But how do you feel about morphine, doctor?
Laycock H, Casely E, Bantel C.
Background
Pain in hospitals continues to be managed insufficiently(Hefand 2009). Causes are multifactorial,but includedoctors’ prescribing habits. The process of prescribingis influenced by the patient, traditions, guidelines and cost(Ljungberg 2007),but may also involve highly sophisticated learning and memory schemas,which generate certain concepts or values about specific therapies (Higgins 2005). Moderate and severe acute pain is commonly treated with opioids. Barriers leading to ineffective opioid prescribing include safety concerns and “fear” of addiction or abuse (Murnion 2010). However terminology used to describe these barriers appears to be similar to those associated with value judgments. Therefore, are value judgments a barrier in opioid prescribing and can they be modified? This study aims to evaluate if a dedicated teaching session on opioid use in acute pain improves newly qualified doctors confidence and reduces perceived difficulty in dealing with acute pain, whilst also altering individual value judgments regarding morphine.
Method
Newly qualified doctors completed questionnaires before and after a teaching session. The teaching session was Consultant led and focused on intravenous morphine use in severe acute pain. It included a video based clinical scenario, tips on opioid use, complications, side effects and time for questions.
The questionnaire included a written casedescribing a patient in severe acute pain requiring immediate management. Doctors then evaluatedconfidence and case difficulty by marking on 100mm visual analogue scales (VAS) anchored with easy / difficult and unconfident / confident. A further two pages were headed with either 30mg morphine or 1g paracetamol, with ten 100mm VAS scales underneath. Each VAS wasanchored with value judgment words with opposite meanings. 5 word pairs came from a junior doctor generated word database describing morphine and paracetamol. The remaining 5 word pairs were synonyms of the original pairs included to ensure inter-individual scoring validity.
Results
100% responder rate (n=18). Mean difficulty VAS scores changed by 20mm towards the “easy” anchor and the range of individual scores reduced by 30mm following teaching. All doctors scored the case easier to manage following teaching. Mean confidence VAS scores improved by 17mm following teaching and 94% of doctors had improved confidence following teaching irrespective of original confidence. Two VAS were removed from the value judgment section due to lack of scoring consistency. The remaining mean VASscores prior to teaching showed morphine scores trended towards potent, apprehensive, excessive and dangerous anchor words whereas paracetamol scores trended towards weak, unconcerned, inadequate and safe. All mean VAS scores following teaching were within a few millimeters of the pre teaching scores, except paracetamol,which scoredas increased risk following teaching.
Conclusion
Newly qualified doctors reported increased confidence and ease in dealing with an acute pain scenario, following a dedicated teaching session on opioid use in acute pain. This session focused on improving knowledge but this single educational intervention did not alter individual value judgments regarding morphine, they remained unchanged. This may indicate value judgments are not influenced by improved technical knowledge. Therefore if value judgments are important in influencing junior doctor prescribing of opioids, teaching needs to be focused on altering these aspects in addition to improving knowledge.
References
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