is patient-controlled analgesia controlled by the patient?

Per~mon S0277-9536(96)00056-1

Sot'. Sci. Med. Vol. 43. No. 7, pp. 1137-1143, 1996 Copyright ~ 1996 Elsevier Science Ltd

Printed in Great Britain. All rights reserved 0277-9536/96 $15.00 + 0.00

IS PATIENT-CONTROLLED ANALGESIA CONTROLLED BY THE PATIENT?

NElL TAYLOR, I G E O R G E M. HALL t and PETER SALMON 2.

'Department of Anaesthesia, St George's Hospital Medical School, Jenner Wing, Cranmer Terrace, London SWI7 ORE and -'Department of Clinical Psychology, University of Liverpool, Whelan Building,

PO Box 147, Liverpool L69 3BX, U.K.

Abstract--Using patient-controlled analgesia (PCA) after surgery, a patient can obtain pain-relieving injections of morphine without the direct involvement of a nurse or doctor. The present study was a response to the conventional view that patients value PCA because of the control which it affords them over their own treatment. Twenty-six patients underwent semi-structured interviews postoperatively, shortly after discontinuation of PCA. Responses were examined qualitatively to identify recurring themes in patients' experience of PCA. Negative as well as positive evaluation was found. PCA was only rarely described as a way of gaining control over analgesia and, in general, this was not valued. Instead, PCA was valued as a way to avoid the difficulty of disclosing pain or securing pain relief within the usual nurse-patient relationship. In turn, PCA strained the nurse-patient relationship where it impeded either the patient's or the nurse's wish for the nurse to take responsibility for pain relief. The results showed that the professionally and theoretically constructed concept of PCA as a method of self-control over pain is inconsistent with patients" experience of it. Copyright ,~ 1996 Elsevier Science Ltd

Key words--patient-controlled analgesia, control, pain, nurse-patient relationship

INTRODUCTION

The belief that responsibility for health rests with the individual appears to be growing in Western societies [1, 2]. Correspondingly, the principle that patients should influence their own treatment increasingly shapes delivery of health care [3, 4]. The scientific case for this rests on two bodies of empirically based theory. One states that when individuals feel in control of stressful events--such as those involved in health care-- their negative physiological and emotional impact is reduced [5-7]. The second is the view that choice of and control over treatment increases its acceptability and therefore improves patient compliance and satisfaction [8, 9]. There is, however, very little evidence about whether patients are willing to take control that is offered them, or about the ways in which they exercise such control.

A salient instance of self-control of health care is the use of patient-controlled analgesia (PCA). The essential principle is that the patient, by a simple action (pressing a button), injects a bolus of analgesic (typically morphine) through an indwelling intra- venous cannula. In principle, therefore, the patient can achieve analgesia within approximately 5 minutes of their decision to inject, without the intervention of nursing or medical staff. Delivery is monitored and controlled electronically to prevent the quantity of drug delivered from exceeding a preset safety level. The procedure is typically used for 2-3 days after

*Author for correspondence.

major surgery. Its use has become widespread because of the belief that it allows the patient to titrate analgesia to pain in a finer way than conventional administration of analgesia by the nurse, which cannot easily cope with the 10-fold variability in dose of analgesic necessary to control pain in all patients.

Compared with traditional analgesic regimes, PCA is associated with a large increase in patient satisfaction which cannot be readily attributed to the relatively small and variable improvement in analgesia which it produces [10-12]. The assumption has been that improved satisfaction reflects patients' preference to have control over their pain relief. This view is consistent with the prevailing attitude to patients' role in health care, and PCA is widely regarded as demonstrating the validity of that approach. However, there are no data with which to evaluate this view. Because of the increasing popularity of PCA in health care, and its theoretical importance in terms of patient control, it is important to find out how it is perceived by patients.

The aim of the present study was therefore to describe patients" perceptions of PCA. Quantification of patients' experience, such as by structured questionnaire, would be premature because it would assume that we know in advance the important components of patients experience of PCA. First, an account of the range of reactions that patients experience is needed. Our methodology was therefore to use exploratory interviews which allowed patients to express their experiences in their own terms. Our

1t37

1138 Neil Taylor et al.

content analysis of the resulting data was qualitative. The aim was, by categorizing and organizing the elements of patients' accounts, to produce a taxonomy of patients' experience based on themes that recur in their statements [13].

METHOD

Subjects

Twenty-six patients were approached at random at the rate of one/week over a 6-month period from those who had received PCA for postsurgical pain relief. All agreed to take part. Details are shown in Table I. Each patient was interviewed within 2 days after PCA had been discontinued. Patients had undergone major abdominal surgery with general anaesthesia. The PCA machine contained 50 mg morphine in 50 ml normal saline. It was programmed to deliver a bolus of I mg with a lockout time of 5min. The maximum dose (8-12mg/hr) was set according to each patient 's clinical condition, age and body weight. Patients were prescribed prochiorper- azine (12.5 mg i.-m.) or metoclopramide (10 mg i.-m. or orally) as rescue antiemetics. Diclofenac (100 mg) was also prescribed to be given as required either rectally or orally. The first dose was administered on completion of surgery (maximum dose: 150mg/ 24 hr). Each patient was instructed in the use of PCA by a single nursing sister of the pain team.

Procedure

Patients were interviewed individually in their hospital bed or in a private area of the ward. They were assured of the confidentiality of the interview and told that their comments would not be identified with their name and would not be revealed to those

caring for them. The interviewer first asked "How did you feel about your pain relief?.", then prompted the patient for their comments in the following areas: pain, side-effects, emotional state, the PCA machine and nursing care. The pace and sequencing of the interview depended on the patient: the interviewer encouraged patients to talk in their own way and avoided closed questions. Once this procedure was exhausted, and if the topic had not previously emerged, the interviewer asked the patient "Did you feel the PCA gave you any control over your pain?", then "Do you think this was important for you?". Further closed questions are not reported here. For each patient, the interviewer recorded, in the patients' own words, any statement which described a belief or opinion about PCA or an evaluation of it.

Once 16 interviews were complete, the comments were organized into categories. The only category that was specified in advance concerned control over pain. Otherwise the procedure followed established conventions for ensuring that the categories are "grounded" in the data rather than reflecting pre-existing ideas [13, 14]. First, a preliminary categorization by one author was based on careful reading and re-reading of the patients' statements. Then this was tested by a second author who attempted to fit the statements to the defined categories and was modified in the light of this. When "cycling" between data and analysis [15] appeared complete, four further interviews were carried out to test the categorization which was elaborated as a result. Six further interviews were carried out which did not require further elaboration of the analysis. In the results that follow, statements are presented which demonstrate the range and commonality of content of each category. Patient identification numbers are given for each statement.

Table 1. Details of interviewed patients. Only patient 18 had previously received PCA

Patient Age Sex Surgery I 49 F Abdominal hysterectomy 2 66 M Radical nephrectomy 3 45 F Abdominal hysterectomy 4 49 F Abdominal hysterectomy 5 76 M Laparatomy 6 43 F Abdominal hysterectomy 7 21 F Ovarian cystectomy 8 42 F Abdominal hysterectomy 9 54 F Colonic resection 10 53 F Vaginal hysterectomy I I 47 F Abdominal hysterectomy 12 48 F Abdominal hysterectomy 13 51 M Total hip replacement 14 50 F Abdominal hysterectomy 15 31 F Abdominal hysterectomy 16 59 M Laparatomy 17 65 F Laparatomy 18 50 M Total knee replacement 19 19 M Fractured pelvis 20 30 M Total hip replacement 21 45 F Abdominal hysterectomy 22 46 F Abdominal hysterectomy 23 26 F Thoracotomy 24 47 F Abdominal hysterectomy 25 45 F Abdominal hysterectomy 26 56 F Laparatomy

RESULTS

The patients" comments were divided into three main categories: (i) evaluation, (ii) interaction of PCA with the nurse-patient relationship and (iii) implications of PCA for control over pain.

Evaluative Comments

Positive evaluation

Many patients evaluated PCA in an unambiguous positive way: .fantastic (patient 10); really t,ery good (8); definitely a good idea (7); I can't recommend it highly enough... I f they cost £5000 each the)"re still worth it (2). The major specific benefit was clearly that it provided great pain relief (15) and it was very good.., did the trk'k when you used it (17). Patients differed, however, in the timing of analgesia. The report that I pressed when l.[elt the pain building up and, after a few minutes, it started to ease off a bit (4) is in line with known pharmacokinetics. Others, for

Patient-controlled analgesia 1139

Evaluation Positive Adequate analgesia \ .Advlmtao~ over Ke~ adfering

nursing care ~ t o onoeelf

\ \ \ \ \

Negative anal iaanadaquate i lUl~ I

Side-effects

Impact on nurse-patient relationship

Conflict with nurses

Nurse's helple~ne~ in face of patient's pain

Nurses take control of PCA

Fig. 1. Patients' accounts of PCA: summary of categories of statements concerning evaluation and the nurse-patient relationship.

whom relief was in seconds (I 5, 17) or for whom you press the button and the relief is almost instant (22) are describing a faster process. Relief of pain was not the only major benefit of PCA; it was also valued for the relief that it provided from the fear of pain. It's reassuring to be able to reach out and touch that button; gives you a safety margin (2). Knowing it was in my hand, knowing it was there and I could press it, it helped (16). For the majority of positive patients, however, enthusiasm for PCA reflected attitudes to the nursing care, considered below.

Negative evaluation

Evaluation was, however, not exclusively positive. Criticisms revolved around two problems. Comments such as I wasn't happy at all. I was in pain all the time. It didn't help at all... ( I I ) or A couple o f aspirins would have done as well... 1 don't think pressing the button made a halfpennyworth o f difference (5) show that PCA is not universally an effective analgesic regime. Poor analgesia did not simply reflect initial skepticism. 1 wasn't helped at all... No-one seemed able to help me. I thought it was a wonderful idea when they explained it, but it certainly did not live up to expectations (6). Neither can they be attributed to disenchantment with all analgesia, as critical patients compared traditional pain relief to PCA very favourably. Then l [elt all the pain drain away [after Volatorol suppository] and 1 stopped pressing the button (i I). The suppository had more effect than the pump and without the side-effects (14). This comment identifies a second major source of dissatisfaction: unpleasant side-effects. For a number of patients

these were sufficiently unpleasant to prompt very negative evaluation: severe problems (14). It made me .feel very sick and dizzy; people should be warned and given an ahernative (1 i).

The perceived inadequacy of paincontrol was not always associated with strong negative evaluation of PCA. It was evident in other comments, which described its failure in a more matter-of-fact or even tentative way. I kept pressing because I wanted to be pain .free, but I couldn't feel an)' effect (11). One patient observed that The machine kept beeping... nothing happened... Wasn't sure it was giving anything (6). Similarly, another pressed before 1 got out o f bed--don't know i f it did anything (1). In the same vein, another pressed before moving, but probabO' didn't wait long enough because I still had some pain (3). Others simply reported no relief (7) or that they didn't notice an), immediate effect (2, 3).

Other negative comments reflected the place of PCA in the nurse-patient relationship, considered below. The structure of evaluative comments is summarized in Fig. I.

Interaction o f PCA with Nursing Care

Perceptions of nursing ('are which determine positive evaluation of PCA

In general, benefits and demerits of PCA were dependent, not on intrinsic properties of the procedure, but on the patients' attitude to nursing care.

To keep suffering to onesel[~ A surprisingly pervasive theme was that PCA protected patients from having to call nurses. In its clearest manifes-


tation patients simply preferred privacy, especially when in pain or distress. Fd rather keep a bit of distance [from the nurses] (!). You just prefer to be left alone when you feel aaful (9). At times I'd rather just rest alone (I 2). In the extreme case, attention from the nurses was seen negatively. It's good not getting bugged all the time by the nurses (15).

To avoid bothering the nurses. For other patients, the value of not seeking help from the nurses was described differently. I hate being a nuisance to anyone you know (26). It's great that I didn't have to bother nurses; I wouldn't dream of bothering other people (4). I didn't have to bother anyone when I woke up in pain in the night (8). You feel embarrassed to call the nurse each time. This way, no-one knows you're in pain--you do it yourself(24). These comments do not describe a positive experience of privacy when suffering. Instead, they suggest a need to avoid the discomfiture attached to seeking help or displaying dependence.

To reduce the nurses' load. A third type of value that was attached to not having to call the nurses was in terms, not of avoiding the patients' discomfiture at seeking help, but of easing the nurses' workload. The nurses have enough to do; it saves them time (17). It was good not to have to call the nurse--frees them up for other things (14). I know they've a real problem with staff shortage here, so I wouldn't want to disturb them (12). Such statements are a common obser- vation in hospital wards, often including the suggestion that other patients are in more need than oneself.

PCA better than inadequate nursing care. Many patients made it explicit that PCA was evaluated positively because of the perceived inadequacy of nursing care. PCA provided a way of circumventing the suffering that results to a patient in pain because of lengthy response time by nurses. To some extent this was seen as inescapable--You're not relying on other people... It's better than having to call nurse, who then has to go and get the drug, then give the injection (2)--or excusable--Nurses are ridiculously busy... they do their best .... but it means you won't suffer if they can't get to you (3). However, criticism was implicit also. When you call sometimes no-one comes. I f you have to have a nurse to attend you sometimes you never get the attention, but this is very good--you do it yourself(24). Waiting 5 minutes to press the button again is better than waiting.for the doctor or nurse to come (15). It's a lot less hassle than having to call a nurse (1).

Impact of PCA on nurse-patient relationship

The removal of pain control from the nurses' authority and competence confused some patients' experience of the nurse-patient relationship. One patient.felt a bit guilty really that I was doing them out of a job (15). Serious conflicts arose where the patient felt that PCA was inadequate or ineffective. They kept saying to press the button [in recovery] but i couldn't

.feel it working. I was in terrible pain the first night...I wasn't taken seriously when I said I was in pain. I said the machine wasn't working and they should give me something different and the nurses just told me the machine was working and tom me to keep pressing (1 I). In this instance, PCA has clearly disrupted the basis of the nurse-patient relationship. Although the patient regards her pain as within her nurses' responsibility, they have ceded responsibility to the machine. The resulting loss of the nurses' competence to exercise what one patient sees as the nursing role was made explicit. There didn't seem to be any communication between the pain team and the nurses and that made me a little bit angry (I). For other patients, the result was helplessness rather than conflict: the nurses were seen as helpless in the face of the mystery of the machine and the patient as helpless in the face of nurses' own inability to intervene.This was described by two patients for whom the PCA machine malfunctioned. Nurses felt they couldn't do anything--they said it was working ,'hen it wasn't. Nurses didn't have enough knowledge of the machine and that's a bad thing People didn't believe me that the pump wasn't working. No-one seemed to be able to help (6). The only disadvantage is it bleeps by itself every 5 minutes. That's the only snag. So the nurse keeps coming in in a bad temper. They have to call another nurse and so on to come and see. (24).

It was, however, possible for PCA to remain, in both the patient's and nurse's view, within the nurse's responsibility. When the machine broke down I knew the nurses were here and that the)' would sort it out you know (26). [I injected] ,'hen the)' said press it a couple of times before the), ,'ere going to do something (23). I was told, even if you don't feel the pain, press--so that's what I did, even though I had no pain. It heals quicker (24). These patients clearly accepted the nurse's claim to control PCA as overriding their own. Statements concerning the nurse-patient relationship are summarized in Fig. i.

Control Over Analgesia

Indiff'erence

All but one patient failed to comment on the value of being in control of pain relief until explicitly asked by the interviewer. Once prompted, the typical response was that control was not an issue. I don't think it's particularly important (20). When you're in pain you don't care whether you're in control (3).

Statements of control afforded by PCA

Feeling of control over analgesia. One patient spontaneously observed that it was there when I wanted it. It was there on demand. 1 ,'as in control of my pain (I 8). Clear feelings of control over analgesia emerged from two further patients, but only when asked. Yes, l.[elt in control without a doubt (16). 1 think it's much better when you can control things


yourself. I always worry you're going to get addicted. The main advantage is that I would suit myself. You don't sit there watching the clock. You please yoursel.f--(f you don't need it you don't have to have it (26). However, this patient also commented that I hate being a nuisance, you know (26).

Reiteration o f professional assumptions. The re- maining positive comments that were made about control over analgesia frequently and transparently reflected the patient's briefing rather than their own experience: You are in control--that's the idea o f it isn't it? (22). Although a second patient stated that It's a good idea to control pain yourself, when later asked explicitly about control, she added It's not an issue (I).

More control over analgesia than over unresponsive nurses. The major way in which patients expressed positive views about the control which PCA gave them was by comparing it favourably to their ability to control nurses. 1 didn't want to worry the nurses. It 's better psychologically than relying on the nurse (22). Other comments were more critical. Only you know what your pain's l ike--you might not have pain when nurses ask, but it might come back as soon as the)' go (17). You've more control than having to wait 20 minutes .for the nurse after you call her--by then you've suffered 20 minutes of pain which could have gone away by the time she comes (7). You have to wait longer for pain relief when you call the nurses (10).

Restrictions to control over analgesia

The majority of comments about control over analgesia described the lack of control which PCA afforded patients.

Pharmacological and feared side-fffects. For many patients, their scope for controlling pain by PCA was restricted by the need to titrate analgesia against side-effects, particularly nausea. 1 .felt 1 had some control, but only to a point because I'd.feel sick i f I pressed it too much (12). I thought, I 'm not going to press it because I'll be sick (25). Another patient described being in control of analgesia, but used the term in a more qualified way than professional views of PCA would imply. After [the first day] l f e h very much in control. I started experimenting with the dose to see how much I could give myself without feeling sick (I 4). For other patients, freedom to control analgesia was restricted, not by the experience of negative effects of PCA, but by their fears of the effects of its "over-use" which were sometimes explicit--(/ was afraid o f becoming addicted (12); 1 was worried... I don't want to get addicted (19))---but often diffuse or unspecified--I held off once because ! thought I might have been pressing too qften (4).

Machine limits. Practical limitations of the machine were seen as definite or threatened restrictions on the patient's ability to control their analgesia. For one patient, these were reassuring, lt 's regulated, so you can't go mad with it (13). More commonly, these restrictions were a source of concern. The nurses said

there's only 2 ml left, so I was worried I might not get enough morphine. Not getting enough might make the cancer worse (I 7). You're only in control so far. It gives you a dose ever), 5 minutes. I f you were in really bad pain, you'd have to ask for extra pain-killers, wouldn't you? (23). Other patients described their reluctance to inject for fear of "using up" the analgesic.

Dependence on experts. More commonly, patients' feelings of control over analgesia were limited by their knowledge that correct function of the machine depended on experts. This could be a source of anxiety rather than reassurance. As a nurse 1 was worried about safeO,. I knew there was a staff shortage and prayed the right nurse had set it up right (12). A worrying aspect was a dif~culty the nurses had in determining how much had been used... It gave me a .feeling o f insecurity. I was told you can't overdose or give too much, but I 'm an engineer (18). As a result, acceptance of PCA reflects, not necessarily the acceptance of a controlling role but, more conventionally, a passive acceptance of hospital staff's instructions. I f people are genuine, seem to know their job and say the), know what's best for me, I'll take their word (2). I 'm someone who is easy for the nurses. I f the)' want to give me something 1 take it. I f it wasn't good.for me, they wouldn't give it to me (25). You have to trust that the), know what's best for you [17]. Lack of control over the decision to use PCA and over the way it was set up was more explicit where such powerlessness was resented rather than accepted. It made me very sick and dizzy. People should be warned and given an alternative (11 ).

Autonomy o f the machine. The properties of the machine which restricted control over it were not always specified. A patient who had experienced poor analgesia stated that I don't think I had an)' control. 1 didn't trust the machine to give me anything (6). Reference to a machine as "untrustworthy" in its "giving" of analgesia implies autonomy which might oppose attempts to control it. Statements concerning control over analgesia are summarized in Fig. 2.

DISCUSSION

PCA has been viewed professionally as a way of giving acute pain patients control over their own pain relief and it has been assumed that patient satisfaction with the procedure reflects positive experience of this control [10]. This view must be revised in light of our results, which provide the first systematic description of how PCA is, in practice, perceived by patients who receive it in a conventional postoperative regimen including the availability of non-steroidal anti-inflammatory drugs and antiemetics.

As expected, many patients valued PCA for its analgesic effects. However, the immediate benefit reported by some indicates a placebo effect rather than a pharmacological one (which would be


expected in minutes rather than seconds). Moreover, some patients perceived more benefit from traditional analgesic regimes. Furthermore, it can no longer be assumed that patients' experience of PCA is consistently positive. Negative experiences were reported also. These were related, for some patients, to perceived ineffectiveness and, for others, to its side- effects, particularly nausea. Therefore the first major implication of this study is to show that the conventional view of PCA as a positive experience does not adequately cover the range of patients' perceptions. The second component of the professional view which is inconsistent with our results is the importance of PCA as a vehicle for providing control over pain-relief. Only one patient referred to the control afforded by PCA before being explicitly prompted and, once prompted, indifference was the major theme. Although some patients expressed their indifference explicitly, for others it was implicit in the way that their comments merely echoed what they had been told. Although health care is increasingly guided by the presumption that patients desire control over it, and despite the pivotal nature of the concept of control in current theory in health psychology, the present results show that control is not necessarily perceived as a salient or positive dimension of health care.

Furthermore, our results indicate logical problems with the concept of control as applied to PCA. First, control over analgesia was complicated by the reality that the object of control was often not pain-relief, but the titration of analgesia against side-effects or against the imagined consequences of

"over-use" which PCA clearly shares with conventional analgesia [16]. Secondly, the experience of control over analgesia was restricted also by perceived intrinsic properties of the PCA machine. There was awareness that the machine was programmed to restrict its use, and there were fears that its finite contents might be used up by frequent use. Some comments reflected a view of it as an autonomous object, with a mind of its own. In this respect, the PCA machine shares the mystery that other complex, electronically controlled machines hold for many individuals in ordinary life. For other patients, the machine's power was not autonomous, but derived from the experts that had set it up. In this way, PCA can be seen to represent, not the taking of control over one's own treatment, but a passive acceptance of a machine's autonomy or experts' authority. Therefore, when tested against patients' experience of PCA, the concept of control appears flawed and contradictory.

Our analysis of PCA is consistent with existing evidence that patients prefer responsibility for their analgesia to rest with doctors or nurses [16, 17]. Therefore, by contrast with the conventional view that patients seek control over health care which professionals aim to retain, our results support the opposite view: that patients resist attempts by professionals to divest themselves of control for their patients' wellbeing [17]. At least as applied to analgesia, the concept of "control" may therefore more accurately be seen as a professional and theoretical construction than as a dimension of patients' experience.

control over analgesia

Experience of Indifference

Statements of control ~ Feeling of control

Reiteration of profeuional assumptions

Greater control than over unresponsive nurses

Restrictions to control

Feared Machine l imits

Autonomy of the machine Fig. 2. Patients' accounts of PCA: summary of categories of statement concerning control over analgesia.


To the extent that control over pain-relief was described, it was not as the irreducible manifestation of personal autonomy but merely as a method of analgesia preferable to the nursing care that provided the alternative. A further major implication of our results is therefore to show that the experience of PCA cannot be understood except in the context of the experience of nursing care. Its value was contingent, in large measure, on patients' negative attitude to analgesia administered as part of nursing care. First, the nurses were seen as providing no viable alternative to PCA for many patients who did seek help. Nurses were seen as unavailable and their analgesic value was compromised by delay. Patients' preference for PCA should therefore be regarded as a view about nursing care as much as about PCA itself. In addition, however, PCA provided escape from the embarrassment of displaying distress to and seeking help from nurses. Other patients did not describe their embarrassment explicitly, but referred to "how busy" the nurses were. Whether this kind of statement is an alternative account of their own discomfort is beyond the scope of this paper. However, both accounts report discomfort which, while reflecting ordinary social conventions about seeking help, may be compounded by nurses' own attempts to distance themselves from their patients' distress [19]. Previous evidence has established patients' reluctance to request analgesia from nurses [16, 181.

In this way, the nursing context determines the experience of PCA. However, PCA also has an important impact on the nurse-patient relationship. It focused conflict between patients' and nurses' perceptions of their respective roles. Although instances were seen of the nurse taking control over PCA from the patient, conflict typically involved what the patient saw as nurses' inability or unwillingness to accept the responsibility for pain relief, at tr ibuting it to the PCA machine which they were powerless to question or override. This illustrates how PCA can serve as a way in which the professional can shift to the patient the responsibility for their own welfare. Even with conventional analgesia, nurses tend to rely on patients to take the initiative in requesting analgesia [20]. PCA may provide a more effective way of shedding responsibility.

In conclusion, we have shown that patients" experience of a commonly used regimen of PCA diverges in important ways from the assumptions that are made about it. Their experience is not consistently positive. Their comments do not reflect the desire for control over analgesia that is conventionally assumed to underlie the benefits of PCA [10]. Indeed patients' accounts cast doubt on the validity of the concept of control in this instance of health care. Preference for

PCA depends on deficiencies in the nurse-patient relationship and its use further complicates that relationship.

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SSM 43/7--E

is patient-controlled analgesia controlled by the patient?

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