Nurses' Knowledge, Attitudes, and Practice Patterns Regarding Titration of Opioid Infusions at the End of Life:

Impact of a Nurse-Driven Opioid Titration Protocol on Quality of Orders at End of Life

At our community teaching hospital, orders for end of life often lacked instructions to titrate opioids based on evidence-based principles and failed to address nonpain symptoms. An order set and a nursing-driven opioid titration protocol were implemented in August 2016 after extensive education. The purpose of this retrospective preintervention and postintervention study was to evaluate the impact of this intervention on the quality of end-of-life orders. We evaluated 69 patients with terminal illness receiving morphine infusions. After implementation, more morphine infusion orders included an as-needed bolus dose with an objective indication and appropriate instructions on when and how to titrate the infusion compared with before the intervention (94.6% vs 18.8%, P < .0001). Morphine infusion orders were also significantly more likely to include a maximum dose (P = .041) and an initial bolus dose (P < .0001). In addition, prescribers were more likely to order additional medications to manage nausea/vomiting, constipation, anxiety, or pain using a nonopioid (P < .05 for all). In this study, implementation of a standardized opioid titration protocol and symptom management order set led to an improvement in the quality of morphine infusion orders for pain management at the end of life and increased the use of medications to manage nonpain symptoms in dying patients.

Educating Nurses on the Use of the Clinical Opiate Withdrawal Scale to Improve Care of Adult Patients Undergoing Buprenorphine Induction

INTRODUCTION

Opioid addiction disease has become a global health and social problem complicated by drug misuse and abuse (Pearlman, 2016; Rettig & Yarmolinsky, 1995; Watkins, 2016). Buprenorphine, a partial opioid agonist, is an effective treatment for opioid addiction disease (Loreck et al., 2016). Its induction can trigger severe precipitated withdrawal in opioid-dependent patients whose mu receptors are occupied opioids (American Society of Addiction Medicine, 2015). Knowledge of assessing a patient's level of withdrawal using a validated tool is key to successful transition from other opioids to buprenorphine.

AIM

The aim of this study was to evaluate the effectiveness of training nurses on the use of the Clinical Opioid Withdrawal Scale (COWS) screening instrument by assessing their confidence in assessing and satisfaction with communicating withdrawal information crucial for patient safety.

METHOD

Ten registered nurses and three nurse practitioners working at a mental health community service center completed two surveys at three time points (Pre, Post, and Post-90 days). The first survey measured nurses' confidence in assessing, whereas the second survey measured their satisfaction with communicating withdrawal symptoms.

RESULTS

The means' (M) magnitude for both assessment and satisfaction scores increased with time (across Pre, Post, and Post-90). Standard deviations tended to become smaller. Improvements were noted in nurses' confidence in the assessment of and satisfaction in communicating withdrawal symptoms after the intervention.

CONCLUSION

Participants expressed increased knowledge, confidence, and satisfaction with the COWS screening instrument. Ultimately, the patients benefited from the participants having more experience, education, skills, and confidence in monitoring withdrawal symptoms depicted by aggregate data of COWS screenings postintervention.

Using Opioids With Surgical Patients: Nurses' Attitudes and Experiences

Opioids such as morphine are effective analgesics and have been recognized worldwide for many years; yet, they are underutilized. The study explores the attitudes and experiences relating to opioids, in general, and morphine, in particular, among Jordanian surgical nurses. The Opioids Attitudes Scale was used. A total of 123 questionnaires were distributed, and 120 were returned, achieving a response rate of 96%. Focus group discussions (n = 4) were conducted with surgical nurses (n = 34). The majority of nurses believe that the addiction is the most serious side effects of opioids. Qualitative analysis revealed 2 major themes. The first theme was referred to as "not being in the same boat," highlighting a lack of teamwork, and comprised 2 subthemes: blame culture and physicians versus nurses. The second "morphine as the last on the list" was also made up of 2 subthemes: the lack of confidence and the fear of legal persecution. Nurses showed negative attitudes and misconceptions about opioids and morphine use within a fragmented surgical unit culture. Therefore, serious efforts must be made to create and sustain an effective unit culture reform and communications path from patient to nurse and doctor.