Attitude and Intention Regarding Pain Management among Chinese Nursing Students: A Cross-Sectional Questionnaire Survey

Original Article Attitude and Intention Regarding Pain Management among Chinese Nursing Students: A Cross-Sectional Questionnaire Survey Liang-yu Fang, RN,*,† Yin-chuan Xu, MD, PhD,‡ Dan-ni Lin, RN,§ Jing-feng Jin, RN,§ and Min Yan, MD†* ---

From the *Department of Acute Pain Service, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China; †Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China; ‡Department of Cardiology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China; § Department of Nursing, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China. Address correspondence to Jing-feng Jin, RN, Department of Nursing, The Second Affiliated Hospital of Zhejiang University, School of Medicine, No. 88 Jiefang Road, Hangzhou 310009, People’s Republic of China. and Min Yan, MD, Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, No.88 Jiefang Road, Hangzhou 310009, People’s Republic of China E-mail: zrjzkhl@ zju.edu.cn, [email protected] Received April 5, 2016; Revised November 2, 2016; Accepted January 12, 2017. 1524-9042/$36.00 Ó 2017 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2017.01.001

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ABSTRACT:

Optimal pain management is a priority in effective nursing care. Lack of sufficient pain knowledge associated with inadequate pain management has been proved. However, the intention, defined as the predictor of behavior, regarding pain management remains unknown. Therefore, the study was to determine the attitude and intention regarding pain management among Chinese nursing students and investigate the underlying determinants and their interactions in terms of intention toward pain management. The Pain Management Survey Questionnaire, comprising the key determinants of the theory of planned behavior—that is, direct attitude, belief-based intention, subjective norm, direct control, and indirect control—was used to collect data from 512 nursing students who undertook clinical rotation in an affiliated hospital of a medical college in China. Data were analyzed using descriptive statistics, independent sample t test, Pearson correlation analysis, or structural equation modeling analysis. Chinese nursing students reported negative attitudes and behavioral intentions toward pain management. Direct control, subjective norm, belief-based attitude, and indirect control independently predicted nursing students’ intention to treat patients with pain. Direct control was the strongest predictor. Structural equation modeling analysis further revealed 39.84% of the variance associated with intention that could be explained by determinants of the theory of planned behavior. Additionally, educational school level and previous pain management training had great effects on pain management intention. Overall, this study identified intention as an important factor in effective pain treatment. Chinese nursing students have negative attitudes and insufficient intention to pain management. Therefore, hospitals and universities in China should manage these factors to improve nursing students’ practice regarding pain management. Ó 2017 by the American Society for Pain Management Nursing Pain Management Nursing, Vol -, No - (--), 2017: pp 1-10

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Pain, described as an unpleasant emotional sensation, is the most common symptom experienced by a large number of people. Pain could exert negative effects both on patients’ physical activity and psychological status. Therefore, relieving pain is a fundamental requirement of patients (Chou et al., 2016; Ferrell, 2005). As part of the health system, nurses play an indispensable role in effective pain management, including providing accurate evaluation, appropriate intervention, and sufficient pain education to patients (Brown, 2013). Carrying out these roles requires that nursing students have gained adequate knowledge of pain management in nursing schools and have been trained for pain management during the early stage of their career. Several studies conducted in Western countries have highlighted the importance of pain knowledge in effective nursing care (Al Khalaileh & Al Qadire, 2013; Goodrich, 2006; Lui, So, & Fong, 2008; Plaisance & Logan, 2006; Rahimi-Madiseh, Tavakol, & Dennick, 2010; Samuels & Leveille, 2010; Shaw & Lee, 2010), providing the evidence that nursing students’ knowledge is essential for their roles in clinical practice and their future roles as nurses. Studies concerning knowledge about pain management of nurses in China are few. The knowledge and attitude survey regarding pain (KASRP) scale was used by Wei, Run, Shuang, Hong, and Xiuqiong (2014) to investigate the cognitive situation of pain in 440 clinical nurses of hospitals in the Fujian province of China. The average correct response rate was 48.35%, far less than the data reported by similar studies performed in Western countries (63.6% in the United States, 73.8% in the United Kingdom, and 62.7% in Italy, respectively) (Keefe & Wharrad, 2012), revealing that Chinese nurses had severe pain knowledge deficits. Therefore, nursing educators in China have adopted targeted measures to solve problems of inadequate knowledge in nursing pain management, including the implementation of pain education programs for nurses. However, the effective pain management is still a big challenge for nursing care, prompting us to identify other factors that might influence the efficacy of pain treatment. According to the theory of planned behavior (TPB) developed by Edwards et al. (2001), intention can predict an individual’s behavior, how hard the person is willing to try, and how much effort they are planning to expend to perform the behavior. We should realize that only knowledge that is transformed into prompt behavior could provide optimal pain management, and intention is the major determinant in the transformational process from knowledge to

behavior. Therefore, intention has been considered a pivotal factor to affect pain management (Ajzen, 2011). Several studies using the TPB indicate that attitude, subjective norm, and perceived behavioral control, the key determinants of TPB, could influence one’s intention significantly (Aldrich, 2015; Dumitrescu, Wagle, Dogaru, & Manolescu, 2011; Guo, Wang, Liao, & Huang, 2016). Attitude is determined by the person’s positive or negative belief from an evaluation outcome of behavior. Subjective norms indicate the person’s perceptions after understanding other people’s expectations and motivation according to others’ practice. Perceived behavioral control is regarded as confidence and belief in behavior performance (Dumitrescu et al., 2011). Generally, the greater positive attitude, subjective norms, and favorable behavioral control, the stronger the behavior intention. Therefore, using TPB is an optimal approach for understanding the important role of intention in effective pain management.

AIM AND RESEARCH QUESTIONS To our knowledge, few studies have been conducted to identify the intention and attitude of nursing students regarding pain management in China. This study aimed to determine the attitude and intention regarding pain management among Chinese nursing students and to investigate the underlying determinants and their interaction in terms of intention toward pain management. The following four questions were asked: 1. What are the attitudes and intentions regarding pain management among nursing students in China? 2. What are the determinants and their interactions in terms of intention toward pain management among Chinese nursing students? 3. What proportion of the variance in behavioral intention could be explained by determinants of TPB? 4. Do characteristics of Chinese nursing students affect their intention toward pain management?

METHODS Design, Sample, and Setting A descriptive, analytical and cross-sectional survey design was used by distribution of a self-administered questionnaire. The study was conducted at an affiliated hospital of a medical college in Zhejiang province in China over a period of 1 month in September 2015. The sample inclusion criteria were nursing students who were bachelor-degree candidates, had

Pain Management among Chinese Nursing Students

undertaken clinical orientation in the aforementioned hospital, and agreed to participate in the study. The sample size was estimated using the software G* power V.3.1 with two tails, an effect size of 0.5, a statistical power of 0.95, and statistical significance of 0.05. The estimated sample size was 210. However, a larger sample size (N ¼ 512) was enrolled in the current study. According to the principles and practice of structural equation modeling analysis (SEMA), sample size should be more than 200 because complex models require a larger sample size (Rex, 2005), thus the current sample size was sufficient. Instruments and Measures Self-administered questionnaires, consisting of two sections, were used. The first section comprised general information and asked participants for their age, sex, educational school level, experience of clinical orientation in hospitals, previous history of pain management training, frequency of using objective tools of pain assessment, and the way to acquire pain knowledge. The second section was the pain management survey questionnaire (PMS), developed by Edwards et al. (2001). The PMS is a 39-item, multiple-choice test, measured on a Likert-scale, to evaluate the attitude and intention related to pain management. The PMS contains general attitude and six dimensions, including direct attitude, belief-based attitude, subjective norms, direct control, indirect control, and behavioral intention. The detailed information of the PMS and items for score calculation of general attitude and the six dimensions are available in Supplemental Tables 1 and 2, respectively. The general attitude and direct attitude were measured on a 5-point Likert scale, while the remaining 5 dimensions were calculated on a 7-point Likert scale. The 5-point Likert scale ranged from 1 (strongly agree) to 5 (strongly disagree), while the 7-point Likert scale was measured from þ3 (likely, desirable) to –3 (unlikely, undesirable). The possible range scores of the six dimensions were 9～45, 54 ～54, 36～36, 9～9, 45～45, and 9～9, respectively. The measured Cronbach’s alpha coefficients were 0.78, 0.61, 0.67, 0.68, 0.68, and 0.79. All dimensions were scored consistently so that higher scores indicated more positive attitude and intention toward pain management. General Attitude and Direct Attitude Nineteen items in the PMS were developed to measure the general attitude, and nine items were to address the direct attitude toward pain management. They were calculated on a 5-point Likert scale by the summation

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of an individual’s score for the set of items in the scale, reflecting willingness to administer pain-relief medicine. Belief-Based Attitude Two groups of items, including three positive and three negative consequences, were measured on a 7-point Likert scale, aiming to assess belief-based attitude, that is, ‘‘When you administer pro re nata (P.R.N) narcotic analgesic, how likely is it that the following consequences will occur for the patient?’’ and ‘‘How desirable do you feel each of the following consequences would be for a patient who has received P.R.N narcotic analgesic?’’ The score for belief-based attitude was achieved by multiplying each belief score by the corresponding evaluation score and then summing across the six products. Subjective Norm Two groups of items were developed to address subjective norm, which refers to the unconscious intention to deal with pain from the related person, namely, ‘‘How likely is it that the following people would think that you should administer P.R.N narcotic analgesic to a patient with pain?’’ and ‘‘How likely are you to go along with the wishes of the following people?’’ Each group of items had four subordinate effect factors, including the patient, the patient’s family, nursing colleagues, and medical staff. A subjective norm score was calculated by summing the cross products of the corresponding scores on the measures of effect factors. Direct Control and Indirect Control Direct control refers to the extent to which the behavior is performed and is related to outside opportunity. It was assessed by three items (e.g., ‘‘How much do you agree that administering P.R.N narcotic analgesic to a patient with pain is within your control?’’ ‘‘How easy is it for you to administer P.R.N narcotic analgesic to a patient with pain?’’ and ‘‘How much control would you have in administering P.R.N narcotic analgesic to a patient?’’). The score of direct control was calculated by the summation of an individual’s score for the set of items in the scale. Indirect control is associated with the nursing ward expectations, the route of administration, type of pain, patients’ medical or surgical condition, and patients’ characteristics. Two groups of items (e.g., ‘‘How much effect do ward expectations have on whether you administer P.R.N opioid analgesia to a patient with pain?’’ and ‘‘How often do you consider ward expectations prior to administering P.R.N opioid analgesia to a patient with pain?’’) were developed to

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evaluate the effect of these five aspects on nurses’ administration of P.R.N opioid analgesics. An indirect control score was calculated by summing the cross products of the corresponding scores on the measures of the five aspects. Behavior Intention Behavioral intention is considered as the possibility of performing effective pain management by participants. The behavioral intention was assessed using the 7-point Likert scale. Three items were developed to address behavioral intention: ‘‘How much do you agree that you intend to administer P.R.N narcotic analgesic when caring for a patient with pain?’’ ‘‘How likely are you to give a narcotic analgesic prescribed on a P.R.N (as needed) basis to a patient who has pain?’’ ‘‘How likely are you to try to administer P.R.N narcotic analgesic when caring for a patient with pain?’’ The score of behavior intention was calculated by the summation of individual’s score for the set of items in the scale. Compared with the KASRP to assess the pain knowledge of nursing staff, the PMS has the advantages of analyzing the influence of behavioral intention on pain management, especially the nursing staff’s tendency to administer narcotic analgesic medication in the process of pain care (Edwards et al., 2001). In our study, we used PMS translated into Chinese. Previous studies have provided evidence that language translation does not affect the validity of the PMS (the Cronbach’s alpha of the Chinese version of the PMS was 0.73, and the Cronbach’s alpha of the six dimensions were 0.73, 0.68, 0.67, 0.58, 0.80, and 0.56, respectively) (He & Tao, 2011; Hua, Yang, & Linlin, 2014). Ethical Considerations The current study was approved by the research and ethical committee of the Second Affiliated Hospital of Zhejiang University, School of Medicine. Researchers explained the purpose and procedures of the study to the participants before having them answer the questionnaire. The responses from nursing students were kept confidential, and anonymity was ensured throughout the whole study. Participation was completely voluntary, and withdrawal at any stage of the study was permitted. Study Procedure All the participants enrolled in this study were taking part in their clinical rotation in an affiliated hospital of a medical college in Zhejiang province in China. After obtaining ethical approval from the ethics committee of the hospital and receiving permission to conduct the study from the Nursing Department,

blank questionnaires and information sheets were sent to the clinical ward. The research team visited the clinical unit, and the aims of the study were explained to the participants. The participants were then asked to complete the questionnaires, which were returned to a designated box. Data Collection and Analyses Of the 542 distributed questionnaires, 512 completed questionnaires were received, providing a response rate of 94.5%. All completed questionnaires were independently checked by two people. All uncompleted forms were excluded from further analyses. Data were entered into a computerized database, and IBM SPSS software version 19 (SPSS 19.0, Inc., Chicago, IL, USA) was used for statistical analyses. A p value less than .05 was considered statistically significant. The general characteristics of nursing students regarding pain management were recorded using descriptive statistics. Independent sample t test was used to assess the difference in behavioral intention between subgroups as classified by students’ characteristics. Pearson correlation analysis was performed to evaluate the correlations between intention and the PMS dimensions. To further examine the relative contributions of TPB determinants in predicting behavioral intention toward pain management, variables were examined in SEMA using AMOS 21.0 software (SPSS, Inc.). To assess how well data fit structural equation models, we calculated parameters including the comparative fit index (CFI), goodness-of-fit index (GFI), TuckerLewis Index (TLI), root mean square error of approximation, (RMSEA), and the standardized root mean square residual (SRMR). The SEMA model as hypothesized was accepted if the p value of the chi-square test exceeded .05. The standard of well data fitting is a CFI and TLI value ranging from 0.9-1.0, a GFI value exceeding 0.9, an RMSEA value less than 0.05, and an SRMR value less than 0.05.

RESULTS The results are presented in four sections. The first section comprises descriptive statistics of current attitude and intention toward pain management. The second section focuses on correlations between TPB determinants and behavioral intension toward pain management. The third section shows the relative contributions of TPB determinants in predicting behavioral intention toward pain management. The last section includes the characteristics of nursing students that could affect behavioral intention regarding pain management.

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Pain Management among Chinese Nursing Students

Participants’ Characteristics The mean age of nursing students was 22 years (standard deviation [SD] ¼ 1.25, range ¼ 19-25). The majority of nursing students were women (89.6%, n ¼ 459). One-third of nursing students were from university-level nursing schools in large cities (31.3%, n ¼ 160), while others (68.7%, n ¼ 352) were from general nursing schools. All participants in this study had attended clinical orientation in hospitals for at least 6 months. Half of the students (51.2%) reported that they had ever received pain management training, and 38.5% reported that they always used objective tools for pain assessment. Additionally, 73.6% of the students gained their pain knowledge from an Acute Pain Service Department (APS) in hospitals, and 52.2% from medical books or journals. The general characteristics of the participants are detailed in Table 1. Overall Attitude and Intention Regarding Pain Management The score of general attitude and behavioral intention was 51.13 (SD ¼ 5.84) and 0.06 (SD ¼ 3.31), respectively, indicating that the overall intention related to pain management is negative. Further calculation of scores of five dimensions, including direct attitude, belief-based attitude, subjective norm, indirect control, and direct control, were 22.32, 7.54, 3.78, 10.79, and 1.71, respectively. The mean score for nursing students with relevant responses on each dimension of the PMS is listed in Table 2. Correlations between Behavioral and TPB Determinants Intention correlated positively with direct control, subjective norm, belief-based attitude, and indirect control. Direct control was the strongest correlator. The percentage of nursing students with responses on direct control of PMS and the correlations among other dimensions of the model are shown in Tables 3 and 4, respectively. Structural Equation Modeling Analysis Structural equation modeling analysis was performed using the AMOS technique to further assess the contribution of determinants of TPB to predict behavioral intention toward pain management. The initial behavior intention model included the paths from TPB components, such as direct attitude, beliefbased attitude, subjective norm, direct control, and indirect control, and correlations among them (Fig. 1). The final model (Fig. 2) was modified based on the analysis of initial structure and fitted well with all

TABLE 1. General Characteristics of the Sample (N ¼ 512) Variables

n

%

Age, years: Mean ¼ 21.91; SD ¼ 1.25 Sex Male 53 10.4 Female 459 89.6 Educational school level University-level nursing school in a large city 160 31.3 General nursing school 352 68.7 Experienced clinical orientation in hospitals #6 mo 305 59.6 6-8 mo 166 32.4 >8 mo 41 8.0 Previous pain management training Yes 262 51.2 No 250 48.8 Frequency of using objective tools for pain assessment Never or rarely 115 22.4 Sometimes 200 39.1 Always 197 38.5 Require pain knowledge from APS in hospitals Yes 377 73.6 No 135 26.4 Acquire pain knowledge from books or journals Yes 267 52.2 No 245 47.8 SD ¼ standard deviation; APS ¼ Acute Pain Service.

samples: c2 ¼ 4.571 (d.f. ¼ 4, p ¼ .334), GFI ¼ .997, CFI ¼ .998, TLI ¼ .992, RMSEA ¼ .017, and SRMR ¼ .0185. Furthermore, the model revealed a statistically significant influence of direct control, subjective norm, and belief-based attitude, which together explained 39.84% of the variance in intention to improve pain management practice. Characteristics of Nursing Students Affect Intention Regarding Pain Management To identify other factors that might affect intention, we compared the difference in behavioral intention

TABLE 2. Scores of PMS Dimensions Items

N

Min

Max

Mean

SD

General attitude Direct attitude Belief-based attitude Subjective norm Indirect control Direct control Behavioral intention

512 512 512 512 512 512 512

19 9 36 21 24 9 9

75 43 54 36 45 9 9

51.13 22.32 7.54 3.78 10.79 1.71 0.06

5.84 4.69 12.23 8.09 10.19 3.60 3.31

PMS ¼ Pain Management Survey Questionnaire; SD ¼ standard deviation.

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TABLE 3. Percentage of Nursing Students with Responses on Direct Control of PMS (N ¼ 512) No.

Items of Narcotic Analgesic

Score 1

Score 2

Score 3

Strongly agree 36b Administering PRN narcotic analgesic to a patient with pain is within my control

15 (2.9%)

Neutral 42 (8.2%) 45 (8.8%)

Extremely easy 38

39

How easy would it be for you to administer PRN narcotic analgesic to a patient with pain? How much control do you believe you would have in administering PRN narcotic analgesic to a patient?

20 (3.9%)

Complete control 18 (3.5%)

Score 4

109 (21.3%)

Score 5

Score 6

Strongly disagree 68 (13.3%) 103 (20.1%) 130 (25.4%)

Neutral 29 (5.7%) 67 (13.1%) 141 (27.5%) 130 (25.4%)

Extremely difficult 87 (17.0%) 38 (7.4%)

Neutral 43 (8.4%) 68 (13.3%) 193 (37.7%)

Score 7

No control 74 (14.5%)

62 (12.1%)

54 (10.5%)

PMS ¼ Pain Management Survey Questionnaire; PRN ¼ pro re nata.

between subgroups classified by students’ characteristics. Analyses revealed that behavioral intention consistently differed with educational school level (t ¼ 3.56, p < .001) and previous pain management training (t ¼ 3.47, p ¼ .001), but there was no difference in other variables. Nursing students from university-level nursing schools in large cities acquired higher scores on intention than those from general nursing schools, and nursing students’ intention was more positive than those without experience of pain training. The detailed information is described in Table 5.

DISCUSSION This study identified the intention of nursing students as another important factor in effective pain treatment. Nursing students in China have an overall negative attitude and behavioral intention toward pain management. Direct control, subjective norm, beliefbased attitude, and indirect control were found to independently predict nursing students’ intention to treat patients with pain. Direct control was the strongest predictor. A total of 39.84% of the variance in intention could be explained by determinants of TPB. Additionally, educational school level and previous

pain training experience also had significant effects on pain management intention. Negative Attitude Affects Intention Toward Pain Management Many previous studies have used different versions of the KASRP questionnaire to determine the role of knowledge in optimal pain management (Chow & Chan, 2015). Seven large, descriptive cross-sectional studies conducted in Western countries revealed that inadequate pain knowledge was by far the major hindrance preventing nursing staff from achieving effective pain treatment (Al Khalaileh & Al Qadire, 2013; Al Khawaldeh, Al Hussami, & Darawad, 2013; Duke, Haas, Yarbrough, & Northam, 2013; Goodrich, 2006; Plaisance & Logan, 2006; Rahimi-Madiseh, Yavakol, & Dennick, 2010; Shaw & Lee, 2010). Furthermore, Alzghoul and Abdullah (2015) provide evidence that knowledge of pain management has a strong association (69% contributions) with pain management practice. The situation in China is similar. Hence, targeted measures to solve problems of inadequate knowledge, including various pain education programs implementation, have been adopted worldwide. Despite all of these efforts, effective pain management is still a challenge for

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Pain Management among Chinese Nursing Students

TABLE 4. Correlations* between Behavioral Intention and TPB Determinants Correlation Coefficients* Dimension GA DA BA SN DC IC BI

GA

DA

BA

SN

DC

IC

BI

1 0.051 0.046 0.032 0.069 0.004 0.056

1 0.046 0.090† 0.067 0.083 0.085

1 0.221‡ 0.124‡ 0.226‡ 0.211‡

1 0.141‡ 0.282‡ 0.263‡

1 0.061 0.559‡

1 0.204‡

1

TPB ¼ theory of planned behavior; GA ¼ general attitude; DA ¼ direct attitude; BA ¼ belief-based attitude; SN ¼ subjective norm; DC ¼ direct control; IC ¼ indirect control; BI ¼ behavioral intention. *Pearson’s correlation. † Correlation is significant at the .05 level (2-tailed). ‡ Correlation is significant at the .01 level (2-tailed).

nursing care, indicating that optimal pain management is influenced by other factors in addition to knowledge. Therefore, we aimed to investigate the role of behavioral intention in pain management among Chinese nursing students based on TPB, which is a novelty of this study. According to TPB, attitude had a strong effect on intention, suggesting that the more positive a person’s attitude, the more likely he or she is to intend to improve his or her behavior. Of note, the scores of attitude in our study were relatively low (direct attitude: 22.32 vs. 31.70) compared with the finds of Edwards et al. (2001), indicating a much more negative attitude of nursing students in China regarding pain management. Worries about the side effects of analgesics, including drug addiction and intelligence retardation, accounted for the difference in nursing students’ attitude between China and Western countries. Additionally, traditional Chinese culture may be another major factor

Direct Attitude Belief-based Attitude Subjective Norm

Behavioral Intention

Direct Control

Indirect Control

FIGURE 1. - Initial hypothesis to explain predicting factors of behavioral intention regarding pain management.

contributing to the negative attitude of Chinese nursing students toward pain relief medication. In China, people who endure pain are considered brave, and this perspective is handed down from generation to generation and is widely accepted by most nursing students.

Insufficient Behavioral Intention Toward Pain Management The score of behavioral intention in this study was –0.06 versus 5.58 in Edwards et al. (2001), suggesting the very low tendency of Chinese nursing students to provide pain relief. Further analysis of correlations between intention and TPB determinants showed that direct control was the strongest predictor to intention regarding pain management, which was different from other studies, which demonstrated that attitude exerted the strongest effect on intention prediction. The score of direct control in this study was –1.71, far less than the data from studies conducted in Western countries, indicating that nursing students in China do not fully recognize their important role in effective pain management. The general view in China that the doctor is in charge of administering pain relief medication is the major factor contributing to the deficit of self-efficacy toward pain management among Chinese nursing students. The SEMA carried out in this study has advantages for analyzing complex linkage between intention and TPB determinants. It allows the modeling of the potential variables, which reduces the likelihood of regression dilution (Dumitrescu et al., 2011). The model revealed a statistically significant influence of direct control, subjective norm, and belief-based attitude, which together explained 39.84% of the

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Fang et al.

34.09

**

1

E7

3.93

5.44

28.11

**

*

65.32

1

1

*

0.02

**

0.06

Behavioral Intention

Subjective Norm **

** 12.96

0.54

1

E5

** 23.19

Belief-based Attitude

**

E4 * 4.09

**

1

E3

E1

-0.01 0.00

149.24

*

21.81

Direct Attitude

**

2.80

1.19

6.26

1

E2

3.33

General Attitude

** 21.98

1.46

Direct Control

0.02

**

103.54

2.24

E6

1

Indirect Control

Condition Number: 39.84 FIGURE 2. - Structural equations modeling analysis of intention regarding pain management within different dimensions. Significance is indicated by an asterisk (**p < .001, *p < .05). Circles labeled E1-E7 indicate the measurement error of corresponding observed variables. Single-headed arrows indicate the hypothesized direction of causality, and doubleheaded arrows indicate nondirectional associations. Numbers adjacent to arrows represent the standardized direct effect. Condition number is automatically calculated by software, indicating the proportion of the variance in behavioral intention that could be explained by TPB determinants.

background could influence the pain knowledge and attitude of nursing students (Latchman, 2014). These findings also highlight the importance of pain education and training in cultivating nursing students during the early stage of their nursing career.

variance in intention to improve pain management practice, reflecting the close relationship between intention and TPB determinants. In addition to TPB determinants, our study was also able to identify other factors that might affect behavioral intention. We found a statistical difference in behavioral intention between subgroups classified by educational school level and previous pain management training, indicating that the higher level of educational school and more previous training in pain management result in more positive intention regarding pain management. This result is consistent with previous studies that reported that academic

Implications for Nursing Education, Practice, and Research This study has highlighted the important role of behavioral intention in pain management and identified the factors that might affect the intention. To improve the effectiveness of pain management, nursing educators in China are recommended to

TABLE 5. Differences in Behavioral Intention between Subgroups of Students’ Characteristics (N ¼ 512) Variables Educational school level University-level nursing school in a large city General nursing school Previous pain management training Yes No SD ¼ standard deviation.

t

p

N

Mean ± SD

160 352

0.71  3.60 0.40  3.11

3.56

<.001

262 250

0.46  3.66 0.55  2.86

3.47

.001

Pain Management among Chinese Nursing Students

use our results to encourage nursing students to enhance their self-efficacy toward pain management. Furthermore, continuing educational programs and seminars regarding pain management are essential for nursing student training. In addition, our study has demonstrated that TPB determinants explain about 40% of the variance with regard to the intention to manage pain. It is recommended that further research be undertaken to identify factors that contribute to the remaining 60% of the variance in the intention, which may provide more approaches for managing pain effectively. Limitations Although our study provides information about Chinese nursing students’ attitudes and intentions regarding pain management, the following limitations need to be considered. First, the design of our study was cross-sectional and descriptive, which provides linkages between study variables but not causality. Second, the significant difference may not reflect the whole status of pain attitude and intention among all nursing students in China, since the population of enrolled samples was limited to undergraduate

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students. Therefore, a larger scale survey, including nursing students of different cultural and academic backgrounds, is highly recommended.

CONCLUSION This study provides evidence that Chinese nursing students have negative attitudes and insufficient intention regarding pain management. Thus, hospitals and universities in China should manage these factors to improve nursing students’ practices regarding pain management. Acknowledgments Our sincere appreciation is extended to all participating nursing students for their cooperation and Dr. Hong Lu from the University of Kentucky, USA, for her manuscript editing.

SUPPLEMENTARY DATA Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.pmn.2017.01.001.

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