title: Nurses and opioids: results of a bi-national survey on mental models regarding opioid administration in hospitals.
abstract: OBJECTIVE
  Pain remains insufficiently treated in hospitals. Increasing evidence suggests human factors contribute to this, due to nurses failing to administer opioids. This behavior might be the consequence of nurses' mental models about opioids. As personal experience and conceptions shape these models, the aim of this prospective survey was to identify model-influencing factors.
  
  
  METHODS
  A questionnaire was developed comprising of 14 statements concerning ideations about opioids and seven questions concerning demographics, indicators of adult learning, and strength of religious beliefs. Latent variables that may underlie nurses' mental models were identified using undirected graphical dependence models. Representative items of latent variables were employed for ordinal regression analysis. Questionnaires were distributed to 1,379 nurses in two London, UK, hospitals (n=580) and one German (n=799) hospital between September 2014 and February 2015.
  
  
  RESULTS
  A total of 511 (37.1%) questionnaires were returned. Mean (standard deviation) age of participants were 37 (11) years; 83.5% participants were female; 45.2% worked in critical care; and 51.5% had more than 10 years experience. Of the nurses, 84% were not scared of opioids, 87% did not regard opioids as drugs to help patients die, and 72% did not view them as drugs of abuse. More English (41%) than German (28%) nurses were afraid of criminal investigations and were constantly aware of side effects (UK, 94%; Germany, 38%) when using opioids. Four latent variables were identified which likely influence nurses' mental models: "conscious decision-making"; "medication-related fears"; "practice-based observations"; and "risk assessment". They were predicted by strength of religious beliefs and indicators of informal learning such as experience but not by indicators of formal learning such as conference attendance.
  
  
  CONCLUSIONS
  Nurses in both countries employ analytical and affective mental models when administering the opioids and seem to learn from experience rather than from formal teaching. Additionally, some attitudes and emotions towards opioids are likely the result of nurses' cultural background.
authors.affiliation: Pain Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Guest
authors.affiliation: Division of Epidemiology and Biometry, Department of Health Services Research, Faculty 6, Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany.
authors.forename: Fabian
authors.initials: F
authors.lastname: Sobotka
authors.affiliation: Pain Service, Barts Health, St Bartholomew's Hospital, London, UK.
authors.forename: Athina
authors.initials: A
authors.lastname: Karavasopoulou
authors.affiliation: Pain Service, Barts Health, St Bartholomew's Hospital, London, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Ward
authors.affiliation: Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Oldenburg University, Klinikum Oldenburg Campus, Oldenburg, Germany; Department of Surgery and Cancer, Anaesthetics Section, Imperial College London, Chelsea and Westminster Hospital Campus, London, UK.
authors.forename: Carsten
authors.initials: C
authors.lastname: Bantel
keywords: decision-making; mental models; nurses; opioids