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Nurse Education Today 35 (2015) 921–925
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Nursing students' assessment of pain and decision of triage for different ethnic groups: An experimental study Joanne C.Y. Chan a,⁎, Takeshi Hamamura b a b
The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong School of Psychology and Speech Pathology, Curtin University, Australia
a r t i c l e
i n f o
Article history: Accepted 1 April 2015 Keywords: Pain Pain assessment Triage Nursing students Ethnic groups
s u m m a r y Background: Pain management is a priority in nursing care but little is known about the factors that affect nursing students' assessment of pain expressed by patients of different ethnic backgrounds. Objectives: This study examined undergraduate nursing students' assessment of pain and decision of triage when pain was expressed in different languages and their relation to students' empathy and social identity. Comparison between students with and without clinical experience was also carried out. Design: This is a cross-sectional quantitative design. Setting: This study took place at a university in Hong Kong. Participants: 74 female undergraduate nursing students. Methods: Students listened to eight audio recordings in which an individual expressed pain in one of the two dialects of Chinese, either Cantonese or Putonghua. For each dialect, two recordings depicted mild pain and two depicted severe pain. After listening to each recording, students rated the pain level and indicated their decision of triage. Subsequently, students completed a questionnaire that measured their empathy and social identity and reported their demographics. The data were analyzed by descriptive statistics, correlational analyses, and t-tests. Results: Severe pain described in Putonghua was rated as more intense than that described in Cantonese but it was not classified as more urgent. Students with clinical experience tended to perceive mild pain as less painful and less urgent than those without clinical experience. For mild pain described in Cantonese, students with clinical experience evaluated it as more urgent than those without such experience. The empathy level of students with and without clinical experience was comparable. Students with more empathy, especially those without clinical experience, reported heightened perceived intensity of severe pain described in Putonghua. Conclusions: Nurse educators should note that empathy, social identity, and clinical experience may alter students' pain assessment of patients from different ethnicities. Pain education needs to be reinforced. © 2015 Elsevier Ltd. All rights reserved.
Introduction
Background
Pain management is a priority in health care but it has not been thoroughly addressed (Duke et al., 2013). To meet the pain management needs of patients from diverse backgrounds, it is essential to prepare nurses adequately, as their interaction with patients is the most frequent among all healthcare providers (Duke et al., 2013). Better still, if nursing students are sufficiently prepared for pain management, they can readily contribute to the effective pain management of patients once they enter the workforce (Al-Khawaldeh et al., 2013). The first step in pain management is an accurate assessment of pain. As nurse educators, understanding the accuracy of nursing students' assessment of pain and its associating factors is pivotal for educational and training purposes.
Pain Management and Nursing Students
⁎ Corresponding author at: The Nethersole School of Nursing, Rm 827, Esther Lee Building, The Chinese University of Hong Kong, Shatin, The New Territories, Hong Kong. Tel.: +852 3943 6023; fax: +852 2603 5935. E-mail address: [email protected] (J.C.Y. Chan).
http://dx.doi.org/10.1016/j.nedt.2015.04.004 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
Previous research on pain management and nursing students has mainly focused on their pain knowledge and attitudes. Nursing students in different countries such as the United States, Iran, and Jordan have been surveyed and have consistently revealed their inadequacy in pain knowledge as well as attitudes (Al Khalaileh and Al Qadire, 2013; Al-Khawaldeh et al., 2013; Duke et al., 2013; Plaisance and Logan, 2006; Rahimi‐Madiseh et al., 2010). Several pain education programs that aimed at improving nursing students' pain knowledge and attitudes have also been documented (e.g., Keefe and Wharrad, 2012; MacLaren et al., 2008; Owens et al., 2014). Other researchers have examined the back pain beliefs of female nursing students (Burnett et al., 2009), student nurses' misconceptions of chronic nonmalignant pain (Shaw and Lee, 2010), and nursing students' conceptions and experiences of pain (Bergh et al., 2008).
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One knowledge gap in nursing students' pain management is the consideration of facilitators, barriers, and associating factors, psychological factors in particular, with regard to the assessment of pain. In this study, we aimed to fill the research gap by investigating associations between empathy and social identity of Hong Kong Chinese nursing students with regard to the assessment of pain of patients from two different ethnicities, namely, Mainland Chinese and Hong Kong Chinese.
and outgroup members (Brewer and Brown, 1998). As such, among nursing students in Hong Kong, those identifying strongly with Hong Kong culture may assess pain expressed by Hong Kongers relatively more favorably (e.g., pain is more severe and requires more urgent medical attention) than pain expressed by Mainland Chinese.
Empathy of Nursing Students
In this study, we aimed to compare nursing students' assessment of pain in two ethnic groups—Hong Kong Chinese and Mainland Chinese in Hong Kong. As the experimental design made use of audio recordings, we used the Cantonese and Putonghua dialects in the current study to mark the identity of Hong Kong Chinese and Mainland Chinese, respectively. Our objectives were to investigate (1) whether nursing students in Hong Kong would judge the pain level of Hong Kong Chinese and Mainland Chinese differently; (2) whether Hong Kong Chinese and Mainland Chinese would be triaged differently at different pain levels (mild pain versus severe pain); (3) whether there were any differences between students who had not started clinical placement versus students who have had clinical placement in pain assessment and triage; (4) whether there were any associations between nursing students' empathy and their perception of pain, and whether such an association was evident in evaluating pain expressed by Hong Kong Chinese and Mainland Chinese; (5) whether there were any associations between nursing students' identification with Hong Kong and their perception of pain; and (6) whether social identity was predictive of more favorable judgments (more intense perceived pain and more urgent triaging) of Hong Kong Chinese over Mainland Chinese.
Empathy is defined as “the ability to understand another person's feelings, experience etc” (Oxford Advanced Learner's English–Chinese Dictionary, 2004, p. 556). It is an important element for caring and for maintaining a caring environment (Cunico et al., 2012). To establish and maintain nurse–patient relations, nurses need to have empathy but little is known about nursing students' empathy (McKenna et al., 2012). McKenna et al. (2012) found that nursing students in Australia had a high empathy level with a mean of 107.34 within a possible range of scores of 20–140 on the Jefferson Scale of Physician Empathy (Health Professional Version). A longitudinal study on undergraduate nursing students in Turkey found that students had an increase in empathic skills but a decrease in empathic tendency throughout their education (Ozcan et al., 2010). Ward et al. (2012) also found that undergraduate nursing students decreased their empathy with increased exposure to patients. According to Cikara et al. (2011), whether people will have empathy for others may depend on whether they have a common ground, for example, membership in the same social, religious, or cultural group. Different group membership may result in a failure of empathy (Cikara et al., 2011). However, there is limited research on how nursing students' empathy may affect their pain assessment of individuals who are in the same ethnic group as they are (ingroup) compared with those who are not (outgroup), and whether having clinical experience will make a difference in their pain assessment. Pain Assessment of Patients from Different Ethnic Groups In Hong Kong, ethnicity differences, especially the difference between Hong Kongers and recent immigrants from Mainland China, are a salient societal issue. In recent years, the competition between Mainland Chinese and Hong Kong Chinese over healthcare resources in Hong Kong has created tension and has led to policy change. For instance, in January 2013, “[A] ban was introduced on mainland women giving birth in public hospitals, whether or not they were married to [a] Hongkonger” (Siu, 2014). As such, an investigation of how nursing students respond to pain expressed by Hong Kongers and Mainland Chinese is timely and important. Such an investigation can also extend previous research findings. Previous research has repeatedly identified ethnic and racial differences in pain assessment and nurses have identified cultural differences as one of the top barriers in pain management (Strassels et al., 2008, as cited in Duke et al., 2013; Tait and Chibnall, 2014). In addition, racial differences have been observed in triage assessment, for example, African American and Hispanic patients were less likely to be assessed as having an urgent condition compared with whites (López et al., 2010). Nevertheless, little research, if any, has compared nursing students' assessment of pain and triage of patients from different ethnic groups of the same race, as in the case of the differences between Hong Kongers and Mainland Chinese. Such an investigation is important in illuminating cues, for example, dialects of Chinese that are spoken by Hong Kongers (Cantonese) and Mainland Chinese (Putonghua), that may underlie nurses' differential assessment of pain experienced among patients from different ethnic groups. In addition, there are likely substantial individual differences among nursing students regarding these issues. One factor that may predict such variation would be social identification. The strength of individuals' identification with their own social group, or social identity, is known to have implications on the differentiation between ingroup
Aims of the Current Study
Methods Participants Announcement of the study was made in class for students in their second and third year of study at The Nethersole School of Nursing, The Chinese University of Hong Kong. The researcher specified that recruitment was for female nursing students only. Only female students were recruited because they are proportionally representative in each level of nursing education in Hong Kong. The final sample consisted of 80 female nursing students. About half of the students were secondand third-year students from a four-year curriculum who had already taken clinical practicum, whereas the other half were second-year students from a five-year curriculum who had not yet had such experience. Most students in this program were multilingual, competent in at least three languages: Cantonese, Putonghua, and English. Cantonese was the mother tongue for all but one participant. English is the official medium of instruction for the Faculty of Medicine at this university, to which the School of Nursing belongs, and all the participants had learned Putonghua for at least three years (M = 11.69, SD = 4.13). The study materials described below were presented in English, except for the pain evaluation task as detailed below. Procedure The study took place in a computer room on campus at The Chinese University of Hong Kong. Multiple sessions were arranged and the students participated in groups. A website containing the consent form, the study materials and the questionnaires with demographics was created for the study. After completing the consent form, the participants were asked to put on their headphones and begin the study. They listened to eight short audio recordings of pain descriptions on the computer. These descriptions were narrated by female postgraduate nursing students. With reference to the Pain Intensity Verbal Rating Scale in Chinese, half of the clips described severe pain—pain was described as “crucifying pain” (Chung et al., 1999) with corresponding voice tones. The other half of the clips described mild pain––pain was
J.C.Y. Chan, T. Hamamura / Nurse Education Today 35 (2015) 921–925
described as “painful” (Chung et al., 1999) with corresponding voice tones. The severity of pain was crossed with language. Hence, half of the clips were recorded in Putonghua and the other half in Cantonese by native speakers of the respective language. In summary, there were two clips each for severe and mild pain narrated in both Cantonese and Putonghua. After listening to each clip, the participants answered two questions. The first question asked the participants to assess the pain expressed in the clip on a scale of 0 for “no pain” to 10 for the “worst possible pain.” The second question asked the participants to triage the individual as either “critical,” “emergency,” “urgent,” “semi-urgent,” or “non-urgent.” The responses were indicated on a 5-point scale with the higher number indicating lower urgency. These triage labels were adopted from the Guide to Accident & Emergency Services by the Hospital Authority of Hong Kong (Hospital Authority, Internet source). After listening to all the clips, the participants were asked whether they recognized any of the voices in the audio clips. Those who answered yes to this question were excluded from the analyses to prevent the possibility of their knowledge affecting the results. Hence, although the study was originally administered to 80 students, responses from six of them were excluded for this reason. Next, the participants completed a questionnaire consisting of the following measures. Empathy was measured by the empathic concern subscale of the interpersonal reactivity index (Davis, 1983). The subscale consisted of seven items (alpha = .66). Sample items were “I often have tender, concerned feelings for people less fortunate than me” and “Sometimes I don't feel very sorry for other people when they are having problems” (reverse item). Wordings in three items were changed to facilitate better understanding among the participants, with advice from the author of the scale. Responses were indicated on 5-point scales ranging from “does not describe me well” to “describes me very well.” The participants' social identification was measured by four items (alpha = .82) adopted from past research (Roccas et al., 2010). These items were “Being a Hong Konger is an important part of my identity,” “I see myself as a typical Hong Konger,” “The term Hong Konger describes my identity well,” and “When I talk about Hong Kongers I usually say ‘we’ instead of ‘they’.” Responses were indicated on 5-point scales ranging from “strongly disagree” to “strongly agree.” After completing the study, the students provided demographic information including their age and mother tongue. Students were given HKD20 (~USD3) as a token of appreciation. Ethical Considerations Ethics approval was obtained from the Survey and Behavioral Research Ethics Committee at The Chinese University of Hong Kong. Results Data Analysis Strategy The analyses focused on whether verbal expressions of pain recorded in the audio clips were more or less painful depending on the severity of pain expressed and the language in which pain was expressed. We also analyzed whether participants' prior clinical experience affected their pain ratings. T-tests and ANOVAs were used for these analyses. Role of participants' social identity and empathy in affecting their pain ratings was analyzed by computing correlations. Perceived Intensity and Urgency of Pain as Functions of Description Language and Nursing Students' Clinical Experience Table 1 reports the descriptive statistics of the means and standard deviations of perceived pain level, decision of triage, identification with Hong Kong, and empathy of students with and without clinical experience. First, we examined whether the severity of pain described in
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the audio clips was differentiated as intended. As expected, overall, the descriptions of severe pain were rated as more painful [t(73) = 20.62, p b .001] and requiring more urgent attention [t(74) = 16.22, p b .001] than the descriptions of mild pain. This pattern, however, emerged somewhat differently across languages. Specifically, severe pain described in Putonghua was rated as more painful than severe pain described in Cantonese [t(73) = 2.01, p = .05]. This may be due to the descriptions of severe pain that conveyed more intense pain being (unexpectedly) assigned to Putonghua. Or it might have been that severe pain described in Putonghua sounded more intense than severe pain described in Cantonese. Despite this difference, the nursing students did not triage severe pain described in Putonghua more urgently (t b 1). Hence, although severe pain described in Putonghua was perceived as more serious than severe pain described in Cantonese, it was not judged as requiring more urgent attention. We also examined whether the descriptions of pain were perceived and classified differently depending on whether the participants had prior clinical experience. This analysis revealed that the severity of perceived pain was more differentiated among the students without prior clinical experience than those with such experience [F (1, 73) = 3.93, p = .05]. In particular, though the two groups did not differ on how they perceived severe pain, students with clinical experience tended to perceive mild pain as less painful than those without clinical experience, though this difference was not statistically significant [F (1, 72) = 1.82, p = .18]. A similar pattern was found for triaging [F (1, 73) = 2.90, p = .09] and this pattern was driven by students with clinical experience rating mild pain less urgently than those without clinical experience [F (1, 73) = 5.03, p = .03]. In addition to these patterns, a close inspection of the data suggests that in triaging mild pain described in Cantonese, the two groups of students differed [t(73) = 2.35, p = .02], and the description was evaluated as deserving more urgent attention among students with clinical experience compared with those without such experience. Role of Social Identity To test whether students' social identity had any influence on their decision of triage, correlational analyses were performed to test the relationship between their identification with Hong Kong and the triage of a patient when pain was expressed in Cantonese. This analysis found that among the participants with clinical experience, identification with Hong Kong predicted more urgent classification of mild pain (r = − .28, p = .09). Interestingly, this pattern was not evident among the students without clinical experience (r = .03, ns). Correlations were not significant between the students' social identity and the classification of severe pain expressed in Cantonese. Table 1 Means and standard deviations of the variables measured for students with and without clinical experience. Students with clinical experience (n = 38)
Students without clinical experience (n = 36)
Perceived pain (11-point scale ranging from 0: no pain to 10: worst pain possible) Cantonese severe 5.84 (1.76) 5.76 (1.85) Cantonese mild 3.80 (1.54) 3.26 (1.57) Putonghua severe 6.16 (1.55) 6.29 (1.68) Putonghua mild 3.54 (1.64) 3.17 (1.73) Triaging (5 -point scale ranging from 1: critical to 5: non-urgent). Cantonese severe 3.34 (.80) 3.41 (.82) Cantonese mild 4.07 (.67) 4.41 (.58) Putonghua severe 3.26 (.72) 3.31 (.77) Putonghua mild 4.26 (.64) 4.42 (.51) 3.95 (.59) 4.09 (.56) Identification with Hong Kong (5 -point scale ranging from 1: strongly disagree to 5: strongly agree). 3.70 (.54) 3.75 (.47) Empathy (5 -point scale ranging from 1: does not describe me well to 5: describes me very well).
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Role of Empathy Next, we analyzed the role of empathy in the participants' assessment and triage of the pain descriptions. There was a significant positive correlation between empathy and perceived intensity of severe pain described in Putonghua (r = .25, p = .03). This pattern was more strongly evident among students with no clinical experience (r = .32, p = .05). Correlations were not significant between students' empathy and mild pain described in Putonghua or pain described in Cantonese (either for assessment or for triage). Discussion Pain Assessment, Decision of Triage, and Clinical Experience The results revealed some differences in the Hong Kong Chinese nursing students' assessment of pain of Hong Kong Chinese compared with Mainland Chinese. In general, nursing students in this study rated severe pain expressed in Putonghua as more intense than that in Cantonese but did not triage the individuals differently. As a result, the individuals with severe pain were classified between urgent and emergency during triage, regardless of the language they spoke. One possible explanation is that the differences in pain levels were not perceived to be sufficient for classification into two different levels in triage. An alternative explanation is that the students had a tendency to underestimate the urgency of Mainland Chinese pain, so even though they were assessed as having more severe pain, they were subjected to a similar triage outcome as Hong Kong Chinese. Another difference with regard to clinical experience was that students without clinical experience tended to regard mild pain as more painful and more urgent than those with clinical experience. One speculation of this finding is that these students lacked exposure to pain expressed by patients and thus overestimated mild pain. For those with clinical experience, they might have observed how patients with mild pain might overreport their pain and thus they interpreted the mild pain with a reduction in the pain level. Another possibility is that with real-life exposure to different levels of pain expressed by patients, students became more calibrated to mild pain, which comparatively has fewer implications for treatment compared with severe pain.
the triage decision will not be made independently before they become registered nurses. We used postgraduate nursing students as actresses in the audio tapes and they were not actually in pain when they reported pain. According to Hall-Lord and Larsson (2006), the use of hypothetical patients provides insufficient information and there is a gap between how nurses assess hypothetical patients compared with real patients. Future research should take place in clinical settings with real patients. Postgraduate nursing students were instructed to express “crucifying pain” that corresponded to level 10 and “painful” that corresponded to level 4 on a pain intensity scale (Chung et al., 1999). According to Puntillo et al. (2003, p. 172), “Nurses' pain assessments were deemed to be accurate if their scores were no greater or less than one point different from the patients' reported pain.” The results showed that most participants underestimated both levels of pain, regardless of whether they had clinical placement experience. This could be due to the underexpression of pain by the actresses or the students might have had a tendency to underestimate pain in general. As stated earlier, nurses' assessment of patients' pain not only relies on their verbal expression of pain. The absence of other cues in the study may account for the underestimation of pain in “patients” who were expressing pain. Only female postgraduate students were used as patients in the current study and given inconsistent evidence with regard to gender differences in pain management (Hirsh et al., 2014), future research should also investigate how nursing students assess the pain of male patients from different ethnic backgrounds. Students in this study were from one school of nursing, which might have limited the generalizability of the results. Only female nursing students were used in the study and future research should include male nursing students as well. The evaluation of empathy and social identification relied on self-report and might have issues of social desirability. Implications for Nursing Education
There were some indications of pain described in Cantonese as being judged relatively more favorably than pain described in Putonghua among those who strongly identified with Hong Kong culture, and such a tendency was more apparent among students with clinical experience. Our interpretation of this finding is that pain experienced by ingroup members was assessed more favorably by students with greater exposure to healthcare settings in Hong Kong. There was no statistically significant difference in empathy between students with and without clinical placement experience. Students, especially those without clinical experience, reported greater perceived intensity of severe pain described in Putonghua. One possible interpretation is that empathy was an important feature for nursing students who had a tendency to perceive severe pain with more intensity in people who were not from their ethnic group. However, clinical experience might have diffused the impact of empathy on pain assessment.
While the expression of pain can be a very subjective matter and can be influenced by the patients' gender and culture, enabling nursing students to assess pain accurately is a priority in nursing education. The current study provided insight into how nursing students might assess pain differently depending on the language in which pain was expressed, implying that there might be a discrepancy among patients from different ethnic groups. As nurse educators, using soundtracks with real patients from different ethnic backgrounds recorded while they are hospitalized to teach and test pain assessment may be deemed appropriate in enhancing students' accuracy of pain assessment. Such a learning activity may be especially useful to students prior to their first clinical placement. According to Duke et al. (2013), in general, inadequacy in knowledge and attitudes of nursing students with regard to pain is evident. With the increase in globalization, nursing students will have increased opportunities to care for patients from different ethnic backgrounds, which may complicate pain assessment if they are not sufficiently prepared (Campesino, 2008; Lim et al., 2004). Being able to assess pain and care for ingroup and outgroup members equally is pivotal in quality nursing care. Therefore, nurse educators can endeavor to design learning activities that facilitate students' understanding of ethnic differences to enhance their cultural awareness and respect for ethnic groups that are different from their own.
Limitations of the Study
Conclusions
In reality, nurses base their pain assessment not only on patients' verbal expression of pain but also visual cues such as facial expression and body language as well as physical assessment. Therefore, although this study attempts to highlight the impact of language on pain assessment, it does not mirror the full circumstances of pain assessment. In addition, nursing students will be supervised by registered nurses and
This is the first study to examine undergraduate nursing students' assessment of pain and decision of triage of Hong Kong Chinese and Mainland Chinese, which are two ethnicities of the same race. Results showed that the severe pain of Mainland Chinese was rated as more painful but not triaged more urgently. Students without clinical experience had a tendency to assess mild pain as more painful and urgent
Pain Assessment, Social Identity, and Empathy
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compared with those with clinical experience. In addition, empathy and social identity contributed to the students' assessment of pain of their ingroup members versus the outgroup members. More research on the pain assessment of patients from different ethnic groups is warranted. Nursing educators also need to enhance nursing students' accuracy of pain assessment in general and ensure equal pain assessment of patients from different ethnic groups. Acknowledgments Payments to the participants were funded by Direct Grant (# 4052006) awarded to Hamamura from The Chinese University of Hong Kong. Preparation of the manuscript was supported by departmental grant from The Nethersole School of Nursing. We would like to thank the postgraduate students at The Nethersole School of Nursing for their help in the experiment, Yi Xu and Mak Ka Wai for their help in data collection, and Leung Ming Shin, Jade for her help in the preparation of the manuscript. References Al Khalaileh, M., Al Qadire, M., 2013. Pain management in Jordan: nursing students' knowledge and attitude. Br. J. Nurs. 22 (21), 1234–1240. http://dx.doi.org/10. 12968/bjon.2013.22.21.1234. Al-Khawaldeh, O.A., Al-Hussami, M., Darawad, M., 2013. Knowledge and attitudes regarding pain management among Jordanian nursing students. Nurse Educ. Today 33 (4), 339–345. http://dx.doi.org/10.1016/j.nedt.2013.01.006. Bergh, I., Jakobsson, E., Sjöström, B., 2008. Worst experiences of pain and conceptions of worst pain imaginable among nursing students. J. Adv. Nurs. 61 (5), 484–491. http://dx.doi.org/10.1111/j.1365-2648.2007.04506.x. Brewer, M.B., Brown, R.B., 1998. Intergroup relations. In: Gilbert, D.T., Fiske, S.T., Lindzey, G. (Eds.), The Handbook of Social Psychology, 4th ed. vol. 2. McGraw-Hill, Boston, pp. 554–594. Burnett, A., Sze, C.C., Tam, S.M., Yeung, K.M., Leong, M., Wang, W.T., O' Sullivan, P., 2009. A cross-cultural study of the back pain beliefs of female undergraduate healthcare students. Clin. J. Pain 25 (1), 20–28. http://dx.doi.org/10.1097/AJP.0b013e3181805a1e. Campesino, M., 2008. Beyond transculturalism: critiques of cultural education in nursing. J. Nurs. Educ. 47 (7), 298–304. http://dx.doi.org/10.3928/01484834-20080701-02. Chung, J.W.Y., Wong, C.H., Yang, J.C.S., Wong, T.K.S., 1999. The construction of a pain intensity verbal rating scale in Chinese. Acta Anaesthesiol. Sin. 37 (2), 65–71. Cikara, M., Bruneau, E.G., Saxe, R.R., 2011. Us and them: intergroup failures of empathy. Curr. Dir. Psychol. Sci. 20 (3), 149–153. http://dx.doi.org/10.1177/0963721411408713. Cunico, L., Sartori, R., Marognolli, O., Meneghini, A.M., 2012. Developing empathy in nursing students: a cohort longitudinal study. J. Clin. Nurs. 21 (13‐14), 2016–2025. http:// dx.doi.org/10.1111/j.1365-2702.2012.04105.x. Davis, M.H., 1983. Measuring individual differences in empathy: evidence for a multidimensional approach. J. Pers. Soc. Psychol. 44 (1), 113. http://dx.doi.org/10.1037/ 0022-3514.44.1.113. Duke, G., Haas, B.K., Yarbrough, S., Northam, S., 2013. Pain management knowledge and attitudes of baccalaureate nursing students and faculty. Pain Manag. Nurs. 14 (1), 11–19. http://dx.doi.org/10.1016/j.pmn.2010.03.006.
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Nursing students' assessment of pain and decision of triage for different ethnic groups: An experimental study Joanne C.Y. Chan a,⁎, Takeshi Hamamura b a b
The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong School of Psychology and Speech Pathology, Curtin University, Australia
a r t i c l e
i n f o
Article history: Accepted 1 April 2015 Keywords: Pain Pain assessment Triage Nursing students Ethnic groups
s u m m a r y Background: Pain management is a priority in nursing care but little is known about the factors that affect nursing students' assessment of pain expressed by patients of different ethnic backgrounds. Objectives: This study examined undergraduate nursing students' assessment of pain and decision of triage when pain was expressed in different languages and their relation to students' empathy and social identity. Comparison between students with and without clinical experience was also carried out. Design: This is a cross-sectional quantitative design. Setting: This study took place at a university in Hong Kong. Participants: 74 female undergraduate nursing students. Methods: Students listened to eight audio recordings in which an individual expressed pain in one of the two dialects of Chinese, either Cantonese or Putonghua. For each dialect, two recordings depicted mild pain and two depicted severe pain. After listening to each recording, students rated the pain level and indicated their decision of triage. Subsequently, students completed a questionnaire that measured their empathy and social identity and reported their demographics. The data were analyzed by descriptive statistics, correlational analyses, and t-tests. Results: Severe pain described in Putonghua was rated as more intense than that described in Cantonese but it was not classified as more urgent. Students with clinical experience tended to perceive mild pain as less painful and less urgent than those without clinical experience. For mild pain described in Cantonese, students with clinical experience evaluated it as more urgent than those without such experience. The empathy level of students with and without clinical experience was comparable. Students with more empathy, especially those without clinical experience, reported heightened perceived intensity of severe pain described in Putonghua. Conclusions: Nurse educators should note that empathy, social identity, and clinical experience may alter students' pain assessment of patients from different ethnicities. Pain education needs to be reinforced. © 2015 Elsevier Ltd. All rights reserved.
Introduction
Background
Pain management is a priority in health care but it has not been thoroughly addressed (Duke et al., 2013). To meet the pain management needs of patients from diverse backgrounds, it is essential to prepare nurses adequately, as their interaction with patients is the most frequent among all healthcare providers (Duke et al., 2013). Better still, if nursing students are sufficiently prepared for pain management, they can readily contribute to the effective pain management of patients once they enter the workforce (Al-Khawaldeh et al., 2013). The first step in pain management is an accurate assessment of pain. As nurse educators, understanding the accuracy of nursing students' assessment of pain and its associating factors is pivotal for educational and training purposes.
Pain Management and Nursing Students
⁎ Corresponding author at: The Nethersole School of Nursing, Rm 827, Esther Lee Building, The Chinese University of Hong Kong, Shatin, The New Territories, Hong Kong. Tel.: +852 3943 6023; fax: +852 2603 5935. E-mail address: [email protected] (J.C.Y. Chan).
http://dx.doi.org/10.1016/j.nedt.2015.04.004 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
Previous research on pain management and nursing students has mainly focused on their pain knowledge and attitudes. Nursing students in different countries such as the United States, Iran, and Jordan have been surveyed and have consistently revealed their inadequacy in pain knowledge as well as attitudes (Al Khalaileh and Al Qadire, 2013; Al-Khawaldeh et al., 2013; Duke et al., 2013; Plaisance and Logan, 2006; Rahimi‐Madiseh et al., 2010). Several pain education programs that aimed at improving nursing students' pain knowledge and attitudes have also been documented (e.g., Keefe and Wharrad, 2012; MacLaren et al., 2008; Owens et al., 2014). Other researchers have examined the back pain beliefs of female nursing students (Burnett et al., 2009), student nurses' misconceptions of chronic nonmalignant pain (Shaw and Lee, 2010), and nursing students' conceptions and experiences of pain (Bergh et al., 2008).
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One knowledge gap in nursing students' pain management is the consideration of facilitators, barriers, and associating factors, psychological factors in particular, with regard to the assessment of pain. In this study, we aimed to fill the research gap by investigating associations between empathy and social identity of Hong Kong Chinese nursing students with regard to the assessment of pain of patients from two different ethnicities, namely, Mainland Chinese and Hong Kong Chinese.
and outgroup members (Brewer and Brown, 1998). As such, among nursing students in Hong Kong, those identifying strongly with Hong Kong culture may assess pain expressed by Hong Kongers relatively more favorably (e.g., pain is more severe and requires more urgent medical attention) than pain expressed by Mainland Chinese.
Empathy of Nursing Students
In this study, we aimed to compare nursing students' assessment of pain in two ethnic groups—Hong Kong Chinese and Mainland Chinese in Hong Kong. As the experimental design made use of audio recordings, we used the Cantonese and Putonghua dialects in the current study to mark the identity of Hong Kong Chinese and Mainland Chinese, respectively. Our objectives were to investigate (1) whether nursing students in Hong Kong would judge the pain level of Hong Kong Chinese and Mainland Chinese differently; (2) whether Hong Kong Chinese and Mainland Chinese would be triaged differently at different pain levels (mild pain versus severe pain); (3) whether there were any differences between students who had not started clinical placement versus students who have had clinical placement in pain assessment and triage; (4) whether there were any associations between nursing students' empathy and their perception of pain, and whether such an association was evident in evaluating pain expressed by Hong Kong Chinese and Mainland Chinese; (5) whether there were any associations between nursing students' identification with Hong Kong and their perception of pain; and (6) whether social identity was predictive of more favorable judgments (more intense perceived pain and more urgent triaging) of Hong Kong Chinese over Mainland Chinese.
Empathy is defined as “the ability to understand another person's feelings, experience etc” (Oxford Advanced Learner's English–Chinese Dictionary, 2004, p. 556). It is an important element for caring and for maintaining a caring environment (Cunico et al., 2012). To establish and maintain nurse–patient relations, nurses need to have empathy but little is known about nursing students' empathy (McKenna et al., 2012). McKenna et al. (2012) found that nursing students in Australia had a high empathy level with a mean of 107.34 within a possible range of scores of 20–140 on the Jefferson Scale of Physician Empathy (Health Professional Version). A longitudinal study on undergraduate nursing students in Turkey found that students had an increase in empathic skills but a decrease in empathic tendency throughout their education (Ozcan et al., 2010). Ward et al. (2012) also found that undergraduate nursing students decreased their empathy with increased exposure to patients. According to Cikara et al. (2011), whether people will have empathy for others may depend on whether they have a common ground, for example, membership in the same social, religious, or cultural group. Different group membership may result in a failure of empathy (Cikara et al., 2011). However, there is limited research on how nursing students' empathy may affect their pain assessment of individuals who are in the same ethnic group as they are (ingroup) compared with those who are not (outgroup), and whether having clinical experience will make a difference in their pain assessment. Pain Assessment of Patients from Different Ethnic Groups In Hong Kong, ethnicity differences, especially the difference between Hong Kongers and recent immigrants from Mainland China, are a salient societal issue. In recent years, the competition between Mainland Chinese and Hong Kong Chinese over healthcare resources in Hong Kong has created tension and has led to policy change. For instance, in January 2013, “[A] ban was introduced on mainland women giving birth in public hospitals, whether or not they were married to [a] Hongkonger” (Siu, 2014). As such, an investigation of how nursing students respond to pain expressed by Hong Kongers and Mainland Chinese is timely and important. Such an investigation can also extend previous research findings. Previous research has repeatedly identified ethnic and racial differences in pain assessment and nurses have identified cultural differences as one of the top barriers in pain management (Strassels et al., 2008, as cited in Duke et al., 2013; Tait and Chibnall, 2014). In addition, racial differences have been observed in triage assessment, for example, African American and Hispanic patients were less likely to be assessed as having an urgent condition compared with whites (López et al., 2010). Nevertheless, little research, if any, has compared nursing students' assessment of pain and triage of patients from different ethnic groups of the same race, as in the case of the differences between Hong Kongers and Mainland Chinese. Such an investigation is important in illuminating cues, for example, dialects of Chinese that are spoken by Hong Kongers (Cantonese) and Mainland Chinese (Putonghua), that may underlie nurses' differential assessment of pain experienced among patients from different ethnic groups. In addition, there are likely substantial individual differences among nursing students regarding these issues. One factor that may predict such variation would be social identification. The strength of individuals' identification with their own social group, or social identity, is known to have implications on the differentiation between ingroup
Aims of the Current Study
Methods Participants Announcement of the study was made in class for students in their second and third year of study at The Nethersole School of Nursing, The Chinese University of Hong Kong. The researcher specified that recruitment was for female nursing students only. Only female students were recruited because they are proportionally representative in each level of nursing education in Hong Kong. The final sample consisted of 80 female nursing students. About half of the students were secondand third-year students from a four-year curriculum who had already taken clinical practicum, whereas the other half were second-year students from a five-year curriculum who had not yet had such experience. Most students in this program were multilingual, competent in at least three languages: Cantonese, Putonghua, and English. Cantonese was the mother tongue for all but one participant. English is the official medium of instruction for the Faculty of Medicine at this university, to which the School of Nursing belongs, and all the participants had learned Putonghua for at least three years (M = 11.69, SD = 4.13). The study materials described below were presented in English, except for the pain evaluation task as detailed below. Procedure The study took place in a computer room on campus at The Chinese University of Hong Kong. Multiple sessions were arranged and the students participated in groups. A website containing the consent form, the study materials and the questionnaires with demographics was created for the study. After completing the consent form, the participants were asked to put on their headphones and begin the study. They listened to eight short audio recordings of pain descriptions on the computer. These descriptions were narrated by female postgraduate nursing students. With reference to the Pain Intensity Verbal Rating Scale in Chinese, half of the clips described severe pain—pain was described as “crucifying pain” (Chung et al., 1999) with corresponding voice tones. The other half of the clips described mild pain––pain was
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described as “painful” (Chung et al., 1999) with corresponding voice tones. The severity of pain was crossed with language. Hence, half of the clips were recorded in Putonghua and the other half in Cantonese by native speakers of the respective language. In summary, there were two clips each for severe and mild pain narrated in both Cantonese and Putonghua. After listening to each clip, the participants answered two questions. The first question asked the participants to assess the pain expressed in the clip on a scale of 0 for “no pain” to 10 for the “worst possible pain.” The second question asked the participants to triage the individual as either “critical,” “emergency,” “urgent,” “semi-urgent,” or “non-urgent.” The responses were indicated on a 5-point scale with the higher number indicating lower urgency. These triage labels were adopted from the Guide to Accident & Emergency Services by the Hospital Authority of Hong Kong (Hospital Authority, Internet source). After listening to all the clips, the participants were asked whether they recognized any of the voices in the audio clips. Those who answered yes to this question were excluded from the analyses to prevent the possibility of their knowledge affecting the results. Hence, although the study was originally administered to 80 students, responses from six of them were excluded for this reason. Next, the participants completed a questionnaire consisting of the following measures. Empathy was measured by the empathic concern subscale of the interpersonal reactivity index (Davis, 1983). The subscale consisted of seven items (alpha = .66). Sample items were “I often have tender, concerned feelings for people less fortunate than me” and “Sometimes I don't feel very sorry for other people when they are having problems” (reverse item). Wordings in three items were changed to facilitate better understanding among the participants, with advice from the author of the scale. Responses were indicated on 5-point scales ranging from “does not describe me well” to “describes me very well.” The participants' social identification was measured by four items (alpha = .82) adopted from past research (Roccas et al., 2010). These items were “Being a Hong Konger is an important part of my identity,” “I see myself as a typical Hong Konger,” “The term Hong Konger describes my identity well,” and “When I talk about Hong Kongers I usually say ‘we’ instead of ‘they’.” Responses were indicated on 5-point scales ranging from “strongly disagree” to “strongly agree.” After completing the study, the students provided demographic information including their age and mother tongue. Students were given HKD20 (~USD3) as a token of appreciation. Ethical Considerations Ethics approval was obtained from the Survey and Behavioral Research Ethics Committee at The Chinese University of Hong Kong. Results Data Analysis Strategy The analyses focused on whether verbal expressions of pain recorded in the audio clips were more or less painful depending on the severity of pain expressed and the language in which pain was expressed. We also analyzed whether participants' prior clinical experience affected their pain ratings. T-tests and ANOVAs were used for these analyses. Role of participants' social identity and empathy in affecting their pain ratings was analyzed by computing correlations. Perceived Intensity and Urgency of Pain as Functions of Description Language and Nursing Students' Clinical Experience Table 1 reports the descriptive statistics of the means and standard deviations of perceived pain level, decision of triage, identification with Hong Kong, and empathy of students with and without clinical experience. First, we examined whether the severity of pain described in
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the audio clips was differentiated as intended. As expected, overall, the descriptions of severe pain were rated as more painful [t(73) = 20.62, p b .001] and requiring more urgent attention [t(74) = 16.22, p b .001] than the descriptions of mild pain. This pattern, however, emerged somewhat differently across languages. Specifically, severe pain described in Putonghua was rated as more painful than severe pain described in Cantonese [t(73) = 2.01, p = .05]. This may be due to the descriptions of severe pain that conveyed more intense pain being (unexpectedly) assigned to Putonghua. Or it might have been that severe pain described in Putonghua sounded more intense than severe pain described in Cantonese. Despite this difference, the nursing students did not triage severe pain described in Putonghua more urgently (t b 1). Hence, although severe pain described in Putonghua was perceived as more serious than severe pain described in Cantonese, it was not judged as requiring more urgent attention. We also examined whether the descriptions of pain were perceived and classified differently depending on whether the participants had prior clinical experience. This analysis revealed that the severity of perceived pain was more differentiated among the students without prior clinical experience than those with such experience [F (1, 73) = 3.93, p = .05]. In particular, though the two groups did not differ on how they perceived severe pain, students with clinical experience tended to perceive mild pain as less painful than those without clinical experience, though this difference was not statistically significant [F (1, 72) = 1.82, p = .18]. A similar pattern was found for triaging [F (1, 73) = 2.90, p = .09] and this pattern was driven by students with clinical experience rating mild pain less urgently than those without clinical experience [F (1, 73) = 5.03, p = .03]. In addition to these patterns, a close inspection of the data suggests that in triaging mild pain described in Cantonese, the two groups of students differed [t(73) = 2.35, p = .02], and the description was evaluated as deserving more urgent attention among students with clinical experience compared with those without such experience. Role of Social Identity To test whether students' social identity had any influence on their decision of triage, correlational analyses were performed to test the relationship between their identification with Hong Kong and the triage of a patient when pain was expressed in Cantonese. This analysis found that among the participants with clinical experience, identification with Hong Kong predicted more urgent classification of mild pain (r = − .28, p = .09). Interestingly, this pattern was not evident among the students without clinical experience (r = .03, ns). Correlations were not significant between the students' social identity and the classification of severe pain expressed in Cantonese. Table 1 Means and standard deviations of the variables measured for students with and without clinical experience. Students with clinical experience (n = 38)
Students without clinical experience (n = 36)
Perceived pain (11-point scale ranging from 0: no pain to 10: worst pain possible) Cantonese severe 5.84 (1.76) 5.76 (1.85) Cantonese mild 3.80 (1.54) 3.26 (1.57) Putonghua severe 6.16 (1.55) 6.29 (1.68) Putonghua mild 3.54 (1.64) 3.17 (1.73) Triaging (5 -point scale ranging from 1: critical to 5: non-urgent). Cantonese severe 3.34 (.80) 3.41 (.82) Cantonese mild 4.07 (.67) 4.41 (.58) Putonghua severe 3.26 (.72) 3.31 (.77) Putonghua mild 4.26 (.64) 4.42 (.51) 3.95 (.59) 4.09 (.56) Identification with Hong Kong (5 -point scale ranging from 1: strongly disagree to 5: strongly agree). 3.70 (.54) 3.75 (.47) Empathy (5 -point scale ranging from 1: does not describe me well to 5: describes me very well).
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Role of Empathy Next, we analyzed the role of empathy in the participants' assessment and triage of the pain descriptions. There was a significant positive correlation between empathy and perceived intensity of severe pain described in Putonghua (r = .25, p = .03). This pattern was more strongly evident among students with no clinical experience (r = .32, p = .05). Correlations were not significant between students' empathy and mild pain described in Putonghua or pain described in Cantonese (either for assessment or for triage). Discussion Pain Assessment, Decision of Triage, and Clinical Experience The results revealed some differences in the Hong Kong Chinese nursing students' assessment of pain of Hong Kong Chinese compared with Mainland Chinese. In general, nursing students in this study rated severe pain expressed in Putonghua as more intense than that in Cantonese but did not triage the individuals differently. As a result, the individuals with severe pain were classified between urgent and emergency during triage, regardless of the language they spoke. One possible explanation is that the differences in pain levels were not perceived to be sufficient for classification into two different levels in triage. An alternative explanation is that the students had a tendency to underestimate the urgency of Mainland Chinese pain, so even though they were assessed as having more severe pain, they were subjected to a similar triage outcome as Hong Kong Chinese. Another difference with regard to clinical experience was that students without clinical experience tended to regard mild pain as more painful and more urgent than those with clinical experience. One speculation of this finding is that these students lacked exposure to pain expressed by patients and thus overestimated mild pain. For those with clinical experience, they might have observed how patients with mild pain might overreport their pain and thus they interpreted the mild pain with a reduction in the pain level. Another possibility is that with real-life exposure to different levels of pain expressed by patients, students became more calibrated to mild pain, which comparatively has fewer implications for treatment compared with severe pain.
the triage decision will not be made independently before they become registered nurses. We used postgraduate nursing students as actresses in the audio tapes and they were not actually in pain when they reported pain. According to Hall-Lord and Larsson (2006), the use of hypothetical patients provides insufficient information and there is a gap between how nurses assess hypothetical patients compared with real patients. Future research should take place in clinical settings with real patients. Postgraduate nursing students were instructed to express “crucifying pain” that corresponded to level 10 and “painful” that corresponded to level 4 on a pain intensity scale (Chung et al., 1999). According to Puntillo et al. (2003, p. 172), “Nurses' pain assessments were deemed to be accurate if their scores were no greater or less than one point different from the patients' reported pain.” The results showed that most participants underestimated both levels of pain, regardless of whether they had clinical placement experience. This could be due to the underexpression of pain by the actresses or the students might have had a tendency to underestimate pain in general. As stated earlier, nurses' assessment of patients' pain not only relies on their verbal expression of pain. The absence of other cues in the study may account for the underestimation of pain in “patients” who were expressing pain. Only female postgraduate students were used as patients in the current study and given inconsistent evidence with regard to gender differences in pain management (Hirsh et al., 2014), future research should also investigate how nursing students assess the pain of male patients from different ethnic backgrounds. Students in this study were from one school of nursing, which might have limited the generalizability of the results. Only female nursing students were used in the study and future research should include male nursing students as well. The evaluation of empathy and social identification relied on self-report and might have issues of social desirability. Implications for Nursing Education
There were some indications of pain described in Cantonese as being judged relatively more favorably than pain described in Putonghua among those who strongly identified with Hong Kong culture, and such a tendency was more apparent among students with clinical experience. Our interpretation of this finding is that pain experienced by ingroup members was assessed more favorably by students with greater exposure to healthcare settings in Hong Kong. There was no statistically significant difference in empathy between students with and without clinical placement experience. Students, especially those without clinical experience, reported greater perceived intensity of severe pain described in Putonghua. One possible interpretation is that empathy was an important feature for nursing students who had a tendency to perceive severe pain with more intensity in people who were not from their ethnic group. However, clinical experience might have diffused the impact of empathy on pain assessment.
While the expression of pain can be a very subjective matter and can be influenced by the patients' gender and culture, enabling nursing students to assess pain accurately is a priority in nursing education. The current study provided insight into how nursing students might assess pain differently depending on the language in which pain was expressed, implying that there might be a discrepancy among patients from different ethnic groups. As nurse educators, using soundtracks with real patients from different ethnic backgrounds recorded while they are hospitalized to teach and test pain assessment may be deemed appropriate in enhancing students' accuracy of pain assessment. Such a learning activity may be especially useful to students prior to their first clinical placement. According to Duke et al. (2013), in general, inadequacy in knowledge and attitudes of nursing students with regard to pain is evident. With the increase in globalization, nursing students will have increased opportunities to care for patients from different ethnic backgrounds, which may complicate pain assessment if they are not sufficiently prepared (Campesino, 2008; Lim et al., 2004). Being able to assess pain and care for ingroup and outgroup members equally is pivotal in quality nursing care. Therefore, nurse educators can endeavor to design learning activities that facilitate students' understanding of ethnic differences to enhance their cultural awareness and respect for ethnic groups that are different from their own.
Limitations of the Study
Conclusions
In reality, nurses base their pain assessment not only on patients' verbal expression of pain but also visual cues such as facial expression and body language as well as physical assessment. Therefore, although this study attempts to highlight the impact of language on pain assessment, it does not mirror the full circumstances of pain assessment. In addition, nursing students will be supervised by registered nurses and
This is the first study to examine undergraduate nursing students' assessment of pain and decision of triage of Hong Kong Chinese and Mainland Chinese, which are two ethnicities of the same race. Results showed that the severe pain of Mainland Chinese was rated as more painful but not triaged more urgently. Students without clinical experience had a tendency to assess mild pain as more painful and urgent
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compared with those with clinical experience. In addition, empathy and social identity contributed to the students' assessment of pain of their ingroup members versus the outgroup members. More research on the pain assessment of patients from different ethnic groups is warranted. Nursing educators also need to enhance nursing students' accuracy of pain assessment in general and ensure equal pain assessment of patients from different ethnic groups. Acknowledgments Payments to the participants were funded by Direct Grant (# 4052006) awarded to Hamamura from The Chinese University of Hong Kong. Preparation of the manuscript was supported by departmental grant from The Nethersole School of Nursing. We would like to thank the postgraduate students at The Nethersole School of Nursing for their help in the experiment, Yi Xu and Mak Ka Wai for their help in data collection, and Leung Ming Shin, Jade for her help in the preparation of the manuscript. References Al Khalaileh, M., Al Qadire, M., 2013. Pain management in Jordan: nursing students' knowledge and attitude. Br. J. Nurs. 22 (21), 1234–1240. http://dx.doi.org/10. 12968/bjon.2013.22.21.1234. Al-Khawaldeh, O.A., Al-Hussami, M., Darawad, M., 2013. Knowledge and attitudes regarding pain management among Jordanian nursing students. Nurse Educ. Today 33 (4), 339–345. http://dx.doi.org/10.1016/j.nedt.2013.01.006. Bergh, I., Jakobsson, E., Sjöström, B., 2008. Worst experiences of pain and conceptions of worst pain imaginable among nursing students. J. Adv. Nurs. 61 (5), 484–491. http://dx.doi.org/10.1111/j.1365-2648.2007.04506.x. Brewer, M.B., Brown, R.B., 1998. Intergroup relations. In: Gilbert, D.T., Fiske, S.T., Lindzey, G. (Eds.), The Handbook of Social Psychology, 4th ed. vol. 2. McGraw-Hill, Boston, pp. 554–594. Burnett, A., Sze, C.C., Tam, S.M., Yeung, K.M., Leong, M., Wang, W.T., O' Sullivan, P., 2009. A cross-cultural study of the back pain beliefs of female undergraduate healthcare students. Clin. J. Pain 25 (1), 20–28. http://dx.doi.org/10.1097/AJP.0b013e3181805a1e. Campesino, M., 2008. Beyond transculturalism: critiques of cultural education in nursing. J. Nurs. Educ. 47 (7), 298–304. http://dx.doi.org/10.3928/01484834-20080701-02. Chung, J.W.Y., Wong, C.H., Yang, J.C.S., Wong, T.K.S., 1999. The construction of a pain intensity verbal rating scale in Chinese. Acta Anaesthesiol. Sin. 37 (2), 65–71. Cikara, M., Bruneau, E.G., Saxe, R.R., 2011. Us and them: intergroup failures of empathy. Curr. Dir. Psychol. Sci. 20 (3), 149–153. http://dx.doi.org/10.1177/0963721411408713. Cunico, L., Sartori, R., Marognolli, O., Meneghini, A.M., 2012. Developing empathy in nursing students: a cohort longitudinal study. J. Clin. Nurs. 21 (13‐14), 2016–2025. http:// dx.doi.org/10.1111/j.1365-2702.2012.04105.x. Davis, M.H., 1983. Measuring individual differences in empathy: evidence for a multidimensional approach. J. Pers. Soc. Psychol. 44 (1), 113. http://dx.doi.org/10.1037/ 0022-3514.44.1.113. Duke, G., Haas, B.K., Yarbrough, S., Northam, S., 2013. Pain management knowledge and attitudes of baccalaureate nursing students and faculty. Pain Manag. Nurs. 14 (1), 11–19. http://dx.doi.org/10.1016/j.pmn.2010.03.006.
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