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An examination of critical care nurses' knowledge and attitudes regarding pain management in hospitalized patients
An Examination of Critical Care Nurses’ Knowledge and Attitudes Regarding Pain Management in Hospitalized Patients yyy E. Brantley Erkes, MS, RN, FNP-C,* Veronica G. Parker, PhD,† Rebecca L. Carr, PhD, RN, CS,† and Rachel M. Mayo, PhD‡
y
From the *Carolinas Center for Advanced Management of Pain, Greenville, SC; and the †School of Nursing and ‡Department of Public Health Sciences, Clemson University, Clemson, SC. Address correspondence and reprint requests to Veronica G. Parker, PhD, School of Nursing, Clemson University, 535-A Edwards Hall, Clemson, SC 29634. E-mail: [email protected]. © 2001 by the American Society of Pain Management Nurses 1524-9042/01/0202-0002$35.00/0 doi: 10.1053/jpmn.2001.23177
ABSTRACT:
The purpose of this study was to determine the effectiveness of an educational intervention focused on pain management. The sample consisted of 30 medical/surgical intensive care nurses (age range, 23 to 62 years) employed in a large metropolitan hospital in the southeastern United States. McCaffery and Ferrell’s Nurses’ Knowledge and Attitude Survey Regarding Pain was administered at 2 points in time: before and after the educational program. The survey simultaneously measures knowledge and attitude levels regarding pain control. The paired t test was used to test for differences between pre- and posttest scores. The Point-biserial and Spearman’s correlation coefficients were computed to examine relationships between selected sociodemographic variables and scores (baseline and change) on the survey. Results revealed a significant increase in scores after the educational intervention (t ⴝ 9.60. p ⴝ .0005). Additionally, a statistically significant correlation was found between change scores (posttest minus pretest scores) and years of nursing experience (rs ⴝ .37, p ⴝ .047). However, no significant relationships were found between type of nursing degree and baseline or change scores (rpb ⴝ .11, p ⴝ .575; rpb ⴝ .01, p ⴝ .955). These results support previous research findings related to the problem of inadequate pain management in the hospital setting. Further, the findings indicate that education regarding pain control is crucial for current nursing students as well as practicing nurses. The challenge for nurses is to be responsive to and integrate current pain management techniques in an effort to decrease the discomfort of hospitalized patients. © 2001 by the American Society of Pain Management Nurses Pain Management Nursing, Vol 2, No 2 (June), 2001: pp 47-53
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Many patients admitted to the hospital experience some degree of pain during the course of their stay. The management of this pain by nurses is under scrutiny because of reports of inadequate pain relief documented in the literature (Maxam-Moore, Wilkie, & Woods 1994; Tittle & McMillan, 1994). The National Institute of Nursing Research (1994) identified inpatient pain as a factor for increased hospital stay, longer recovery time, and poorer patient outcomes. Recent literature related to the issue of pain management suggests that there are limitations in the area of nursing knowledge related to clinical pain management techniques (Barnason, Merboth, Pozehl, & Tietjen, 1998). Literature from as long as 30 years ago suggests that patients in the hospital routinely experience moderate to severe uncontrolled pain (Lander, 1990). Lebovits et al. (1997) cited knowledge deficits of currently accepted practices regarding pain management and personal beliefs regarding pain control as possible impediments toward optimal care. Although nurses are not responsible for the prescription of pain medicine, the decision to administer or withhold pain medication is well within the nurse’s realm of practice. Nurses’ pre-existing beliefs/attitudes or knowledge deficits about pain management can affect the level of pain experienced by a patient while in the hospital (Clarke et al., 1996; Greipp, 1992b; McCaffery & Ferrell, 1997). Lebovits et al. (1997) noted the unwarranted fear of contributing to the patient’s addiction as an integral segment of the nurses’ knowledge deficit. McCaffery and Ferrell (1999) reported that nurses remain less likely to relieve the pain of a smiling patient than that of a grimacing patient, regardless of the patient’s own report of pain. There is a call for improved and consistent nursing education regarding proper pain management techniques in the hospital setting (McCaffery & Ferrell, 1999). The problem of inadequate pain management has attracted the attention of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which has released new Pain Standards in an effort to combat the continuance of patient pain in the hospital setting (JCAHO, 1999). Inadequate pain management for hospitalized patients can no longer go unrecognized because of, in part, national attention. The challenge for nurses is to be aware of and to integrate current pain management techniques in an effort to decrease the discomfort of hospitalized patients. The purpose of this study was to examine the knowledge and attitude levels (assessed simultaneously) of critical care nurses to determine the effectiveness of an educational intervention focused on pain management.
Theoretical Framework Greipp’s Model of Ethical Decision Making (1992a), which is based on general systems theory and examines the nurse’s ethical decision-making process, guided this study. In later work, Greipp (1992b) further applied the model to the nurse’s role in pain management, providing a framework for educational endeavors that can affect the management of pain. This linear model progresses from left to right, with the nurse appearing on the far left. The nurse’s learned potential inhibitors (LPIs), which consist of his/her belief system, culture, personal and professional experiences, and education, are located in the center of the model, comprising the ethical framework. Education is described as anything learned or taught that affects behavior. The ethical framework, normative and metaethics, is used to make decisions regarding patient care and, in this study, decisions pertaining to pain management. After this, the nursing process, in conjunction with the patient’s collaboration, is used to make health care decisions such as administration of pain medication. In the present study, interventions were developed to impact on the LPIs and the ethical framework of the nurse. The interventions consisted of a 1-hour videotape focused on pain management, as well as a self-learning module focused on pain control. In combination, these items represented the counterbalancing force used to modify the LPIs of critical care nurses. The intervention also served as a reinforcement of positive LPIs shown by the nurses before implementation of the educational process. Education is designated in the model as a counterbalancing force that can be used to “remediate culture biases that may adversely affect the quality or rightness of nursing care for the client in pain” (Greipp, 1992b, pp. 50, 51). Research Questions The following research questions were addressed in this study: (1) Will nurses’ knowledge and attitudes about pain management change after an educational intervention focused on pain control?; (2) Is there a correlation between type of nursing degree and scores (baseline and change) on the Nurses’ Knowledge and Attitudes Survey Regarding Pain?; and (3) Is there a correlation between years of experience and scores (baseline and change) on the Nurses’ Knowledge and Attitudes Survey Regarding Pain?
METHODOLOGY Study Design This study used a quasi-experimental design. This design was used to compare pre- and posttest scores to
Nurses’ Knowledge Regarding Pain Management
determine the effectiveness of an educational intervention focused on pain management. Specifically, information regarding nurses’ knowledge and attitudes about pain management was collected before and after an educational program. The educational intervention consisted of a 1-hour videotape, which was narrated by Gregory Formanek, MD, a regional oncology pain specialist. The videotape focused on current best practice in managing pain in the inpatient population. In addition, the intervention included a self-learning module focused on pain management. Participants were required to view the videotape within 2 weeks of completing the pretest. The posttest (same as pretest) was completed within a maximum of 2 weeks of viewing the videotape. All participants were given a unique identifier code with the distribution of the pre- and posttests. Sample Nurses who were employed in a 22-bed medical/surgical intensive care unit (ICU) of a large metropolitan hospital located in the southeastern United States comprised the sample. An invitation was extended to all eligible nurses. All participants met the following criteria: (1) employed full- or part-time as a registered nurse in the medical/surgical ICU and (2) had at least 1 year of experience in the profession of nursing. Appropriate Institutional Review Board approval was obtained before data collection and analyses. Consent forms were distributed and collected from each participant before data collection. The participants’ names were not linked to the study in any way, and there were no costs to participate. Instrument Data were collected by using a self-report questionnaire, developed by Ferrell and McCaffery (1998), entitled, Nurses’ Knowledge and Attitude Survey Regarding Pain. The instrument simultaneously assesses nurses’ knowledge and attitudes regarding pain management. McCaffery and Ferrell suggest not distinguishing between items as measuring either knowledge or attitudes. According to the researchers, many items measure knowledge and attitude issues simultaneously. Therefore, the authors of the questionnaire recommend analyzing data in terms of the percentage of complete scores. The Nurses’ Knowledge and Attitude Survey Regarding Pain has been used in numerous pain studies and has been tested for reliability and validity. Ferrell and McCaffery (1998) stated that “the content of the tool is derived from current standards of pain management such as the American Pain Society, the World Health Organization, and the Agency for Health Care
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Policy and Research” (p.1). Construct validity was established by comparing scores of nurses at various levels of expertise and has been identified as discriminating between levels of expertise. “Test-retest reliability (r ⬎ .80) was established by repeat testing in a continuing education class of staff nurses. Internal consistency reliability (alpha r ⬎ .70) was established, with the 37 items reflecting both knowledge and attitude domains” (p.1). Permission to use this tool was obtained from Dr Betty Ferrell (personal communication, August 1999). The Nurses’ Knowledge and Attitude Survey Regarding Pain takes approximately 1 hour to complete. A demographic questionnaire was also used to collect data regarding the nurse’s age, gender, type of nursing degree, years of nursing experience, and work status. Data Management and Analysis The Nurses’ Knowledge and Attitudes Survey Regarding Pain consists of 37 items and was scored with an overall percentage rating. The instrument consists of 22 true/false questions, with the remainder of the test being multiple choice (15 questions). Scores on the knowledge and attitude survey of less than 75% were considered to be low, scores of 75% to 84% were considered to be moderate, and scores of 85% or better were considered to be high. Gender was coded as 1 for women and 2 for men. Type of nursing degree was coded as 1 for an associate’s degree and 2 for a bachelor’s degree. Work status was coded as 1 for part-time and 2 for full-time. Actual ages and number of years of experience were collected and treated as continuous variables. Descriptive statistics (including frequency distributions, measures of central tendency, and measures of dispersion) were used to organize and summarize the data. Continuous or interval-level data were tested for normality, and appropriate statistical procedures were used to address each research question. The paired t test was used to test for differences between pre- and posttest scores. The Point-biserial correlation coefficient and Spearman’s correlation were computed to examine relationships between selected demographic variables and scores (baseline and change) on the survey. The level of significance (␣) was set at 0.05 for all analyses. The Statistical Product and Service Solutions (SPSS, version 8.0) package (SPSS, Chicago, IL) was used to analyze these data (SPSS, 1998).
RESULTS The interval-level data were tested for normality. Age, pretest scores, posttest scores, and change scores on the Nurses’ Knowledge and Attitude Survey Regarding
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Pain were found to be normally distributed. Number of years of nursing experience, however, was found to be non-normal. Parametric tests were used for normally distributed data and nonparametric procedures for non-normal data. Table 1 presents frequency distributions for the sociodemographic variables. The sample consisted of 30 critical care nurses (age range, 23 to 62 years). As shown, the majority of the nurses were 40 years and older (60.0%), with a mean age of 40.2 years. Most (80%) of the sample consisted of female ICU nurses. With respect to type of nursing degree, the sample was almost evenly split. Slightly more nurses earned a bachelor’s degree (53.3%) than an associate’s degree (46.7%). Most of the nurses worked full-time (86.7%), whereas only a small number worked part-time (13.3%). Participants ranged in years of experience from 2 to 36 years. The majority of nurses had 10 or less years of experience (56.7%), whereas the nurses with 21 or more years of experience accounted for the second largest group (23.3%). The mean years of experience for this sample was 12.9. Measures of central tendency and dispersion for pre- and posttest scores are displayed in Table 2. As shown, the mean pretest score was 72.9% and ranged from 51% to 92%. Typically, the posttest scores were
TABLE 1. Sociodemographic Characteristics of the Sample (N ⴝ 30) Variable Age (yr)* 20-29 30-39 40-49 50⫹ Gender Women Men Type of Nursing Degree ADN BSN Work Status Part-time Full-time Years of Experience† 1-5 6-10 11-20 21⫹
Frequency
Percentage
6 6 13 5
20.0 20.0 43.3 16.7
24 6
80.0 20.0
14 16
46.7 53.3
4 26
13.3 86.7
11 6 6 7
36.7 20.0 20.0 23.3
Abbreviations: ADN, associate degree in nursing; BSN, bachelor of science in nursing. *Mean age ⫽ 40.2 years, SD ⫽ 10.5 years. † Mean years of experience ⫽ 12.9, SD ⫽ 10.4.
TABLE 2. Measures of Central Tendency and Dispersion for Pretest and Posttest Knowledge and Attitude Percentage Scores Variable Pretest scores Posttest scores Change scores
Mean (SD) 72.9 (9.6) 86.2 (5.9) 13.3 (7.6)
Range 51 to 92 73 to 97 ⫺2 to ⫺30
higher than pretest scores. The mean posttest score was 86.2% and ranged from 73% to 97%. Change scores are also reported in Table 2; these scores represent the change in scores from pretest to posttest. On average, scores increased from pre- to posttesting by 13.3% points. Table 3 presents the number of participants correctly responding to each true/false item on the preand posttests. On the pretest, overall responses to several items revealed a lack of knowledge in certain areas. Of the 30 participants, only 11 (36.6%) knew that nonsteroidal anti-inflammatory drugs (NSAIDs) are effective analgesics for bone pain caused by metastases (item 6). Additionally, only 6 (20.0%) knew that aspirin 650 mg given orally is approximately equal in analgesic effect to Demerol (Alba Pharmaceutical, New York, NY) 50 mg given orally (item 9). The participants also showed knowledge deficits regarding the long-term use of opioids. For instance, less than half (46.6%) realized that morphine has no ceiling effect (item 14). In addition, of the 30 ICU nurses, only 19 knew that the side effects of opioids decrease over the amount of time they are prescribed (item 8). This finding was surprising because ICU nurses are educated on the use of opioids and dispense them daily. Two items presented problems on both the preand posttests. On the pretest, few (only 3 participants) knew that Phenergan (American Home Products, New York, NY) is not a reliable potentiator of opioid analgesics (item 12). Posttest results did not reflect a major increase in knowledge related to this item. Moreover, only 6 (20.0%) nurses were aware of the usual duration of meperidine given intramuscularly (IM) (item 11); however, results from the posttest revealed a decrease in knowledge levels because only 5 (16.6%) nurses answered this item correctly. Results of the paired t-test analysis revealed a significant change in nurses’ knowledge and attitude scores from baseline to postintervention (t ⫽ 9.60, p ⫽ .0005). Point-biserial correlation analyses indicated no statistically significant relationship between type of
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Nurses’ Knowledge Regarding Pain Management
TABLE 3. Number of Participants Responding Correctly to Each True/False Item on the Nurses’ Knowledge and Attitudes Survey Regarding Pain (N ⴝ 30) Item (Correct Response) 1. Observable changes in vital signs must be relied on to verify a patient’s statement that he/she has severe pain. (F) 2. Because of an underdeveloped neurologic system, children younger than 2 years have decreased pain sensitivity and a limited memory of painful experiences. (F) 3. If the patient can be distracted from his/her pain, this usually means that he/she does not have high pain intensity. (F) 4. Patients may sleep in spite of severe pain. (T) 5. Comparable stimuli in different people produce the same intensity of pain. (F) 6. Aspirin and other NSAIDs are NOT effective analgesics for bone pain caused by metastases. (F) 7. Nondrug interventions (e.g., heat, music, imagery, and so on) are very effective for mild to moderate pain control but are rarely helpful for more severe pain. (F) 8. Respiratory depression rarely occurs in patients who have been receiving opioids over a period of months. (T) 9. Aspirin 650 mg PO is approximately equal in analgesic effect to meperidine (Demerol) 50 mg PO. (T) 10. The World Health Organization pain ladder suggests using a single analgesic rather than combining classes of drugs (e.g., combining an opioid with a nonsteroidal agent). (F) 11. The usual duration of action of meperidine (Demerol) IM is 4 to 5 hours. (F) 12. Research shows that promethazine (Phenergan) is a reliable potentiator of opioid analgesics. (F) 13. Patients with a history of substance abuse should not be given opioids for pain because they are at high risk for repeated addiction. (F) 14. Beyond a certain dosage of morphine, increases in dosage will NOT increase pain relief. (F) 15. Elderly patients cannot tolerate opioids for pain relief. (F) 16. The patient with pain should be encouraged to endure as much pain as possible before resorting to a pain relief measure. (F) 17. Children younger than 11 years cannot report pain with reliability and therefore the nurse should rely on the parent’s assessment of the child’s pain intensity. (F) 18. Based on one’s religious beliefs, a patient may think that pain and suffering is necessary. (T) 19. After the initial recommended dose of opioid analgesic, subsequent doses are adjusted in accordance with the individual patient’s response. (T) 20. The patient should be advised to use nondrug techniques alone rather than concurrently with pain medications. (F) 21. Giving patients sterile water by injection (placebo) is often a useful test to determine if the pain is real. (F) 22. To be effective, heat and cold should only be applied to the painful ara. (F)
Pretest Number (%)
Posttest Number (%)
29 (96.6)
30 (100)
24 (80.0)
29 (96.6)
29 (96.6)
29 (96.6)
25 (83.3) 30 (100) 11 (36.6)
29 (96.6) 30 (100) 21 (70.0)
16 (53.3)
21 (70.0)
19 (63.3)
28 (93.3)
6 (20.0)
15 (50.0)
22 (73.3)
26 (86.6)
6 (20.0) 3 (10.0)
5 (16.6) 4 (13.3)
24 (80.0)
29 (96.6)
14 (46.6)
28 (93.3)
27 (90.0) 30 (100)
30 (100) 30 (100)
30 (100)
29 (96.6)
30 (100)
30 (100)
29 (96.6)
30 (100)
30 (100)
29 (96.6)
25 (83.3)
29 (96.6)
17 (56.6)
16 (53.3)
Abbreviations: T, true; F, false; PO, orally.
nursing degree and baseline or change scores (rpb ⫽ .11, p ⫽ .575; rpb ⫽ .01, p ⫽ .955). Spearman’s correlation analyses revealed a statistically significant correlation between years of experience and change scores (rs ⫽ .37, p ⫽ .047). However, no statistically significant relationship was found between years of experience and baseline scores (rs ⫽ -.33, p ⫽ .078). A total of 19 nurses (63.3%) scored below 75% on the pretest, indicating a low (preintervention) knowl-
edge and attitude score. Of these 19 nurses, 10 had at least 10 years of experience in the field of nursing. Only 1 of these nurses did not improve his/her score on the postintervention survey.
DISCUSSION On average, the nurses included in this study showed low baseline scores on the Nurses’ Knowledge and
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Attitudes Survey Regarding Pain (M ⫽ 72.9%). Only 11 of the 30 participants scored 75% or greater, showing moderate knowledge and attitude scores. Two nurses achieved 85% or greater, indicating high knowledge and attitude scores among 6% of the sample before the educational intervention. These findings are consistent with a study by Clarke et al. (1996) who found that there were deficiencies and inconsistencies in nurses’ knowledge regarding pain management as well as a persistence of inaccurate, negative attitudes about patients in pain. After the educational program, only 1 of the 30 participants scored less than 75% on the knowledge and attitude survey. Twenty-nine of the nurses improved their scores after the educational intervention. Nineteen of the participants scored 85% or better, whereas the overall scores of the nurses improved significantly (M ⫽ 86.2%, p ⫽ .0005). These scores indicated high knowledge and attitude levels regarding pain management after the educational intervention. These results, as in a study by McNaull, McLees, Beylea, & Clipp (1992), support the contention that an educational intervention that includes viewing a videotape focused on pain management is effective in teaching nurses about pain control. The nurses who participated in the study were almost evenly split between earning a bachelor’s degree (53.3%) and an associate’s degree (46.7%). Despite an adequate sampling of nurses with each type of nursing degree, results revealed no significant correlation between the type of nursing degree held by the participant and scores (baseline or change) on the knowledge and attitude survey. This finding supports the contention by McCaffery and Ferrell (1996) that educational interventions for nurses must be set in place for all nursing students as well as practicing nurses. The relationship between years of experience and scores (baseline and change) on the Nurses’ Knowledge and Attitude Survey Regarding Pain is complex. Although there were no statistically significant findings between years of experience and baseline scores, there were noticeably lower baseline scores shown by the nurses with the most years of experience. A larger sample of nurses may have revealed a statistically significant correlation between baseline scores on the survey and years of experience in nursing. Just under half of the sample (43.3%) had 11 or more years of experience in the field of nursing. Of the 7 nurses in this sample with 21 or more years of experience, only 3 achieved scores indicating a moderate knowledge and attitude level on the pretest, whereas none of them achieved a score indicating
high knowledge and attitude levels before the educational intervention. These results may have contributed to the significant findings between years of experience and change scores on the survey (p ⫽ .047). A correlation was found to exist between years of experience in the field of nursing and the amount of improvement from pretest to posttest scores (or change scores). The nurses who improved their scores the most were those with the most years of experience in their field. This correlation could be a result of the lower baseline scores, as mentioned previously, or the length of time since these nurses were educated in the field of nursing. Changes in nursing curriculum have taken place since most of the nurses with many years of experience have graduated from nursing school. This makes the education of practicing nurses in regard to current best practice for pain management even more important, as recommended by several researchers (McNaull et al., 1992; Janjan et al., 1996). Many of the nurses practicing today have not been in school for some time and would benefit greatly from educational programs regarding the best management of their patient’s pain.
CONCLUSIONS Greipp’s Model of Ethical Decision Making (1992b) links the nurse and the nurse’s belief system to the decision-making process in the management of patients with pain. It has been reported (Maxam-Moore et al., 1994; Wilkie & Woods, 1994; Tittle & McMillan, 1994) and suggested in this study that nurses’ knowledge and attitude levels regarding pain management are less than adequate. This affects the amount of pain experienced by patients. Patients experiencing pain unnecessarily are likely to have longer healing times and delays in advancing toward timely discharge (National Institute of Nursing Research, 1994). The problem of inadequate pain management not only leads to needless suffering by the patients but also to millions of extra dollars in health care expenditures for patients with poorer outcomes due to pain. Findings of this study support previous research findings related to the problem of inadequate pain management in the hospital setting. Nurses must be responsive to and integrate current pain management techniques in an effort to decrease the suffering of hospitalized patients. The authors recommend repeating this study with a larger sample size and including variables related to previous experiences with opioids (including abuse of pain medication on a professional or personal level) and pre-existing cultural, religious, or moral beliefs regarding pain medicine.
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REFERENCES Barnason, S., Merboth, M., Pozehl, B., & Tietjen, M. J. (1998). Utilizing an outcomes approach to pain management by nurses: A pilot study. Clinical Nurse Specialist, 12, 28-36. Clarke, E. B., French, B., Bilodeau, M. L., Capasso, V. C., Edwards, A., & Empoliti, J. (1996). Pain management knowledge, attitudes and clinical practice: The impact of nurses’ characteristics and education. Journal of Pain and Symptom Management, 11, 18-28. Ferrell, B. R., & McCaffery, M. (1998). Nurses Knowledge and Attitudes Survey Regarding Pain [On-line]. Accessed July 27, 1999. Available: http://mayday.coh.org/ Instruments/k&a.htm. Greipp, M. E. (1992a). Greipp’s model of ethical decision making. Journal of Advanced Nursing, 17, 734-738. Greipp, M. E. (1992b). Undermedication for pain: An ethical model. Advanced Nursing Science, 15, 44-53. Janjan, N. A., Martin, C. G., Payne, R., Dahl, J. L., Weissman, D. E., & Hill, S. C. (1996). Teaching cancer pain management: Durability of educational effects of a role model program. Cancer, 77, 996-1001. Joint Commission on Accreditation of Healthcare Organizations. (1999, October 10).New JCAHO pain standards [On-line]. Available: http://www.jcaho.org/standard/ pm_frm.html. Lander, J. (1990). Clinical judgements in pain management. Pain, 42, 15-22. Lebovits, A. H., Florence, I., Bathina, R., Hunko, V., Fox, M. T., & Bramble, C. Y. (1997). Pain knowledge and atti-
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tudes of healthcare providers: Practice characteristic differences. Clinical Journal of Pain, 13, 237-43. Maxam-Moore, V. A., Wilkie, D. J., & Woods, S. L. (1994). Analgesics for cardiac surgery patients in critical care: Describing current practice. American Journal of Critical Care, 3, 31-39. McCaffery, M., & Ferrell, B. R. (1999). Opioids and pain management: What do nurses know? Nursing, 29, 48-52. McCaffery, M., & Ferrell, B. R. (1997). Nurses’ knowledge of pain assessment and management: How much progress have we made? Journal of Pain and Symptom Management, 14, 175-188. McCaffery, M., & Ferrell, B. R. (1996). Correcting misconceptions about pain assessment and use of opioid analgesics: Educational strategies aimed at public concerns. Nursing Outlook, 44, 184-190. McNaull, F. W., McLees, J. P., Belyea, M. J., & Clipp, E. C. (1992). A comparison of educational methods to enhance nursing performance in pain assessment. The Journal of Continuing Education in Nursing, 23, 267-271. National Institute of Nursing Research (1994). A report of the NINR priority expert panel on symptom management: Acute pain (NIH Publication No. 94-2421). Rockville, MD: Department of Health and Human Services. Statistical Product and Service Solutions. (1998). SPSS for Windows (Version 8.0) [Computer software]. Chicago: SPSS. Tittle, M., & McMillan, S. C. (1994). Pain and pain related side effects in an ICU and on a surgical unit: Nurses management. American Journal of Critical Care, 3, 25-30.
y
From the *Carolinas Center for Advanced Management of Pain, Greenville, SC; and the †School of Nursing and ‡Department of Public Health Sciences, Clemson University, Clemson, SC. Address correspondence and reprint requests to Veronica G. Parker, PhD, School of Nursing, Clemson University, 535-A Edwards Hall, Clemson, SC 29634. E-mail: [email protected]. © 2001 by the American Society of Pain Management Nurses 1524-9042/01/0202-0002$35.00/0 doi: 10.1053/jpmn.2001.23177
ABSTRACT:
The purpose of this study was to determine the effectiveness of an educational intervention focused on pain management. The sample consisted of 30 medical/surgical intensive care nurses (age range, 23 to 62 years) employed in a large metropolitan hospital in the southeastern United States. McCaffery and Ferrell’s Nurses’ Knowledge and Attitude Survey Regarding Pain was administered at 2 points in time: before and after the educational program. The survey simultaneously measures knowledge and attitude levels regarding pain control. The paired t test was used to test for differences between pre- and posttest scores. The Point-biserial and Spearman’s correlation coefficients were computed to examine relationships between selected sociodemographic variables and scores (baseline and change) on the survey. Results revealed a significant increase in scores after the educational intervention (t ⴝ 9.60. p ⴝ .0005). Additionally, a statistically significant correlation was found between change scores (posttest minus pretest scores) and years of nursing experience (rs ⴝ .37, p ⴝ .047). However, no significant relationships were found between type of nursing degree and baseline or change scores (rpb ⴝ .11, p ⴝ .575; rpb ⴝ .01, p ⴝ .955). These results support previous research findings related to the problem of inadequate pain management in the hospital setting. Further, the findings indicate that education regarding pain control is crucial for current nursing students as well as practicing nurses. The challenge for nurses is to be responsive to and integrate current pain management techniques in an effort to decrease the discomfort of hospitalized patients. © 2001 by the American Society of Pain Management Nurses Pain Management Nursing, Vol 2, No 2 (June), 2001: pp 47-53
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Many patients admitted to the hospital experience some degree of pain during the course of their stay. The management of this pain by nurses is under scrutiny because of reports of inadequate pain relief documented in the literature (Maxam-Moore, Wilkie, & Woods 1994; Tittle & McMillan, 1994). The National Institute of Nursing Research (1994) identified inpatient pain as a factor for increased hospital stay, longer recovery time, and poorer patient outcomes. Recent literature related to the issue of pain management suggests that there are limitations in the area of nursing knowledge related to clinical pain management techniques (Barnason, Merboth, Pozehl, & Tietjen, 1998). Literature from as long as 30 years ago suggests that patients in the hospital routinely experience moderate to severe uncontrolled pain (Lander, 1990). Lebovits et al. (1997) cited knowledge deficits of currently accepted practices regarding pain management and personal beliefs regarding pain control as possible impediments toward optimal care. Although nurses are not responsible for the prescription of pain medicine, the decision to administer or withhold pain medication is well within the nurse’s realm of practice. Nurses’ pre-existing beliefs/attitudes or knowledge deficits about pain management can affect the level of pain experienced by a patient while in the hospital (Clarke et al., 1996; Greipp, 1992b; McCaffery & Ferrell, 1997). Lebovits et al. (1997) noted the unwarranted fear of contributing to the patient’s addiction as an integral segment of the nurses’ knowledge deficit. McCaffery and Ferrell (1999) reported that nurses remain less likely to relieve the pain of a smiling patient than that of a grimacing patient, regardless of the patient’s own report of pain. There is a call for improved and consistent nursing education regarding proper pain management techniques in the hospital setting (McCaffery & Ferrell, 1999). The problem of inadequate pain management has attracted the attention of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which has released new Pain Standards in an effort to combat the continuance of patient pain in the hospital setting (JCAHO, 1999). Inadequate pain management for hospitalized patients can no longer go unrecognized because of, in part, national attention. The challenge for nurses is to be aware of and to integrate current pain management techniques in an effort to decrease the discomfort of hospitalized patients. The purpose of this study was to examine the knowledge and attitude levels (assessed simultaneously) of critical care nurses to determine the effectiveness of an educational intervention focused on pain management.
Theoretical Framework Greipp’s Model of Ethical Decision Making (1992a), which is based on general systems theory and examines the nurse’s ethical decision-making process, guided this study. In later work, Greipp (1992b) further applied the model to the nurse’s role in pain management, providing a framework for educational endeavors that can affect the management of pain. This linear model progresses from left to right, with the nurse appearing on the far left. The nurse’s learned potential inhibitors (LPIs), which consist of his/her belief system, culture, personal and professional experiences, and education, are located in the center of the model, comprising the ethical framework. Education is described as anything learned or taught that affects behavior. The ethical framework, normative and metaethics, is used to make decisions regarding patient care and, in this study, decisions pertaining to pain management. After this, the nursing process, in conjunction with the patient’s collaboration, is used to make health care decisions such as administration of pain medication. In the present study, interventions were developed to impact on the LPIs and the ethical framework of the nurse. The interventions consisted of a 1-hour videotape focused on pain management, as well as a self-learning module focused on pain control. In combination, these items represented the counterbalancing force used to modify the LPIs of critical care nurses. The intervention also served as a reinforcement of positive LPIs shown by the nurses before implementation of the educational process. Education is designated in the model as a counterbalancing force that can be used to “remediate culture biases that may adversely affect the quality or rightness of nursing care for the client in pain” (Greipp, 1992b, pp. 50, 51). Research Questions The following research questions were addressed in this study: (1) Will nurses’ knowledge and attitudes about pain management change after an educational intervention focused on pain control?; (2) Is there a correlation between type of nursing degree and scores (baseline and change) on the Nurses’ Knowledge and Attitudes Survey Regarding Pain?; and (3) Is there a correlation between years of experience and scores (baseline and change) on the Nurses’ Knowledge and Attitudes Survey Regarding Pain?
METHODOLOGY Study Design This study used a quasi-experimental design. This design was used to compare pre- and posttest scores to
Nurses’ Knowledge Regarding Pain Management
determine the effectiveness of an educational intervention focused on pain management. Specifically, information regarding nurses’ knowledge and attitudes about pain management was collected before and after an educational program. The educational intervention consisted of a 1-hour videotape, which was narrated by Gregory Formanek, MD, a regional oncology pain specialist. The videotape focused on current best practice in managing pain in the inpatient population. In addition, the intervention included a self-learning module focused on pain management. Participants were required to view the videotape within 2 weeks of completing the pretest. The posttest (same as pretest) was completed within a maximum of 2 weeks of viewing the videotape. All participants were given a unique identifier code with the distribution of the pre- and posttests. Sample Nurses who were employed in a 22-bed medical/surgical intensive care unit (ICU) of a large metropolitan hospital located in the southeastern United States comprised the sample. An invitation was extended to all eligible nurses. All participants met the following criteria: (1) employed full- or part-time as a registered nurse in the medical/surgical ICU and (2) had at least 1 year of experience in the profession of nursing. Appropriate Institutional Review Board approval was obtained before data collection and analyses. Consent forms were distributed and collected from each participant before data collection. The participants’ names were not linked to the study in any way, and there were no costs to participate. Instrument Data were collected by using a self-report questionnaire, developed by Ferrell and McCaffery (1998), entitled, Nurses’ Knowledge and Attitude Survey Regarding Pain. The instrument simultaneously assesses nurses’ knowledge and attitudes regarding pain management. McCaffery and Ferrell suggest not distinguishing between items as measuring either knowledge or attitudes. According to the researchers, many items measure knowledge and attitude issues simultaneously. Therefore, the authors of the questionnaire recommend analyzing data in terms of the percentage of complete scores. The Nurses’ Knowledge and Attitude Survey Regarding Pain has been used in numerous pain studies and has been tested for reliability and validity. Ferrell and McCaffery (1998) stated that “the content of the tool is derived from current standards of pain management such as the American Pain Society, the World Health Organization, and the Agency for Health Care
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Policy and Research” (p.1). Construct validity was established by comparing scores of nurses at various levels of expertise and has been identified as discriminating between levels of expertise. “Test-retest reliability (r ⬎ .80) was established by repeat testing in a continuing education class of staff nurses. Internal consistency reliability (alpha r ⬎ .70) was established, with the 37 items reflecting both knowledge and attitude domains” (p.1). Permission to use this tool was obtained from Dr Betty Ferrell (personal communication, August 1999). The Nurses’ Knowledge and Attitude Survey Regarding Pain takes approximately 1 hour to complete. A demographic questionnaire was also used to collect data regarding the nurse’s age, gender, type of nursing degree, years of nursing experience, and work status. Data Management and Analysis The Nurses’ Knowledge and Attitudes Survey Regarding Pain consists of 37 items and was scored with an overall percentage rating. The instrument consists of 22 true/false questions, with the remainder of the test being multiple choice (15 questions). Scores on the knowledge and attitude survey of less than 75% were considered to be low, scores of 75% to 84% were considered to be moderate, and scores of 85% or better were considered to be high. Gender was coded as 1 for women and 2 for men. Type of nursing degree was coded as 1 for an associate’s degree and 2 for a bachelor’s degree. Work status was coded as 1 for part-time and 2 for full-time. Actual ages and number of years of experience were collected and treated as continuous variables. Descriptive statistics (including frequency distributions, measures of central tendency, and measures of dispersion) were used to organize and summarize the data. Continuous or interval-level data were tested for normality, and appropriate statistical procedures were used to address each research question. The paired t test was used to test for differences between pre- and posttest scores. The Point-biserial correlation coefficient and Spearman’s correlation were computed to examine relationships between selected demographic variables and scores (baseline and change) on the survey. The level of significance (␣) was set at 0.05 for all analyses. The Statistical Product and Service Solutions (SPSS, version 8.0) package (SPSS, Chicago, IL) was used to analyze these data (SPSS, 1998).
RESULTS The interval-level data were tested for normality. Age, pretest scores, posttest scores, and change scores on the Nurses’ Knowledge and Attitude Survey Regarding
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Pain were found to be normally distributed. Number of years of nursing experience, however, was found to be non-normal. Parametric tests were used for normally distributed data and nonparametric procedures for non-normal data. Table 1 presents frequency distributions for the sociodemographic variables. The sample consisted of 30 critical care nurses (age range, 23 to 62 years). As shown, the majority of the nurses were 40 years and older (60.0%), with a mean age of 40.2 years. Most (80%) of the sample consisted of female ICU nurses. With respect to type of nursing degree, the sample was almost evenly split. Slightly more nurses earned a bachelor’s degree (53.3%) than an associate’s degree (46.7%). Most of the nurses worked full-time (86.7%), whereas only a small number worked part-time (13.3%). Participants ranged in years of experience from 2 to 36 years. The majority of nurses had 10 or less years of experience (56.7%), whereas the nurses with 21 or more years of experience accounted for the second largest group (23.3%). The mean years of experience for this sample was 12.9. Measures of central tendency and dispersion for pre- and posttest scores are displayed in Table 2. As shown, the mean pretest score was 72.9% and ranged from 51% to 92%. Typically, the posttest scores were
TABLE 1. Sociodemographic Characteristics of the Sample (N ⴝ 30) Variable Age (yr)* 20-29 30-39 40-49 50⫹ Gender Women Men Type of Nursing Degree ADN BSN Work Status Part-time Full-time Years of Experience† 1-5 6-10 11-20 21⫹
Frequency
Percentage
6 6 13 5
20.0 20.0 43.3 16.7
24 6
80.0 20.0
14 16
46.7 53.3
4 26
13.3 86.7
11 6 6 7
36.7 20.0 20.0 23.3
Abbreviations: ADN, associate degree in nursing; BSN, bachelor of science in nursing. *Mean age ⫽ 40.2 years, SD ⫽ 10.5 years. † Mean years of experience ⫽ 12.9, SD ⫽ 10.4.
TABLE 2. Measures of Central Tendency and Dispersion for Pretest and Posttest Knowledge and Attitude Percentage Scores Variable Pretest scores Posttest scores Change scores
Mean (SD) 72.9 (9.6) 86.2 (5.9) 13.3 (7.6)
Range 51 to 92 73 to 97 ⫺2 to ⫺30
higher than pretest scores. The mean posttest score was 86.2% and ranged from 73% to 97%. Change scores are also reported in Table 2; these scores represent the change in scores from pretest to posttest. On average, scores increased from pre- to posttesting by 13.3% points. Table 3 presents the number of participants correctly responding to each true/false item on the preand posttests. On the pretest, overall responses to several items revealed a lack of knowledge in certain areas. Of the 30 participants, only 11 (36.6%) knew that nonsteroidal anti-inflammatory drugs (NSAIDs) are effective analgesics for bone pain caused by metastases (item 6). Additionally, only 6 (20.0%) knew that aspirin 650 mg given orally is approximately equal in analgesic effect to Demerol (Alba Pharmaceutical, New York, NY) 50 mg given orally (item 9). The participants also showed knowledge deficits regarding the long-term use of opioids. For instance, less than half (46.6%) realized that morphine has no ceiling effect (item 14). In addition, of the 30 ICU nurses, only 19 knew that the side effects of opioids decrease over the amount of time they are prescribed (item 8). This finding was surprising because ICU nurses are educated on the use of opioids and dispense them daily. Two items presented problems on both the preand posttests. On the pretest, few (only 3 participants) knew that Phenergan (American Home Products, New York, NY) is not a reliable potentiator of opioid analgesics (item 12). Posttest results did not reflect a major increase in knowledge related to this item. Moreover, only 6 (20.0%) nurses were aware of the usual duration of meperidine given intramuscularly (IM) (item 11); however, results from the posttest revealed a decrease in knowledge levels because only 5 (16.6%) nurses answered this item correctly. Results of the paired t-test analysis revealed a significant change in nurses’ knowledge and attitude scores from baseline to postintervention (t ⫽ 9.60, p ⫽ .0005). Point-biserial correlation analyses indicated no statistically significant relationship between type of
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TABLE 3. Number of Participants Responding Correctly to Each True/False Item on the Nurses’ Knowledge and Attitudes Survey Regarding Pain (N ⴝ 30) Item (Correct Response) 1. Observable changes in vital signs must be relied on to verify a patient’s statement that he/she has severe pain. (F) 2. Because of an underdeveloped neurologic system, children younger than 2 years have decreased pain sensitivity and a limited memory of painful experiences. (F) 3. If the patient can be distracted from his/her pain, this usually means that he/she does not have high pain intensity. (F) 4. Patients may sleep in spite of severe pain. (T) 5. Comparable stimuli in different people produce the same intensity of pain. (F) 6. Aspirin and other NSAIDs are NOT effective analgesics for bone pain caused by metastases. (F) 7. Nondrug interventions (e.g., heat, music, imagery, and so on) are very effective for mild to moderate pain control but are rarely helpful for more severe pain. (F) 8. Respiratory depression rarely occurs in patients who have been receiving opioids over a period of months. (T) 9. Aspirin 650 mg PO is approximately equal in analgesic effect to meperidine (Demerol) 50 mg PO. (T) 10. The World Health Organization pain ladder suggests using a single analgesic rather than combining classes of drugs (e.g., combining an opioid with a nonsteroidal agent). (F) 11. The usual duration of action of meperidine (Demerol) IM is 4 to 5 hours. (F) 12. Research shows that promethazine (Phenergan) is a reliable potentiator of opioid analgesics. (F) 13. Patients with a history of substance abuse should not be given opioids for pain because they are at high risk for repeated addiction. (F) 14. Beyond a certain dosage of morphine, increases in dosage will NOT increase pain relief. (F) 15. Elderly patients cannot tolerate opioids for pain relief. (F) 16. The patient with pain should be encouraged to endure as much pain as possible before resorting to a pain relief measure. (F) 17. Children younger than 11 years cannot report pain with reliability and therefore the nurse should rely on the parent’s assessment of the child’s pain intensity. (F) 18. Based on one’s religious beliefs, a patient may think that pain and suffering is necessary. (T) 19. After the initial recommended dose of opioid analgesic, subsequent doses are adjusted in accordance with the individual patient’s response. (T) 20. The patient should be advised to use nondrug techniques alone rather than concurrently with pain medications. (F) 21. Giving patients sterile water by injection (placebo) is often a useful test to determine if the pain is real. (F) 22. To be effective, heat and cold should only be applied to the painful ara. (F)
Pretest Number (%)
Posttest Number (%)
29 (96.6)
30 (100)
24 (80.0)
29 (96.6)
29 (96.6)
29 (96.6)
25 (83.3) 30 (100) 11 (36.6)
29 (96.6) 30 (100) 21 (70.0)
16 (53.3)
21 (70.0)
19 (63.3)
28 (93.3)
6 (20.0)
15 (50.0)
22 (73.3)
26 (86.6)
6 (20.0) 3 (10.0)
5 (16.6) 4 (13.3)
24 (80.0)
29 (96.6)
14 (46.6)
28 (93.3)
27 (90.0) 30 (100)
30 (100) 30 (100)
30 (100)
29 (96.6)
30 (100)
30 (100)
29 (96.6)
30 (100)
30 (100)
29 (96.6)
25 (83.3)
29 (96.6)
17 (56.6)
16 (53.3)
Abbreviations: T, true; F, false; PO, orally.
nursing degree and baseline or change scores (rpb ⫽ .11, p ⫽ .575; rpb ⫽ .01, p ⫽ .955). Spearman’s correlation analyses revealed a statistically significant correlation between years of experience and change scores (rs ⫽ .37, p ⫽ .047). However, no statistically significant relationship was found between years of experience and baseline scores (rs ⫽ -.33, p ⫽ .078). A total of 19 nurses (63.3%) scored below 75% on the pretest, indicating a low (preintervention) knowl-
edge and attitude score. Of these 19 nurses, 10 had at least 10 years of experience in the field of nursing. Only 1 of these nurses did not improve his/her score on the postintervention survey.
DISCUSSION On average, the nurses included in this study showed low baseline scores on the Nurses’ Knowledge and
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Attitudes Survey Regarding Pain (M ⫽ 72.9%). Only 11 of the 30 participants scored 75% or greater, showing moderate knowledge and attitude scores. Two nurses achieved 85% or greater, indicating high knowledge and attitude scores among 6% of the sample before the educational intervention. These findings are consistent with a study by Clarke et al. (1996) who found that there were deficiencies and inconsistencies in nurses’ knowledge regarding pain management as well as a persistence of inaccurate, negative attitudes about patients in pain. After the educational program, only 1 of the 30 participants scored less than 75% on the knowledge and attitude survey. Twenty-nine of the nurses improved their scores after the educational intervention. Nineteen of the participants scored 85% or better, whereas the overall scores of the nurses improved significantly (M ⫽ 86.2%, p ⫽ .0005). These scores indicated high knowledge and attitude levels regarding pain management after the educational intervention. These results, as in a study by McNaull, McLees, Beylea, & Clipp (1992), support the contention that an educational intervention that includes viewing a videotape focused on pain management is effective in teaching nurses about pain control. The nurses who participated in the study were almost evenly split between earning a bachelor’s degree (53.3%) and an associate’s degree (46.7%). Despite an adequate sampling of nurses with each type of nursing degree, results revealed no significant correlation between the type of nursing degree held by the participant and scores (baseline or change) on the knowledge and attitude survey. This finding supports the contention by McCaffery and Ferrell (1996) that educational interventions for nurses must be set in place for all nursing students as well as practicing nurses. The relationship between years of experience and scores (baseline and change) on the Nurses’ Knowledge and Attitude Survey Regarding Pain is complex. Although there were no statistically significant findings between years of experience and baseline scores, there were noticeably lower baseline scores shown by the nurses with the most years of experience. A larger sample of nurses may have revealed a statistically significant correlation between baseline scores on the survey and years of experience in nursing. Just under half of the sample (43.3%) had 11 or more years of experience in the field of nursing. Of the 7 nurses in this sample with 21 or more years of experience, only 3 achieved scores indicating a moderate knowledge and attitude level on the pretest, whereas none of them achieved a score indicating
high knowledge and attitude levels before the educational intervention. These results may have contributed to the significant findings between years of experience and change scores on the survey (p ⫽ .047). A correlation was found to exist between years of experience in the field of nursing and the amount of improvement from pretest to posttest scores (or change scores). The nurses who improved their scores the most were those with the most years of experience in their field. This correlation could be a result of the lower baseline scores, as mentioned previously, or the length of time since these nurses were educated in the field of nursing. Changes in nursing curriculum have taken place since most of the nurses with many years of experience have graduated from nursing school. This makes the education of practicing nurses in regard to current best practice for pain management even more important, as recommended by several researchers (McNaull et al., 1992; Janjan et al., 1996). Many of the nurses practicing today have not been in school for some time and would benefit greatly from educational programs regarding the best management of their patient’s pain.
CONCLUSIONS Greipp’s Model of Ethical Decision Making (1992b) links the nurse and the nurse’s belief system to the decision-making process in the management of patients with pain. It has been reported (Maxam-Moore et al., 1994; Wilkie & Woods, 1994; Tittle & McMillan, 1994) and suggested in this study that nurses’ knowledge and attitude levels regarding pain management are less than adequate. This affects the amount of pain experienced by patients. Patients experiencing pain unnecessarily are likely to have longer healing times and delays in advancing toward timely discharge (National Institute of Nursing Research, 1994). The problem of inadequate pain management not only leads to needless suffering by the patients but also to millions of extra dollars in health care expenditures for patients with poorer outcomes due to pain. Findings of this study support previous research findings related to the problem of inadequate pain management in the hospital setting. Nurses must be responsive to and integrate current pain management techniques in an effort to decrease the suffering of hospitalized patients. The authors recommend repeating this study with a larger sample size and including variables related to previous experiences with opioids (including abuse of pain medication on a professional or personal level) and pre-existing cultural, religious, or moral beliefs regarding pain medicine.
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