A survey examining nurses' knowledge of pain control

18 Journal of Pain and SymptomManagement

Vol. 7 No. 1 January 1992

A Survey Examining Pain Control Joan Hamilton, RN, and Linda Edgar, RN Victoria General Hospital (J.H.), Halifax, Nova Scotia, and Sir Mortimer B. Davis Jewish GeneralHospital (L.E.), Montreal, Quebec, Canada

Three hundred and eighteen (318) nursing staff members at an acute care teaching hospital in Montreal, Canada, were surveyed to identify their knowledge of pain assessmentand management. Two pain instruments were combined and adapted for use. The&al instrument consisted @imurily of truelfabseresponses and took about 10 min to complete. The mean score was 63.9%. Gverall resuhs indicated that nurses la&d knowledge and understanding of opioid addiction, equivalent dosing, properties of opioids, and d@rences in acute and chronic pain. No statistically si&icant d@erences were found in the scores b level of educational preparation or by years of experience. Presentation of the results unit by unit demonstrated that the instrument is suitable as an educational tool as well as an eflective strategy to introduce nursing staff to nursing research. J Pain Symptom Manage 1992;?;18-26. Key wmdr Pain control, nurses’ knowledge

Introduction Few published studies examining nurses’ knowledge and attitudes about pain control have included a complete study questionnaire and results . ‘~3*6,‘1-9 Th e present study was performed to 1) systematically identify the pain assessment and management knowledge base of bedside nursing staff to identify specific learning needs, 2) resensitize nursing staff to pain management content, and 3) provide health care professionals who are interested in pain management with a quick survey instrument and comparison results. The authors were interested in examining nurses’ knowledge and A&es-sreprintrequeststo: Joan Hamilton, RN, 3206 Pennington Street, Halifax, Nova Scotia, Canada, B3L 4A9.

Acceptedfor publication:August 6,

1991.

0 U.S. Cancer Pain Relief Committee, 1992 Pttblished by Else&r, New York, New York

understanding of pain physiology md assessment, and of the general principles of pharmacologic and nonpharmacologic intervention as opposed to focusing primarily on attitudes and beliefs about pain control. On reviewing the literature, it became evident that knowledge, attitudes, beliefs, and practices of pain assessment and management have not usually been examined separately from each other, probably because they have not been viewed as consisting of mutually exclusive content areas. Moreover, most studies have focused either on postoperative pain or pain of chronic malignant disease and not on general pain-control principles. Over the years, many studies have been conducted examining nurses’ involvement in pain control, using a number of different approaches depending on the perspectives and overall aims of the research. Most researchers have exam-

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AJuises’ Knowledge

ined a combination of different issues in the same study. Research studies have examined the nurses’ beliefs about the incidence of patients in pain;5.‘os’ ’ the compatison of patient and nurse perceptions;5*1’-‘3 knowledge of the physiology of pain;r4”’ philosophy, attitudes, and beliefs about pain control;‘*g current practice;‘*s knowledge of drug therapy and side effects;s.‘*” and the effectiveness of educational programs.4*‘“*‘7 Of the many studies in the literature, three have contained a portion or a majority of knowledge questions reiating to narcotic use and side effects, and specifically reviewed the responses to these questions. The first study was conducted in the United States by Weis and colleagues.’ In this study, 70 nurses working on surgical, orthopedic, and gynecology wards responded to a mail-back multiple-choice questionnaire as one part of a larger study on postoperative analgesic care, over& goals of the treatment of pain, and the nurses’ opinion as to whether pain control was adequate. Of the questions to determine knowledge of analgesic use, results indicated that nurses had inaccurate ideas about tbe likelihood of addiction, respiratory depression, and “potentiators” of analgesics. A Canadian study conducted in 1987 by WattWatson’ sampled 106 graduate nurses (diploma and BScN) from medical or neuroscience settings, and 10 1 second and third year baccalaureate nursing students attending pain education programs. The aim of the study was to examine the nurses’ knowledge base about pain assessment and narcotic administration. The questionnaire consisted primarily of 18 questions using true/false, multiple choice and fill in the blank formatting. Watt-Watson also found a lack of knowledge about pain assessment and narcotic administration. The incidence of addiction was overestimated and the sample did not know equianalgesic doses or the correct duration of action of commonly used narcotics. 1 he third study was done most recently by McCaffery et al.’ Responses from a pretest questionnaire collected from a series of pain workshops in 14 states provided data to determine current nursing knowledge of opioid analgesic drugs and incidence of psychological dependence. A total of 2459 nurses (the vast majority of which were registered nurses) made up the sample. Respondents were divided into

of

Pain Control

19

two groups--basic an advanced learners. Advanced Iearners had pain education course. A s examined the nurses’ know classification of seven a the nurse to identify the drug as a narcotic or nonnarcotic. The Past question examined the nurses’ knowledge of drug addiction. Results indicated that nurses lacked knowledge of opioid classification of the seven drugs. Less than 25% of the sample correctly identified the frequency of psychological dependence. Several of the results from the study by McCaffery and colleagues’ can be compared directly with results of the present study because identical questions were asked. Qnly similarities in results can be drawn with the other two studies. The use of the same research instrument would have permitted direct comparisons across settings and provided more useful comparative data and feedback.

ect Se A cross-sectional study was conducted in a 612&d university teaching hospital in Montreal, Quebec, Canada from August 1989 to December 1989. Twenty-two nursing units ranging in size from 6 to 38 beds participated in the study. The psychiatric and obstetric units were excluded due to financial constraints. Both these units are distinct groups and could be separated easily from other clinical areas. Each head nurse was responsible for giving the questionnaire to the nursing staff on his/her unit. The nurses returned the questionnaires anonymously via a designated envelope on the unit over the 3-wk period of data collection.

The self-administered Pain Control Survey instrument was a combination and revision of two instruments obtained from Margo McCaffery, a well-known nursing expert in pain assessment and management. Page one of the ques(Figure 1) examines opioid tionnaire classification and opioid effects. This part of the instrument’s development is described in McCaffery and colleagues.’ Page two consists of 20 true/false statements developed by McCaffery

Jcnwnal of Pain and Symptom Management -

Hamilton and Edgar

20

PAIN CONTROL SURVEY General Information

About You Date:

Please circle or fill in the blank RN (Diploma) RN I(Bacheior’s) Levei o/Preparation: RN (Master’s) Other RNA Student Nurse Years qf E+e&nce Clinical hea:

Age:

<25

as health professional

Medical OR

ER

25-34

Surgical RR 3-4

45-54

OBSGYN Peds Other

ecu KU Gerontology

Oncollogy Psychiatry >54

NARCOTIC/OPlOID

CLASSIFICATION

Based on the PHARMACOLOGICAL DEFINITION of a narcotidopioid please indicate what you know about the following:

analgesic. not on government

laws or regulations,

CIRCLE ONE of these 3 answers:

DRUG Amitriptyiine Codeine Heroin Hydromorphine (Diiaudid) Indomethacin (Indocid) Mepexidine (Demeroi) Morphine Pentazocine (Talwin) Empracet 30

Not Not Not Not Not Not Not Not Not

Narcotic Narcotic Narcotic Narcotic Narcotic Narcotic Narcotic Narcotic Narcotic NARCOTIC/OPIOID

1.

.-

a a a a a a a a a

narcotic narcotic narcotic narcotic narcotic narcotic narcotic narcotic narcotic

Not Not Not Not Not Not Not Not Not

sure/Don’t sure/Don’t sure/Don’t sure/Don’t sure/Don’t sure/Don’t sure/Don’t sure/Don’t sure/Don’t

know know know know know know know know know

EFFECTS

Usingthe

definition below, how Iikeiy is it that narcotidopioid addiction will occur as a result of treating pain with narcotic analgesics? Circle one number closest to what you consider the correct answer:

25% 10% 15% 20% 30% 50% 75% 100% 1% 5%
Demeroi 100 mg PO

3. There is a ceiling on the analgesia or morphine, pain relief. Circle your answer:

TRUE

Demeroi

150 mg PO

75 mg PM? Circle one Demeroi 300 mg PO

i.e., beyond a certain dose, increasing the dose does NOT increase

FALSE

Developed by McCaffery & FerreU, 1988. Revised with permission by Hamilton & Edgar, 1989, Montreal, Canada. Fig 1. Sample survey.

(1986) on pain assessment and management issues (Figure 2). A total of nine revisions were made to the instruments to coincide with drugs and equipment commonly used in the hospital, as well as to make the instrument more comprehensive for staff teaching and review. Under “narcotic/ opioid classification,” of the original instrument, cocaine, ibuprofen and propoxyphene were replaced by amitriptyline, indomethacin, and Empracet 30. In question one, under “narcotidopioid effects,” the option of “Cl%” was not a choice due to a typographical error. On

page two, statements 1, 5, 8, 9, and 12 were revised or changed completely. All questions or statements were equally weighted. A correct response was given a value of one, an incorrect response was given a zero. Unanswered questions were counted as zero. The respondent’s total score was then divided by the maximum score of 32, and multiplied by 100 to give a final score as a percentage value.

Andysis Total scores were correlated with years of experience using Pearson’s correlation. Analysis

Vol. 7 No. I January 1992

Nurs& Knowledge of Pain Control

TRUE-FALSE QUESTIONS-CIRCLE T

F F

T T

F F

T T T T

F F F F

T

F

T

F

T T T T

F F F F

T T T T

F F F F

T

F

T

F

T

21

EITHER “T” FOR TRUE OR “F” FOR FALSE.

1. Heroin controls pain better than morphine. 2. Observable changes in vital sign3 must be relied upon to verify a patient’s statement that he has severe pain. 3. Pain intensity should be rated by the nurse, not the patient. 4. If the patient can be distracted from his pain this usually means he does NOT have as high an intensity of pain as he indicates. 5. A patient who has continuous pain due to cancer should receive analgesia regularly and around the clock. 6. Patients may sleep in spite of severe pain. 7. Comparable stimuli in different people produce the same intensity of pain. 8. Cukneous stimulation techniques that may reduce the intensity of pain include the application of hot or cold compresses. 9. Aspirin and other nonsteroidal antiinflammatory drugs are not effective analgesics for bone pain caused by metastases. 10. When cutaneous stimulation such as cold or massage is used for pain relief, it must be used in the area of pain. 11. Yawning frequently results in some skeletal muscle relaxation. 12. Respiratory depression rarely occurs in patients who have been receiving narcotics over a period of time. 13. Aspirin 650 mg (10 gr) PO is approximately equal in analgesic effect to meperidine (Demerol) 50 mg PO. 14. Giving aspirin or acetaminophen (e.g., Tylenol) along with other narcotics is a logical method of increasing pain relief. 15. The usual duration of action of meperidine (Drmerol) IM is 4-5 hr. 16. Research shows that promethazine (Phenergan) is a reliable pcrentiator of narcotic analgesia. 17. Sleep or sedation can be equated with pain relief. 18. Beyond a certain dosage of strong narcotic (e.g., morphine), increases in dosage will NOT increase pain relief. 19. The potency of the pain relief measure selected for the patient should be determined on ehe basis of known physical stimuli rather than on the basis of the patient’s report of pain intensity. 20. The patient with pain should be encouraged to ensure as much pain as possible before resorting to a pain relief measure.

Developed by McCaffery, 1986. Revised with permission by Hamilton & Edgar, 1989. Montreal, Canada. Fig 2. Sample true/false survey.

of variance (ANQVA) was used to compare scores by educational preparation. Chi-squared analysis was used to compare drug classification hetween this study and that of McCaffery and colleagues.’ All tests used a two-tailed assumption. Critical p values were accepted as those less than 0.01.

A total of 3 18 nursing staff returned the questionnaire from the 22 nursing areas. A total of 263 staff members did not respond, giving a response rate of 54.7%. Table 1 gives the distribution by title of respondents. The RN group and the nurses awaiting licensure (CPNP) represented 78.9% of the total sample. The distribution by educational preparation of respondents was as follows: CEGEP (dipfoma), 42.5% (N = 135); university, 11.9% (N = 38); hospital, 11.3% (N = 36); unanswered, 34.3% (N = 109). Hospital statistics indicate that the educational background of the nursing

population is approximately 18% university prepared, so that the sample is underrepresented in university graduates.

The mean score on the questionnaire was 63.9% (SD, 12.4). The mode was 53.1% and the median was 62.5%. The minimum score was 18.8% and the maximum score was 96.9%. Almost 7% (N = 21) of respondents obtained a Table I

Distributionof Nursing Staff Title

N

%

RN CPNP Student Nurse RNA Other Unanswered

236 15

74.2 4.7

4

11 7 45 318

1.3

3.5 2.2 --14.2 100.0

RN, registered nurse; CPNP, graduate nurse waiting licensure; RNA, registered nursing assistant.

Hamilton and Edgar

22

Juvrnal of Pair&and !;ympknn Management

that there is a statistically significant difference in the responses of 3 of the 5 opioids (codeine, heroin, and pentazocine), A larger proportion of the nursing staff members in the present study classified the drugs correctly. The remaining questions on page one of the survey examined the nurses’ knowledge of opioid effects. Although almost one-third (30.5%) of nursing staff correctly responded to the question of addiction by circling “1%” (which was closest to the correct answer of “cl%“) (Table 4), it is disturbing to note that almost another one-third of respondents (29.0%), reported that there was a one in four likelihood or more (“225%“) of addiction occurring when treating pain with opioids. More than 20% of respondents believed that one of two people, or greater, were likely to become addicted. Table 4 also compares the results of the present study with those of McCaffery and colleagues.’ As indicated earlier, the present study did not offer the choice of “C 1%” as a response. In comparing the estimates of the likelihood of addiction between the two studies, it appears that the McCaffery and colleagues study respondents chose the correct response of 1% or less far more frequently than our respondents.

score of less than 50%. Of the respondents, 45% (AJ = 140) obtained a score of less than 60%. Almost 8% (N = 42) of nursing staff members achieved a score above 80%. There was no statistically significant correlation found between years of experience and total scores (r = -0.02, p >O.Ol). Although the correlation (Pearson’s 7) is negative, suggesting that total scores decreased with years of experience, the magnitude of r is so small that a value of r = 0 is likely to lie within the confidence limits of this estimate. The trend is, therefore, as likely to be in the opposite direction in terms of years of experience affecting total score. No statistically significant difference was found between the total mean score by educational preparation group (F = 0.9123, p >O.Ol).

The first part of the questionnaire asked the respondent to identify which of 9 drugs were opioids. Table 2 illustrates the results of this classification for the total sample. Chi-square analysis was us~.dto compare drug classifications between the present study and that of McCaffery and colleagues’ (Table 3). Responses of subjects from both studies were correct most often with morphine and least often with pentazocine (Talwin). Nursing knowledge of the correct classification of one drug is not likely to be totally independent of the knowledge of the other drug classifications. As a result, and due to the multiple testing effect, the critical p value for x2 in Table 3 was determined by dividing 0.01 bv the number of tests performed (i.e., 5); thus, the criticalp value for Table 3 is 0.002. The comparison revealed

The question most poorly answered was the one on equivalent dosing. Only 37 (11.6%) of 297 nursing staff members were aware that the relative potency of oral to intramuscular meperidine is four to one. Thirty-one point one

percent indicated that 75 mg of intramuscular meperidine is equivalent to 150 mg; 25.8% circled 100 mg; 24.8% circled 75 mg; and 6.6% of the sample did not respond to the question. The last question on page one of the survey Table 2

Survey

Answers-Narcotic’Opioid Classification” Not a

Narcotic %

Drug

narcotic %

Not surei don’t know %

Unanswered %

2.5

73.0 2.2

17.3

7.2

Heroin Hydromorphine (Dilaudid)

96.5 91.5 76.7

3.5 12.9

1.9 5.7

1.3 3.1

Indomethacin Meperidine Morphine

3.8 97.5 K-i

89.3 0.6 -

2.8 -0.3

15.4 5.0

4.4 0.6

Amitriptyline Codeine

(Indocid)

Pentazocine (Talwin) Empracet 30 “Correct responses are

7s.i 918 1

underlined.

-

4.7 4.1 1.6 1.9 4.1 2.5

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Nurses’ Knowledge of Pain Control

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Table 3 Percentage d Correct Res

pioid Classification in the nited States Nurses

Present study (.W = 318)

Qpioid Codeine Heroin Meperidine Morphine Pentazocine (df= 1)

96.5 91.5 97.2 98.1 76.1

(N (iv (N (iV (N

McCaffery et al. study (iv = 2,459)

== 307) = 291) = 310) = 312) = 242)

89 75 93 98 35

asked about the ceiling on the dosage of morphine. Less than one-half of the respondents (44.9%, N = 135) circled the correct response, while 52.2% (IV = 166) of nurses responded incorrectly, and 5.3% (IV = 17) of subjects did not reply. Table 5 lists the coaTect responses to the first page of the survey. Listed in Table 6 are the correct responses and the results to the twenty true/false statements of the second page.

Although nursing staff tended to score highly in identifying which drugs were and were not opioids, knowledge about some principles of opioid pharmacology (addiction, ceiling effect, equivalent dosing, and respiratory depression) was generally weak. Nursing staff members appear to have a sound knowledge base in some areas: the patient is the authority about his/her pain, pain cannot be compared, patients should not endure pain before receiving analgesics, Table 4 Survey Answers-Likeliiood of Opioid Addiction

Response option <1 1 5 10 15 20 25 30 E 100 Unanswered

Present study (%I (N = 318) not 30.5 17.3 6.3 4.1 2.8 3.1 5.0 9.1 8.8 2.8 10.1

a choice (N = 97) (N = 55) (N = 20) (N = 13) (N = 9) (N = 10) (N = 16) (N = 29) (N = 28) (N = 9) (N = 32)

McCaffery et al. study (%) (N = 2459) 24.8 15.2 17.6 6.7 7.5 7.5 5.‘; 4.3 3.3 0.6 6.6

(iV (N (N (N (N -

= = = = =

612) 376) 433) 165) 182)

(N = 182) (N = 144) (N = 106) (N = 82) (N = 140) (N = 163)

(N = 2195) (N = 1838) (N = 2280) (IV = 2417) (N = 847)

p value
and continuous pain requires continuous analgesic. These positive findings are encouraging given that pain educators have been emphasizing many of these principles over the last decade. Although the overall purpose in conducting this research was to identify the knowledge base of the nursing staff in the hospital, it is difficult to make any generalizations about the entire nursing population. Two large nursing departments (psychiatry and obstetrics) were excluded and only 54.7% of nursing staff responded to the questionnaire. There were also several variables that were not addressed in this study and could have influenced the results: age, unit, culture, language, types of pain observed on a unit, pain education, and past experience with pain. Given the large francophone population of nursing staff in this hospital, it is possible that some questions were not answered because of a language comprehension problem. No feedback concerning difficulty in understanding the questions was given to the researchers. A number of concepts were explored in more than one question, enabling the authors to exTable 5 Correct Responses to Pain Control Survey Amitriptyline Codeine Heroin Hydromorphine lndomethacin Meperidine Morphine Pentazocine Empracet 30 1.
Not a Narcotic Narcotic Narcotic Narcotic Not a Narcotic Narcotic Narcotic Narcotic Narcotic

Hamilton and Edgar

24

Journal of Pain and Symptom Management

Table 6

Responses to True/False Statements of True/False Survey (N = 3 18)

Question

Correct response

Answered correctly %

Answered incorrectly %

Unanswered %

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

F F F F T T F T F F T T T T F F F F F F

71.7 53.8 85.5 58.5 95.0 49.4 90.6 87.7 34.6 35.5 55.3 41.5 15.4 50.6 32.7 29.6 42.8 44.7 76.1 93.4

24.2 42.1 9.4 37.4 2.5 47.2 6.0 7.2 61.0 59.7 32.7 54.7 79.2 43.7 63.8 63.5 51.3 50.9 18.9 3.5

4.7 4.1 5.0 4.1 2.5 3.5 3.5 5.0 4.4 4.7 11.9 3.8 5.3 5.7 3.5 6.9 6.0 4.4 5.0 3.1

amine the instrument for internal consistency. Two questions that addressed the concept of equivalent dosing received the two lowest scores of the entire instrument (1 I.S%, 15.4%). Responses to the two questions about ceiling dose were very similar (42.5%, 44.7%), strengthening the conclusion that nursing staff have a poor understanding of this concept. Responses to statements 2,6, and 17 on page two of the questionnaire suggested that staff did not under-

stand the behavioral and physiological adaptation that takes place when a person experiences pain over time. This was confirmed in the sessions with staff when the questionnaire was reviewed with them. The low scores exploring knowledge of addiction and respiratory depression are not surprising given that the literature continues to cite these as major issues in pain management.2 The present study identified trends similar to the three studies mentioned previously. Years of experience and educational preparation were not significant variables in either Watt-Watson’s study’ or the present study. The range of overall scores from the present study (18.8-96.9%) and Watt-Watson’s (U-88%) were similar, and mean scores only differed by 11.9%. The majority of nurses from both studies indicated that the patient was the authority about his/her own

pain (96%. present;

85.5%, Watt-Watson). A large group from both samples (42.1%. present; 58.6%, Watt-Watson) expected changes in vital signs to verify the person’s statement of pain. In Watt-Watson’s study, 75% of the sample did not know the duration of meperidine, while in the present study, 63.8% wrongly believed that the duration was 4-5 hr. In the study by Weis and colleagues,g over 92% of the sample reported that promethazine slightly or markedly increased the analgesic effect of an opioid. In the present study, 63.5% believed it was a reliable potentiator. In the present study as in the McCaffery and colleagues study,’ 41.6% and 28.2% of nurses, respectively, believed there was a greater than 15% likelihood of addiction when treating patients with opioids. Although it is impossible to directly compare results, the Weis and colleagues9 findings indicated that 48% of nurses reported that chances were more than 15% that a 70 kg patient receiving 100 mg of meperidine intramuscularly for 10 days would become addicted, and Watt-Watson’s study” indicated that 66% of graduate nurses had reported that more than 10% of hospital patients with organic pain become addicted. Results of these four studies reveal that nurses continue to hold markedly inaccurate beliefs about addiction.

Vol. 7 No. I Jznuary 1992

Nurses’ Knowledge of Pain Copzlrol

Findings from the study provide educators with concrete data from which to focus further teaching sessions, either on an individual or nursing unit basis. t2iultS suggested nursing staff had incorrect or incomplete knowledge regarding some straight-forward knowledgebased concepts and principles, including the concept of equianalgesic dosing, clinical differences between acute and chronic pain, true risks of addiction, and the duration of action of analgesics. The findings suggest that educators have focused heavily on attitudinal issues while not concurrently providing enough factual knowledge. Perhaps it is this finding, tbe apparent lack of focus on factual information, that may be of greatest value to other pain educators. Attitudinal assessment appears to have been a major focus of many studies of nurses’ knc. +dge of pain assessment and managemenr. Our study has demonstrated a need to also assess the factual knowledge base of nurses. An unexpected outcome of the research was that the instrument itself was identified as an appropriate and effective vehicle for the teacbing of pain assessment and management, especially since feedback can be immediate and provided in an objective fashion. The results of this study were presented hospital wide, and many units requested individual unit-based sessions with the presentation of hospital responses as compared to unit responses. Staff members were eager to participate by determining their responses and scores prior to the question being discussed and previous responses reviewed. Some questions initiated discussion of content areas not specifically on the survey. For example, the statement on promethazine prompted questions on antiemetic therapy. Discussions on addiction led to explanations and discussion on physical dependence and tolerance. A strength of the instrument as an educational tool is that it is applicable to all units in the hospital. It does not focus on a specific type of pain (i.e., acute, chronic), and it emphasizes the principles of pain assessment and management. After many unit presentations, the authors, experienced in the teaching of pain management, believe the tool to be a comprehensive and effective framework for presenting pain control concepts. Findings from the survey suggest that this institution may not be different from others with respect to knowledge toward pain assessment

25

and management, a~t~ougb our comparison was limited. The nursing staff mem some of the ‘standard’ incorrect beliefs on addiction and respiratory depression, which may stem from misinformation and attitudinal bias. Findings do indicate, however, that nurses lack information in pain management that is not necessarily tied to myths or bias lack of information with factua assist in devekiping the nurse’s and improve her/his understanding tice of pain management.

and prac-

1. Chapman P, Ganendran A, Scott R, Basford R. Attitudes and knowledge of nursing staff in relation to management of postoperative pain. Aust NZ J Surg 1987;57:447-450. 2. Spross J, McCuire D, Schmitt R. Oncology Nursing Society position paper on cancer pain. Oncol Nurs Forum 1990;17:595-614. 3. Cartwright P. Pain controii after surgery: a survey of current practice. Ann R Co11 Surg Engl 1985;67: 13-16. 4. Myers J. Cancer pain: assessment of nurses’ knowledge and attitudes. Oncol Nurs Forum 1985; 12:62-66. 5. Rankin M, Snider B. Nurses’ perceptions of cancer patients’ pain. Cancer Nurs 1984;7:14%155. 6. McCaffery M. Ferrell B. Do you know a narcotic when you see one? Nurs 1990;19:62&3. 7. McCaffery M, FerreU B, O’Neil-Page E, Lester M, Ferrell B. Nurses’ knowledge of opioid analgesic drugs and psychological dependence. Cancer Nurs 1990;13:21-27. 8. Watt-Watson 9. Nurses’ knowledge of pain issues: a survey. J Pain Symptom Manage 1987;2:207-211. 9. Weis 0, Sriwatanakul K, Alloza J, Weintraub M, Lasagna L. Attitudes of patients, housestaff and nurses towards postoperative analgesic care. Anesth Analg 1983;62:70-74. 10. Cohen F. Postsurgical pain relief: patients’ status and nurses’ medication choices. Pain 1980;9:265274. 11. Ketovuori H. Nurses’ and patients’ conceptions of wound pain and the administration of analgesics. J Pain Symptom Manage 1987;2:213-218. 12. Camp L. A comparison of nurses’ recorded assessments of pain with perceptions of pain as de-

26

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Journal of Pain and Sympm bfanagement

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Milit Med 1982;

13. Gokosky N, Reardon R. The accuracy of nurses’ and doctors’ perceptions of patient pain. In: Funk S, Tornquist E, Champagne M, Copp L, Wiese R, eds. Key aspects of comfort: management of pain, fatigue and nausea. New York: Springer Publications, 1989:127-134.

16. Charap A. The knowledge, attitudes and experience of medical personnel treating pain in the terminally ill. Mt Sinai J Med 1978;45:561-580.

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project.

Canadian