | | Professional role | | | RN | 55 (37.9%) | | | Health Technician | 17 (11.7%) | | | Licensed Vocational Nurse | 73 (50.3%) | | | | |
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; p=.004). Furthermore, nursing staff with more clinical experience (OR=1.070; p=.002) and higher levels of confidence (OR=1.380; p=.001), were more likely to engage in discussions of addiction risk and pain management. Discussion 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, Wisdom at Work: The Importance of the Older and Experienced Nurse in the Workplace (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). Conclusions 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. Acknowledgments The authors acknowledge the suggestions of the editor, reviewers, and Lisa Zubkoff, PhD, who greatly enhanced the clarity of the manuscript. References Bandura, 1994. 1.Bandura A. Self-efficacy. In: Ramachaudran V editors. Encyclopedia of human behavior. Vol. 4:New York: Academic Press; 1994;p. 71–81. Bookbinder et al., 1996. 2.Bookbinder M, Coyle N, Kiss M, Goldstein ML, Holritz K, Thaler H, et al. Implementing national standards for cancer pain management: Program model and evaluation. Journal of Pain and Symptom Management. 1996;12(6):334–347. Abstract |
Full-Text PDF (924 KB)
|
CrossRef
Brockopp et al., 2003. 3.Brockopp D, Ryan P, Warden S. Nurses' willingness to manage the pain of specific groups of patients. British Journal of Nursing. 2003;12(7):409–415. MEDLINE Brockopp et al., 2004. 4.Brockopp DY, Downey E, Powers P, Vanderveer B, Warden S, Ryan P, et al. Nurses' clinical decision-making regarding the management of pain. International Journal of Nursing Studies. 2004;41(6):631–636. Abstract | Full Text |
Full-Text PDF (197 KB)
|
CrossRef
National Consensus Project for Quality Care, 2009. 5.National Consensus Project for Quality Care (2009). Clinical practice guide lines for quality palliative care, Second edition. Pittsburgh, PA. Retrieved May 13, 2009, from: http://www.nationalconsensusproject.org. Dudley and Holm, 1984. 6.Dudley SR, Holm K. Assessment of the pain experience in relation to selected nurse characteristics. Pain. 1984;18(2):179–186. Abstract |
Full-Text PDF (638 KB)
|
CrossRef
Eccles et al., 2007. 7.Eccles M, Grimshaw J, Johnston M, Steen N, Pitts N, Thomas R, et al. Applying psychological theories to evidence-based clinical practice: Identifying factors predictive of managing upper respiratory tract infections without antibiotics. Implementation Science. 2007;2(1):26. Edlund et al., 2007. 8.Edlund MJ, Steffick D, Hudson T, Harris KM, Sullivan M. Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic noncancer pain. Pain. 2007;129(3):355–362. Abstract | Full Text |
Full-Text PDF (112 KB)
|
CrossRef
Ferrell and McCaffery, 2005. 9.Ferrell B, McCaffery M. Pain assessment and analgesic use survey. Duarte: City of Hope; 2005;. Fishman, 2005. 10.Fishman S. Opioid side effects, addiction, and antiinflammatory medications. Journal of Pain & Palliative Care Pharmacotherapy. 2005;19(1):51–55. MEDLINE |
CrossRef
Fleming et al., 2007. 11.Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. The Journal of Pain. 2007;8(7):573–582. Abstract | Full Text |
Full-Text PDF (138 KB)
|
CrossRef
Florin et al., 2005. 12.Florin J, Ehrenberg A, Ehnfors M. Patients' and nurses' perceptions of nursing problems in an acute care setting. Journal of Advanced Nursing. 2005;51(2):140–149. MEDLINE |
CrossRef
Glajchen, 2001. 13.Glajchen M. Chronic pain: Treatment barriers and strategies for clinical practice. The Journal of the American Board of Family Practice. 2001;14(3):211–218. MEDLINE Glajchen and Bookbinder, 2001. 14.Glajchen M, Bookbinder M. Knowledge and perceived competence of home care nurses in pain management: A national survey. Journal of Pain and Symptom Management. 2001;21(4):307–316. Abstract | Full Text |
Full-Text PDF (324 KB)
|
CrossRef
Hatcher et al., 2006. 15.Hatcher B, Bleich M, Connolly C, Davis K, O'Neill Hewlett P, Stokley Hill K. Wisdom at work: The importance of the older and experienced nurse in the workplace. Princeton, NJ: Robert Wood Johnson Foundation; 2006;. Higginson et al., 2007. 16.Higginson, I., Shipman, C., Gysels, M., White, P., Barclay, S., Forrest, S., Worth, A. Murray, S., Shepherd, J., Dale, J., Dewar, S., Peters, M., White, S., Richardson, A., Hotopf, M., Lorenz, K., & Koffman, J. (2007). Scoping exercise on generalist services for adults at the end of life: Research, knowledge, policy, and future research needs: Report 1—Overview and recommendations for future research in generalist end of life care. London: NHS Service Delivery and Organization R&D Program. Ives et al., 2006. 17.Ives T, Chelminski P, Hammett-Stabler C, Malone R, Perhac JS, Potisek N, et al. Predictors of opioid misuse in patients with chronic pain: A prospective cohort study. BMC Health Services Research. 2006;6(1):46. MEDLINE |
CrossRef
Kumar, 2007. 18.Kumar, N. (2007). WHO normative guidelines on pain management, report of a Delphi study to determine the need for guidelines and to identify the number and topics of guidelines that should be developed by WHO. Retrieved May 16, 2009 from World Health Organization Web site: http://www.who.int/medicines/areas/quality_safety/delphi_study_pain_guidelines.pdf. Manchikanti et al., 2007. 19.Manchikanti L, Giordano J, Boswell M, Fellows BRM, Pampati V. Psychological factors as predictors of opioid abuse and illicit drug use in chronic pain patients. Journal of Opioid Management. 2007;3(2):89–100. MEDLINE Manias et al., 2005. 20.Manias E, Bucknall T, Botti M. Nurses' strategies for managing pain in the postoperative setting. Pain Management Nursing. 2005;6(1):18–29. Abstract | Full Text |
Full-Text PDF (152 KB)
|
CrossRef
McCaffery and Pasero, 1999. 21.McCaffery M, Pasero C. Pain: Clinical manual. St. Louis: Mosby; 1999;. McCaffrey and Ferrell, 1997. 22.McCaffrey M, Ferrell BR. Nurses' knowledge of pain assessment and management: How much progress have we made?. Journal of Pain and Symptom Management. 1997;14(3):175–188. Abstract |
Full-Text PDF (1208 KB)
|
CrossRef
Meredith et al., 2000. 23.Meredith LS, Jackson-Triche M, Duan N, Rubenstein LV, Camp P, Wells KB. Quality improvement for depression enhances long-term treatment knowledge for primary care clinicians. Journal of General Internal Medicine. 2000;15(12):868–877. MEDLINE |
CrossRef
Morgan, 2006. 24.Morgan BD. Knowing how to play the game: Hospitalized substance abusers' strategies for obtaining pain relief. Pain Management Nursing. 2006;7(1):31–41. Abstract | Full Text |
Full-Text PDF (180 KB)
|
CrossRef
Mularski et al., 2006. 25.Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. Journal of General Internal Medicine. 2006;21(6):607–612.
CrossRef
Peabody et al., 2000. 26.Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M. Comparison of vignettes, standardized patients, and chart abstraction: A prospective validation study of 3 methods for measuring quality. Journal of the American Medical Association. 2000;283(13):1715–1722. MEDLINE |
CrossRef
Peabody et al., 2004. 27.Peabody JW, Luck J, Glassman P, Jain S, Hansen J, Spell M, et al. Measuring the quality of physician practice by using clinical vignettes: A prospective validation study. Annals of Internal Medicine. 2004;141(10):771–780. Pearson, 2005. 28.Pearson R. Mining imperfect data: Dealing with contamination and incomplete records. Philadelphia: SIAM; 2005;. Stieger, D.M. et al, 2006. 29.Stieger, D.M., Bausch, S., Johnson, B., & Peterson, A., (2006). The Registered Nurse Population Findings from the March 2004 National Sample Survey of Registered Nurses. US Department of Health and Human Services Association (HRSA) Bureau of Health Professions. Retrieved May 16, 2009 from: ftp://ftp.hrsa.gov/bhpr/workforce/0306rnss.pdf. Randall-David et al., 2003. 30.Randall-David E, Wright J, Porterfield D, Lesser G. Barriers to cancer pain management: Home-health and hospice nurses and patients. Supportive Care in Cancer. 2003;11(10):660–665. MEDLINE |
CrossRef
Russell et al., 2004. 31.Russell D, Rix SE, Brown SK. Staying ahead of the curve 2004: Employer best practices for mature workers. Washington, DC: AARP; 2004;. Sullivan and Ferrell, 2005. 32.Sullivan M, Ferrell B. Ethical challenges in the management of chronic nonmalignant pain: Negotiating through the cloud of doubt. The Journal of Pain. 2005;6(1):2–9. Abstract | Full Text |
Full-Text PDF (113 KB)
|
CrossRef
Seago JA, et al, 2004. 33.Seago, J.A., Spetz, J.,Chapman, S., Dyer, W., & Grumbach, K., (2004). Supply, Demand, and use of licensed practical nurses. National Center for Health Workforce Analysis. US Department of Health and Human Services Health Resources Service Association (HRSA) Bureau of Health Professions. Retrieved May 13, 2009 from: http://bhpr.hrsa.gov/healthworkforce/reports/lpn/LPN1_5.htm. Timming et al., 2009. 34.Timming, R., Daniels, S., Hooten, W., Bonte, B., von Weiss, D., Ferron, S., Smith, J., Belgrade, M., (2008). Assessment and management of chronic pain. Institute for Clinical Systems Improvement (ICSI). Retrieved Feburary 5, 2009 from: http://www.guideline.gov/summary/summary.aspx?doc_id=12998&nbr=006693&string=pain+AND+management. Vallerand et al., 2004. 35.Vallerand A, Hasenau S, Templin T. Barriers to pain management by home care nurses. Home Healthcare Nurse. 2004;22(12):831–838. Weiner and Rudy, 2002. 36.Weiner DK, Rudy TE. Attitudinal barriers to effective treatment of persistent pain in nursing home residents. Journal of the American Geriatrics Society. 2002;50(12):2035–2040. MEDLINE |
CrossRef
Wilson and McSherry, 2006. 37.Wilson B, McSherry W. A study of nurses' inferences of patients' physical pain. Journal of Clinical Nursing. 2006;15(4):459–468. MEDLINE |
CrossRef
∗ Department of Nursing, California State University, Long Beach, California † RAND Corporation, Santa Monica, California ‡ David Geffen School of Medicine at University of California, Los Angeles, California § Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, California  Address correspondence to Joy R. Goebel, RN, PhD, Department of Nursing, California State University 1250 Bellflower Blvd., Long Beach, CA 90840-0201.
PII: S1524-9042(09)00038-1 doi:10.1016/j.pmn.2009.03.009 © 2010 American Society for Pain Management Nursing. All rights reserved. | |
|
FULL TEXT