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Knowledge and Attitudes of Pain Management Among Nursing Faculty
Original Article Knowledge and Attitudes of Pain Management Among Nursing Faculty ---
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From the *School of Nursing, Graceland University, Independence, Missouri; †Oakland University, Rochester, Michigan; ‡Kent State University, North Canton, Ohio. Address correspondence to Barbara Voshall, DNP, RN, School of Nursing, Graceland University, 1311 Deer Run Trail, Blue Springs, MO 64015-1742. E-mail: [email protected] or [email protected] (B.V.) Received January 5, 2012; Revised January 31, 2012; Accepted February 3, 2012. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2012.02.001
Barbara Voshall, DNP, RN,* Karen S. Dunn, PhD, RN,† and Debra Shelestak, PhD, RN‡
ABSTRACT:
A descriptive correlational design was used in this study to examine nursing faculty knowledge and attitudes in pain management. Relationships between age, education level, pain management preparation, length of time practicing as a nurse, length of time teaching nursing, time teaching pain management in the classroom, taught pain guidelines in the classroom, and additional continuing education about pain management were explored. Ninety-six nursing faculty participated from 16 schools of nursing in one Midwestern U.S. region. Findings identified that most of the nursing faculty recalled being taught about pain management in their basic education, but less than one-half felt adequately prepared. Most respondents said that they taught pain management, yet fewer than one-half identified that they used specific pain management guidelines. Faculty demonstrated adequate knowledge of pain assessment, spiritual/cultural issues, and pathophysiology. Areas of weakness were found in medications, interventions, and addiction. Faculty that reported teaching pain management in the classroom and reported more continuing education missed fewer items. Older nursing faculty reported more years of practice, more years of teaching, and more continuing education in pain management than younger faculty. Younger nursing faculty remembered being taught pain management in nursing school and felt more adequately prepared than older nursing faculty. Faculty that reported practicing for longer periods of time felt less prepared in pain management than faculty who practiced for shorter periods of time. More continuing education in pain management may be needed for older nurses to meet the recommendations of the Institute of Medicines’ report on relieving pain in the U.S. Ó 2013 by the American Society for Pain Management Nursing Successful pain management remains a challenge for nursing despite the Joint Commission’s mandate authorizing that every patient has a right to have their pain assessed and managed adequately (Joint Commission , 2010). For example, management of acute postoperative pain remains a major problem in hospitalized patients. Lellan (2004) found unacceptable levels of pain reported among Pain Management Nursing, Vol 14, No 4 (December), 2013: pp e226-e235
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postoperative patients in an experimental study that used a pretest-posttest design aimed to investigate their pain experiences. Sauaia, Leber, Erbacher, Abrams, and Fink (2005) found that 51% of a sample of patients reported that their postoperative pain was too much to bear. Those authors concluded that the potential reason may be related to the lack of pain management education in nursing curricula. Ferrell, Viranie, and Grant (2000) evaluated 700 nursing textbooks and reported that pain management was not adequately covered. In addition, MacLaren, Cohen, Larkin, and Shelton (2008) reported a lack of cognitive-behavioral therapy strategies for pain management in nursing courses. Goodrich (2006) found in a convenience sample of baccalaureate nursing students that faculty appeared to have basic knowledge of pain management, but the integration of pain management was inconsistent in the curriculum. Zalon (1995) cited that nurses are given the responsibility to manage pain, yet earlier research has suggested that educational programs may not have adequately prepared nurses on this topic. Barriers to adequate pain management were identified in a study of 180 nurses who worked with surgical patients (Knaggs, 2008). Reasons for not administering adequate pain medications included inadequate assessment of patients’ pain levels. In that study, nurses were using their own assessment of pain levels from nonverbal cues without asking for a self-report. Other reasons included lack of time due to shortage of staff, lack of knowledge of pain medications, patients’ reluctance to ask for medication, and potential opioid side effects (e.g., respiratory depression, excessive sedation, nausea, constipation, hypotension, pruritus, and retention of urine) (Knaggs, 2008). These side effects may cause nurses to use lower opioid dosages and thus inadequately manage pain intensity levels after surgery (Schafheutle, Cantrill, & Noyce, 2001). On graduation, nurses need to be prepared to practice in a safe manner, be accurate in management of medications, and have compassion for patients in a variety of settings Benner, Leonard, & Day (2010). Benner argued that quality education in complex areas is needed to decrease the education-practice gap. Further, nursing educators are responsible to improve patient outcomes through effective teaching methods, and the ability for students to demonstrate knowledge of this content has been identified as a nurse educator competency (Halstead, 2007). From these reported findings, it is unclear whether nursing education and/or curriculums are lacking in pain management strategies, therefore the need to evaluate nursing faculty levels of knowledge in this area is warranted. Therefore, the purpose of the present research study was to examine nursing faculty’s knowledge of
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pain management and explore its relationships with: 1) age; 2) education level; 3) pain management preparation; 4) length of time practicing as a nurse; 5) length of time teaching nursing; 6) time teaching pain management in the classroom; 7) taught pain guidelines in the classroom; and 8) additional continuing education about pain management. Findings from this study may identify areas in need of improvement in educational programs on pain management.
THEORETIC FRAMEWORK The framework of this study was based on King’s (1981) theory of goal attainment. King viewed nursing as an interactive process that leads to attainment of goals. During this interaction, King emphasized the importance of verbal and nonverbal communication. King’s theory is also based on an assumption that a nurse and patient work together to address health issues. Within this framework, the assessment of pain would then depend on: 1) the capacity of the nurse to recognize and communicate with patients about their pain; 2) being aware of the nonverbal communication of pain; and 3) the verbalization of a painful experience. These competencies, therefore, would need to be included when developing a teaching program for nursing students about pain management. The middle-range theory developed by Good and Moore (1996) that used information from an Acute Pain Management Guideline Panel (1992) to develop clinical guidelines for acute pain was also used in the present study. The guidelines were based on pain research with the desired outcome of balanced pain management. Good and Moore’s middle-range theory is similar to King’s model, because it includes the use of patient teaching with an emphasis of mutual goal setting between the nurse and patient for control of pain, assessment of pain on a regular basis, possible pharmacologic treatment, evaluation of side effects of medications, and effectiveness of interventions (Good, 1998).
LITERATURE REVIEW A review of the research literature was done to determine what nurses know about pain management. D’Arcy (2008) surveyed 2,949 working nurses about their knowledge and attitudes regarding pain management. Findings from that study indicated that nurses answered questions at an acceptable level, but areas of concern included pain assessment and the correct usage of opioids. Nurses incorrectly reported that vital signs were an accurate way to assess the amount of pain a person was experiencing, that patients did not give reliable
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reports of pain, and that nurses could be fostering patient addiction to opioids. The author concluded that nurses need more education about pain assessment, pain intensity, and correct dosing of opioids. Wilson (2007) surveyed 43 nurses who worked in oncology/hospice care and 43 nurses who worked in a general setting regarding pain management. The nurses in the oncology group had received education in pain management, and the nurses in the general group had not received pain education outside of their basic nursing education. The results indicated that the oncology/hospice nurses had a better knowledge base of pain management. The author concluded that increased education in pain management improved the knowledge of nurses on pain control; however, the need to evaluate the influence of the work environment was also needed. The findings indicated that the more experienced the nurse, the better their knowledge of pain management. McCaffery and Robinson (2002) used a questionnaire to evaluate 3,282 nurses’ knowledge about pain management. The results indicated that nurses with more experience, nurses who had a master’s degree, and nurses who worked in oncology or hospice had the highest scores. Fewer than one-half of the respondents, however, scored >80%, which the authors determined to be an acceptable score. Little time spent in nursing education on the topic of pain management was cited as a reason for this finding. Polomano et al. (2008) supported that finding and asserted that lack of adequate education may also result in decreased assessment of adverse reactions to pain medications, resulting in overmedication and risks to patient safety. An educational intervention for cognitivebehavioral pediatric pain management was conducted by MacLaren et al. (2008). The aim of the study was to educate students in evidence-based strategies using cognitive-behavioral techniques for pain management in children and to compare the differences in attitudes, knowledge, and the use of cognitive-behavioral management strategies between students who had the educational intervention and a control group who did not have the intervention. The sample included 58 nursing students in their junior year of a baccalaureate nursing program. The tool that was used to evaluate the students’ attitude and knowledge of pain management was the Knowledge and Attitudes of Pain Management Questionnaire. A role-playing scenario was used to assess the students’ ability to use cognitive-behavioral pain management strategies. The researchers found that the implementation of this intervention in a clinical role-play simulation with the training group did increase the use and quality of cognitive-behavioral pain management strategies compared with the
control group; however, the attitudes toward the use of these strategies were changed. A pilot study conducted by Edwards, Nash, Yates, and Walsh (2001) evaluated a pain management intervention program. The sample comprised registered nurses who worked on surgical wards from 21 surgical units in four metropolitan areas. Of the available nurses, 184 nurses completed the survey. Nurses were excluded if they did not complete preintervention and postintervention questionnaires. The instrument used for the study was a Pain Management Survey developed by the study investigators. Their findings suggested that the intervention changed the participants’ beliefs and perceived control regarding the use of opioids for patients in pain. The researchers further concluded that when nurses have self-efficacy and perceived control over the side effects induced by opioid, they are more likely to administer medications and improve pain management outcomes. Ferrell, McGuire, and Donovan (1993) surveyed members of nursing faculty at 14 baccalaureate nursing programs in the United States. The nursing programs included public and private schools. The subjects were full- and part-time faculty who taught pharmacology or clinical courses. The sample included 498 faculty members. The investigators evaluated the faculty beliefs and attitudes about pain, the faculty evaluation of the amount of pain education in the curriculum of their programs, and the effectiveness of pain management in the program. The areas that received the most teaching time were, in descending order, analgesics, interventions that were nonpharmacologic, assessment of pain, the amount of time spent on current research, teaching beliefs, and misconceptions about pain. On average, the faculty rated their curricula as moderately helpful on teaching pain management. Scores for faculty knowledge about pain were lowest on pharmacologic actions and duration of opioid. The highest correct scores were for assessment of pain and use of nonpharmacologic interventions, including cognitive behaviors. Ferrell, McGuire, and Donovan concluded that the hours spent on pain education was not adequate. Lasch, Greenhill, Wilkes, Carr, Lee, and Blanchard (2002) interviewed 72 medical and nursing students. Those researchers sought to corroborate the findings of earlier research that noted deficits in knowledge and attitudes for adequate pain control in nursing faculty, nursing students, medical faculty, and medical students. The research methods included focus groups, in-depth interviews, and observations of participants. The researchers found support for the earlier findings that health care providers lack the knowledge and attitudes that increase effective pain management in
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cancer patients. They also noted that information may not be communicated efficiently during training because faculty and students frequently bring their own attitudes about pain management and addiction into the care of patients in pain. In summary, empirical findings consistently support the hypothesis that pain management continues to be a nursing challenge. Nurses’ education in pain management, area of experience, and time working as a nurse have been identified as factors that increase knowledge of pain management. Nurses with less experience and little education on pain assessment and treatment failed to perform at an adequate level when tested about pain management knowledge. Several studies have indicated the need for enhanced pain management education in nursing curricula to increase the knowledge base of new nurses. Studies have also evaluated knowledge and attitudes of pain management in nursing faculty and found that not enough time is spent on pain management in nursing programs. Faculty knowledge strengths were found in patient assessment and drug therapy, whereas areas needing improvement included opioid efficacy ranges, tolerance, and narcotic dependence. Therefore, further investigation into nursing faculty knowledge and attitudes regarding pain management is needed.
METHODS A descriptive correlational design was used in the present study to examine nursing faculty knowledge of pain management and explore its relationships between: 1) age; 2) education level; 3) pain management preparation; 4) length of time practicing as a nurse; 5) length of time teaching nursing; 6) time teaching pain management in the classroom; 7) taught pain guidelines in the classroom; and 8) additional continuing education about pain management. Sample and Procedures Approval from Oakland University’s Institutional Review Board was obtained before the study was conducted. A convenience sample of nursing faculty in a Midwestern U.S. metropolitan area were recruited for this study. Deans or chairs of nursing departments at 16 colleges and universities with either an associate degree program or a baccalaureate program in the region were contacted by e-mail and given information about the study and asked to participate. The deans and chairs that were willing to participate were asked to determine the number of faculty who may be interested in participating and completing the survey. The researcher delivered that number of surveys to the college or university with self-addressed stamped
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envelopes. An introductory letter was attached to every survey to give the participants the same information and instructions on how to complete the survey. Participants completed the survey in a setting of their choice and were instructed to return the completed survey to the researcher in the self-addressed stamped envelope. Measures A survey was developed to ask about demographic information (age, sex, education level, pain management preparation, clinical experience, length of time teaching, time teaching pain management, if taught pain management practice guidelines). Participants were also asked to provide any additional training or education they may have had since graduation in pain management. An additional training index was computed by adding these variables to give a total score that was used in the bivariate correlation matrix. The Knowledge and Attitudes Survey Regarding Pain (KASRP) (Ferrell & McCaffery, 2006, 2008) tool was used to evaluate the nursing faculty knowledge and attitudes toward pain. The KASRP was originally introduced in 1987 and was revised and updated in 2006 and 2008. Content validity of the KASRP was obtained by pain experts and derived from current standards of pain management. The construct validity was established through the comparison of scores from nurses across various levels of expertise. Test-retest reliability was estimated at r > .80). The items were determined to reflect both attitudes and knowledge with an overall coefficient alpha of 0.85 (Ferrell & McCaffrey, 2008). The KASRP is a self-administered survey that includes 38 questions. The first 21 items are true/false questions, items 22-36 are multiple choice questions, and items 37 and 38 are case studies. This tool was hand scored by the researcher. The number of missed items were computed per participant and included in the bivariate correlation matrix. In other words, lower numbers reflect an increased level of knowledge. Data Analyses Data were analyzed with the use of SPSS version 17.0 computer software, and the level of significance for each test was preset at .05. Analyses for this study included descriptive statistics and bivariate correlations.
RESULTS Sample For this study, 188 surveys were distributed to 16 nursing schools in a Midwestern metropolitan area for nursing faculty to complete. Ninety-six surveys were mailed back to the researcher, for a response rate
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of 51%. On average, the 96 nursing faculty who participated were 53 years of age with a range of 29-74. The majority were female, white, and married and had advanced degrees in nursing. The average length of time that the faculty practiced as an RN was 27 years (range 4-46 years) with 13 years of teaching experience (range 6 months–44 years). Most of the participants reported that they taught pain management in the classroom (62.5%) with an average time spent teaching pain of 5 time spent teaching pain of approximately five percent of class time. The majority of the respondents, however, reported that they did not teach specific pain management guidelines (64.6%; Table 1). Although 72.9% of the sample recalled being taught pain management, fewer than one-half (36.5%)
TABLE 1. Demographic Data of Respondents (n ¼ 96) Characteristics
n
%
Age 52.71 y Sex Male 5 5.2 Female 91 94.8 Race White 92 95.8 Other 3 4.2 Marital status Married 77 80.2 Unmarried couple 2 2.1 Divorced 10 10.4 Separated 1 1.0 Never married 6 6.3 Educational history BSN 5 5.2 MSN 59 61.5 MS in other than nursing 2 2.1 PhD in nursing 18 18.2 DNP, ND, DNSc 3 3.1 Other (PhD student) 1 1.0 EdD 3 3.1 JD 1 1.0 Years of practice as RN 26.9 y Years of teaching 13.26 y How many teach pain management in the classroom No 34 35.4 Yes 60 62.5 Percentage of time teaching 90 5.3 Recall being taught pain management No 25 26 Yes 70 72.9 Felt adequately prepared No 58 60.4 Yes 35 36.5 Teach specific pain management guidelines 64.6 No 62 64.6 Yes 32 33.3
felt adequately prepared on the topic of pain management. To increase their knowledge base regarding pain management, most of the nursing faculty read a journal article (78.1%), attended a meeting (44.8%), or purchased a book (28.1%). Other written responses not included on the survey were related to ‘‘doing their master’s or graduate research projects on the topic of pain management’’ (Table 2). Knowledge and Attitudes of Nursing Faculty For each item of the KASRP, the percentage of faculty who answered the question correctly was calculated. For data display, items were synthesized into six categories of questions on medications (n ¼ 23), pain assessment (n ¼ 8), interventions (n ¼ 3), addiction (n ¼ 3) spiritual/cultural issues (n ¼ 2), and pathophysiology (n ¼ 1; Table 3). On average, faculty scored 31 out of a possible 40 points, or 77.88%. The percentage of participants who scored above the recommended score of 80% (McCaffery & Pasero, 1999) was 42.9%. Among the medication items, 100% of faculty knew that the statement ‘‘Patients should be encouraged to endure as much pain as possible before using an opioid’’ was false. Ninety-nine percent knew that combining analgesics that work differently may result in better pain control with fewer side effects. Only 38.5% knew that aspirin and nonsteriodal antiinflammatory medications were effective for bone cancer, and only 44.8% were aware that research has shown that Phenergan and Vistaril are not reliable potentiators of opioid analgesics. In addition, only 35.4% knew that Vicodin (5 mg hydrocodone plus 500 mg acetaminophen) is approximately equal to 5-10 mg oral morphine. Within the assessment category, 100% of faculty knew that children <11 years old can reliably report pain. Approximately 97% also reported that vital signs were not reliable indicators of pain intensity. Only
TABLE 2. Continuing Education Related to Pain Management (n ¼ 96) Type
n
%
Purchased book Attended conference Took course Conference session Attended a meeting Sought an expert Joined specialty organization Read a journal Other
27 9 21 18 43 8 4 75 9
28.1 9.4 21.9 18.8 44.8 8.3 4.2 78.1 9.4
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TABLE 3. Percentage of Faculty with Correct Responses on Each Question, (n ¼ 96) Test Question Medication category Aspirin and other nonsteroidal antiinflammatory agents are NOT effective analgesics for painful bone metastases. Respiratory depression rarely occurs in patients who have been receiving stable doses of opioids over a period of months. Combining analgesics that work by different mechanisms (e.g., combining an opioid with an NSAID) may result in better pain control with fewer side effects than using a single analgesic agent. The usual duration of analgesia of 1-2 mg morphine IV is 4-5 hours. Research shows that promethazine (Phenergan) and hydroxyzine (Vistaril) are reliable potentiators of opioid analgesics. Opioids should not be used in patients with a history of substance abuse. Morphine has a dose ceiling (i.e., a dose above which no greater pain relief can be obtained). Elderly patients cannot tolerate opioids for pain relief. Patients should be encouraged to endure as much pain as possible before using an opioid. After an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with the individual patient’s response. Vicodin (5 mg hydrocodone þ 500 mg acetaminophen) PO is approximately equal to 5-10 mg morphine PO. Anticonvulsant drugs such as carbamazepine (Tegretol) produce optimal pain relief after a single dose. Benzodiazepines are not effective pain relievers unless the pain is due to muscle spasm. The recommended route of administration of opioid analgesics for patients with persistent cancerrelated pain is ... The recommended route administration of opioid analgesics for patients with brief, severe pain of sudden onset such as trauma or postoperative pain is ... Which of the following analgesic medications is considered the drug of choice for the treatment of prolonged moderate to severe pain for cancer patients? Which of the following IV doses of morphine administered over a 4-hour period would be equivalent to 30 mg oral morphine given q 4 hours? Analgesics for postoperative pain should initially be given ... A patient with persistent cancer pain has been receiving daily opioid analgesics for 2 months. Yesterday the patient was receiving 200 mg/h morphine intravenously. Today he has been receiving 250 mg/h intravenously. The likelihood of the patient developing clinically significant respiratory depression in the absence of new comorbidity is ... The most likely reason a patient with pain would request increased doses of pain medication is ... Which of the following is useful for treatment of cancer pain? The time to peak effect for morphine given IV is ... The time to peak effect for morphine given orally is ... Total medication mean Assessment category Vital signs are always reliable indicators of the intensity of a patient’s pain. Patients may sleep in spite of severe pain. Children <11 years old cannot reliably report pain, so nurses should rely solely on the parent’s assessment of the child’s pain intensity. Giving patients sterile water by injection (placebo) is a useful test to determine if the pain is real. If the source of the patient’s pain is unknown, opioids should not be used during the pain evaluation period, because this could mask the ability to correctly diagnose the cause of the pain. The most accurate judge of the intensity of the patient’s pain is ... Scenario 37a. Andrew is 25 years old, and this is his first day after abdominal surgery. As you enter his room, he smiles at you and continues talking and joking with his visitor. Your assessment reveals the following information: BP ¼ 120/80; HR ¼ 80; RR ¼ 18; on a scale of 0-10 (0 ¼ no pain/discomfort; 10 ¼ worst pain/discomfort) he rates his pain as 8. On the patient’s record you must mark his pain on the scale below. Circle the number that represents your assessment of Andrew’s pain. Patient B: Robert is 25 years old, and this is his first day after abdominal surgery. As you enter his room, he is lying quietly in bad and grimaces as he turns in bed. Your assessment reveals the following information: BP: 120/80; HR ¼ 80; RR ¼ 18; on a scale of 0 to 10 (0 ¼ not pain/discomfort, 10 ¼ worst
% Correct 38.5 76.0 99.0 83.3 44.8 80.2 62.5 96.9 100.0 96.9 35.4 93.8 53.1 59.4 84.4 76.0 53.1 84.4 44.8
95.8 81.3 81.3 67.7 73.4 97.9 92.7 100.0 97.9 66.7 96.9 93.8
96.9 (Continued )
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TABLE 3. Continued Test Question
% Correct
pain/discomfort) he rates his pain as 8. On the patient’s record you must mark his pain on the scale below. Circle the number that represents your assessment of Robert’s pain. Total assessment mean Intervention category Patients who can be distracted from pain usually do not have severe pain. Your assessment, above, is made 2 hours after he received 2 mg morphine IV. Half-hourly pain ratings after the injection ranged from 6 to 8, and he had no clinically significant respiratory depression, sedation, or other untoward side effects. He has identified 2/20 as an acceptable level of pain relief. His physician’s order for analgesia is ‘‘morphine IV 1-3 mg q 1 h PRN pain relief.’’ Check the action you will take at this time. Your assessment, above, is made 2 hours after he received morphine 2 mg IV. Half-hourly pain ratings after the injection ranged from 6 to 8, and he had no clinically significant respiratory depression, sedation, or other untoward side effects. He has identified 2/10 as an acceptable level of pain relief. His physician’s order for analgesia is ‘‘morphine IV 1-3 mg q 1 h PRN pain relief.’’ Check the action you will take at this time. Total intervention mean Addiction category Narcotic/opioid addiction is defined as a chronic neurobiologic disease, characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Using this definition in patients without a history of drug abuse, how likely is it that opioid addiction will occur as a result of treating pain with opioid analgesics? How likely is it that patients who develop pain already have an alcohol and drug abuse problem? After abrupt discontinuation of an opioid, physical dependence is manifested by the following ... Total addiction mean Spiritual/cultural category Patients’ spiritual beliefs may lead them to think that pain and suffering are necessary. Which of the following describes the best approach for cultural considerations caring for patients in pain? Total spiritual/cultural mean Pathophysiology category Because their nervous system is underdeveloped, children <2 years old have decreased pain sensitivity and limited memory of painful experiences. Pathophysiology mean
66.7%, however, knew to give an opioid even if the source of the patient’s pain was unknown. Of the four remaining smaller item categories (interventions, cultural/spiritual, addiction, and pathophysiology) more than one-half of the faculty answered the questions accurately except for the addiction category. Only 45.8% were able to accurately estimate that 5%-15% of patients who develop a pain problem already have an existing alcohol or drug abuse problem. To determine how well the faculty did per category, the mean percentages of correct answers per item within each category were summed and averaged. The total overall mean score for medications (n ¼ 23) was 73.4%, pain assessment (n ¼ 8) 92.9%, interventions (n ¼ 3) 70.5%, addiction (n ¼ 3) 54.9%, spiritual/cultural issues (n ¼ 2) 97.9%, and pathophysiology (n ¼ 1) 88.5%. Bivariate Relationships A specific aim of the present research study was to examine nursing faculty knowledge and application of
92.9 92.7 55.2
63.5
70.5 66.7
45.8 52.1 54.9 97.9 97.9 97.9 88.5 88.5
pain management and explore its relationships with: 1) age; 2) education level; 3) pain management preparation; 4) length of time practicing as a nurse; 5) length of time teaching nursing; 6) time teaching pain management in the classroom; 7) taught pain guidelines in the classroom; and 8) additional continuing education about pain management. Very interesting and significant relationships were found among these study variables. A significant positive correlation was found between age and additional training in pain management (r ¼ 0.32; p < .01). Older nursing faculty reported more continuing education in pain management than the younger faculty. Significant negative correlations were also found between age and remembering being taught pain management in nursing school (r ¼ .29; p < .01) and between age and feeling adequately prepared (r ¼ .28; p < .01). Younger nursing faculty remembered being taught pain management in nursing school and felt more adequately prepared than older nursing faculty (Table 4).
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A significant positive correlation was found between education level and years of teaching (r ¼ 0.29; p < .01). Faculty who reported more years of teaching nursing had higher educational levels than faculty who reported less years of teaching. Significant positive correlations were found between length of time practicing nursing and years of teaching (r ¼ 0.53; p < .01) and between length of time practicing nursing and additional training in pain management (r ¼ 0.28; p < .01). Faculty that reported practicing for longer periods of time also taught for longer periods of time and had more continuing education in pain management than faculty that had practiced for shorter periods of time. A negative correlation was found between years of practice and adequate preparation (r ¼ .21; p < .05). Faculty that reported practicing for longer periods of time felt less prepared in pain management than faculty who practiced for shorter periods of time. Significant positive correlations were found between age and years of practice (r ¼ 0.79; p < .05) and between age and years of teaching (r ¼ 0.58; p < .01). Older nursing faculty reported more years of practice and more years of teaching than younger faculty. Faculty that reported teaching for longer periods of time were found to teach pain management significantly less often than faculty who taught for shorter periods of time (r ¼ .25; p < .05). Those faculty who remembered being taught pain management in nursing school reported feeling significantly more adequately prepared than faculty who could not remember being taught pain management (r ¼ 0.24; p < .05). A significant negative correlation was found between feeling adequately prepared to teach pain management and obtaining additional training in pain management (r ¼ .26; p < .05). Faculty that felt adequately prepared sought out less additional training in pain management than faculty who felt inadequately prepared. Significant correlations were found between faculty who taught pain management guidelines and achieving additional training in pain management (r ¼ 0.28; p < .01) and between faculty who taught pain management guidelines and amount of time teaching pain management in the classroom (r ¼ 0.43; p < .01). Faculty who reported teaching pain management guidelines in the classroom had more additional training in pain management and spent longer classroom time teaching pain management than faculty who did not teach pain management guidelines. Faculty that reported teaching pain management in the classroom (r ¼ .24; p < .05) and reported more continuing education had significantly less wrong answers on the KASRP (r ¼ .37; p < .01) than faculty
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who did not teach pain management and reported less continuing education.
DISCUSSION Very interesting and important information regarding the educational backgrounds in pain management among nursing faculty in one large Midwestern metropolitan was found in this study. The age of the majority of participants was 53 years, and many had advanced degrees in nursing. Approximately three-fourths of the participants recalled being taught about pain management in their basic education programs, but fewer than one-half felt adequately prepared on the topic. Most of the participants identified that they taught pain management, but fewer than one-half stated that they did not teach specific pain management guidelines. To increase knowledge of pain management, nursing faculty in the present study reported reading journal articles, attending meetings on the topic, and purchasing books. These findings support earlier research conducted by McCaffery and Robinson (2002) and Polomano et al. (2008) that little time was given within nursing curricula on the topic of pain management in the past and therefore that older faculty may have limited knowledge. These findings may also indicate that students in this region may not be receiving the most current information on pain management based on evidenced-based practice guidelines. The significant positive relationship found between age and additional training may also provides support that older nurses may not have gotten sufficient educational training in pain management. This was further supported with the significant negative association found with age: Younger nursing faculty remembered being taught pain management in nursing school and felt more adequately prepared than older nursing faculty. These findings may indicate that the plethora of research done regarding pain management and the Joint Commissions’ (2011) pain management standards have currently increased pain management education in nursing schools. This study also found that on average, faculty scored 78%, with fewer than one-half scoring the recommended score of >80% on the KASRP. Similar findings also have been reported (d’Arcy, 2008; McCaffery & Robinson, 2002). Faculty in this study demonstrated adequate knowledge levels in the areas of pain assessment, spiritual/cultural issues, and pathophysiology. Areas of weakness were found in medications, interventions, and addiction. Support for these findings was noted in Ferrell et al.’s (1993) study of 498 faculty members. Faculty in the present study also scored
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TABLE 4. Correlations Between Study Variables 1
2
3
1. Age 1.0 2. Education level 0.16 3. RN practice 0.80** 0.12 4. Years teaching nursing 0.58** 0.29** 0.53** 5. Teach pain 0.00 0.17 0.03 6. Pain education 0.29** 0.01 0.13 7. Adequate preparation 0.28** 0.10 0.21* 8. Teach pain guidelines 0.18 0.13 0.09 9. Wrong answers 0.08 0.10 0.01 10. Additional training 0.32** 0.14 0.28** 11. Time teaching pain 0.10 0.15 0.16 management
4
5
6
0.15 0.06 0.04 0.18 0.11 0.24* 0.04 0.42** 0.07 0.00 0.24* 0.07 0.10 0.17 0.08 0.25* 0.61** 0.00
7
8
9
10
11
0.03 0.00 0.21 0.26* 0.28** 0.37** 0.09 0.43** 0.09 0.16 1.0
*p < .05 (2 tailed). **p < .01 (2 tailed).
lower on medication questions and higher in assessment, but they were better at identifying nonpharmacologic interventions. Goodrich (2006) reported similar findings in a convenience sample of nursing students and faculty. Faculty in the present study scored highest in questions about assessment and drug therapy and lowest in knowledge about the ceiling effect of opioid medications and the differences between addiction, physical dependency, and drug tolerance. Lack of knowledge in major areas regarding medications was also a concern in this study. Fewer than one-half of the faculty were not aware that aspirin and nonsteroidal antiinflammatory medications were effective for cancer pain. Other questions that were missed by the majority of faculty were that Phenergan and Vistaril are not reliable potentiators of opioid analgesics and on the topic of opioid equivalencies. This lack of knowledge in equivalency doses with opioid has been found in other studies as well (Al-Shaer, Hill, & Anderson, 2011; Lui, 2008; Xue, Schulman-Green, Czaplinski, Harris, & McCorkle, 2007). Matthews and Malcolm (2007) tested nurses working in an orthopedic unit using a modified version of the KASRP and concluded that the nurses may be undertreating pain. In the patient vignette section of the survey, only 29.2% of the nurses identified the correct dose of morphine for a postoperative patient who reported a pain rating of 8 and was smiling, and 45.1% for a similar situation except that the patient was grimacing. In our study, 55% answered the question correctly for the scenario with the patient smiling and 63% for the patient who was grimacing. More correct answers were noted but they were still below the standard of 80%. Finally, faculty that reported more continuing education in pain management and spending more
classroom time teaching pain management did significantly better on the KASRP than faculty who had less continuing education. In addition, faculty who had more continuing education in pain management also reported teaching pain management guidelines in the classroom. Earlier research supports the need for continuing education in pain management. Greenberger et al.’s (2006) study of 1,149 Israeli nursing students and certified nurses found that higher educational levels were the most predictive of higher scores on the older version of the KASRP. What those researchers found most perplexing in that study, however, was that participants with higher scores on the questionnaire also reported that they provided inadequate pain management to patients.
STUDY LIMITATIONS Although very interesting information was obtained from this study, there are limitations. The use of a convenience sample from one region in the U.S. limits the ability to generalize these findings to other populations. In addition, the descriptive correlational research design can only provide significant linkages between study variables, not causality.
CONCLUSION Significant results were found in this study that reflected the participants’ background, knowledge, and attitudes regarding pain management. The Institute of Medicine’s (IOM) report on ‘ Relieving Pain in America’’ (2011) emphasized the need for nursing curricula to improve pain management education based on evidence-based practices. In addition, the IOM specifically defined the role
Knowledge and Attitudes of Pain Management
of nursing to include treating patients with acute and chronic pain in both hospital and outpatient settings. To meet these recommendations, nursing curricula may need to be strengthened in the topic of pain management. Furthermore, the importance of encouraging the use of pain management guidelines must be
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emphasized to provide consistency for nurses entering into clinical practice in all settings. In addition, requirements in obtaining continuing education in pain management may be needed for all nurses to increase knowledge and keep current in pain management protocols.
REFERENCES Acute Pain Management Guideline Panel (1992). Acute Pain management: Operative or medical procedures and trauma. Clinical practice guideline. AHCPR publication no. 92-0032. Rockville, MD: Agency for Health Care Policy and Research. Al-Shaer, D., Hill, P. D., & Anderson, M. S. (2011). Nurses’ knowledge and attitudes regarding pain assessment and intervention. Medsurg Nursing, 29(1), 7–11. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. d’Arcy, Y. (2008). Pain management survey report. Nursing, 38(6), 43–49. Edwards, H. E., Nash, R. E., Yates, P. M., Walsh, A. M., Fentiman, J. K., McDowell, J. K., Skerman, H. M., & Najman, J. (2001). Improving pain management by nurses: A pilot peer intervention program. Nursing and Health Sciences, 3(1), 35–45. Ferrell, B. R., & McCaffery, M. (2006). City of Hope Knowledge and Attitudes Survey Regarding Pain. Retrieved September 14, 2009 from http://prc.coh.org/ Knowledge%20%20Attitude%20Survey%208-06 Ferrell, B. R., & McCaffery, M. (2008). City of Hope Knowledge and Attitudes Survey Regarding Pain. Retrieved November 20, 2009 from http://prc.coh.org/ Knowldege%20%20Attitude%20Survey%20-%20updated% 205-08.pdf Ferrell, B. R., McGuire, D. B., & Donovan, M.,I. (1993). Knowledge and beliefs regarding pain in a sample of nursing faculty. Journal of Professional Nursing, 9(2), 79–88. Ferrell, B. R., Viranie, R., & Grant, M. (2000). Analysis of symptom assessment and management content in nursing textbooks. Journal of Palliative Medicine, 2(2), 161–172. Good, M. (1998). A middle-range theory of acute pain management: Use in research. Nursing Outlook, 46(3), 120–124. Good, M., & Moore, S. M. (1996). Clinical practice guidelines as a new source of middle-range theory: Focus on acute pain. Nursing Outlook, 44(2), 74–79. Goodrich, C. (2006). Students’ and faculty members’ knowledge and attitudes regarding pain management: A descriptive survey. Journal of Nursing Education, 45(3), 140–142. Greenberger, C., Reches, H., & Riba, S. (2006). Levels and predictors of knowledge and attitudes regarding pain among Israeli baccalaureate nursing students and nurses pursuing specialty certification. International Journal of Nursing Education Scholarship, 3(1), 1–23. Halstead, J. A. (Ed.). (2007). Nurse educator competencies: Creating an evidence-based practice for nurse educators. New York: National League for Nursing. Institute of Medicine (2011). Relieving pain in America: A blueprint for transforming prevention, care, education research. Washington, DC: National Academies Press.
Joint Commission (2010). Pain management. Retrieved April 18, 2010, from http://www.jcrinc.com/JCR-Good-PracticesDatabase-for-Hospitals/JCR-Good-Practice-Examples-of-SurveyComplian/Pain-Manage/ Joint Commission (2011). Facts about pain management. Retrieved September 2, 2011 from http://www.joint commission.org/pain_management/ King, I. M. (1981). A theory for nursing systems, concepts, process. New York: Wiley Medical. Knaggs, R. D. (2008). Providing effective pain management. British Journal of Hospital Medicine, 69(8), 120–122. Lasch, B. A., Greenhill, B. A., Wilkes, G., Carr, D., Lee, M., & Blanchard, R. (2002). Why study pain? A qualitative analysis of medical and nursing faculty and students’ knowledge of and attitudes to cancer pain management. Journal of Palliative Medicine, 5(1), 57–71. Lellan, K. M. (2004). Postoperative pain: Strategy for improving patient experiences. Journal of Advanced Nursing, 46(2), 179–185. Lui, L. Y., So, W. K., & Fong, D. U. (2008). Knowledge and attitudes regarding pain management among nurses in Hong Kong medical units. Journal of Clinical Nursing, 17(15), 2014–2021. MacLaren, J. E., Cohen, L. L., Larkin, K. T., & Shelton, E. N. (2008). Training nursing students in evidence-based techniques for cognitive-behavioral pediatric pain management. Journal of Nursing Education, 47(8), 351–358. McCaffery, M., & Robinson, E. (2002). Your patient is in pain: Here’s how your respond. Nursing, 32(10), 36–45. Pasero, C., & McCaffery, M. Pain assessment and pharmacologic management. St. Louis: Mosby Elsevier. Polomano, R. C., Dunwoody, C. J., Krenzischek, D. A., & Mas, D. A. (2008). Perspective on pain management in the 21st century. Pain Management Nursing, 9(1), S3–S10. Sauaia, A., Min, S., Leber, C., Erbacher, K., Abrams, F., & Fink, R. (2005). Postoperative pain management in elderly patients. Journal of the American Geriatrics Society, 53(2), 274–282. Schafheutle, E. I., Cantrill, J. A., & Noyce, P. R. (2001). Why is pain management suboptimal on surgical wards? Journal of Advanced Nursing, 33(6), 728–737. Wilson, B. (2007). Nurses’ knowledge of pain. Journal of Clinical Nursing, 16(6), 1012–1020. Xue, Y., Schulman, D., Czaplinski, C., Harrais, D., & McCorkle, R. (2007). Pain attitudes and knowledge among RNs, pharmacists, and physicians on an inpatient oncology service. Clinical Journal of Oncology Nursing, 11(5), 687–695. Zolan, M. L. (1995). Pain management instruction in nursing curricula. Journal of Nursing Education, 34(6), 262–267.
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From the *School of Nursing, Graceland University, Independence, Missouri; †Oakland University, Rochester, Michigan; ‡Kent State University, North Canton, Ohio. Address correspondence to Barbara Voshall, DNP, RN, School of Nursing, Graceland University, 1311 Deer Run Trail, Blue Springs, MO 64015-1742. E-mail: [email protected] or [email protected] (B.V.) Received January 5, 2012; Revised January 31, 2012; Accepted February 3, 2012. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2012.02.001
Barbara Voshall, DNP, RN,* Karen S. Dunn, PhD, RN,† and Debra Shelestak, PhD, RN‡
ABSTRACT:
A descriptive correlational design was used in this study to examine nursing faculty knowledge and attitudes in pain management. Relationships between age, education level, pain management preparation, length of time practicing as a nurse, length of time teaching nursing, time teaching pain management in the classroom, taught pain guidelines in the classroom, and additional continuing education about pain management were explored. Ninety-six nursing faculty participated from 16 schools of nursing in one Midwestern U.S. region. Findings identified that most of the nursing faculty recalled being taught about pain management in their basic education, but less than one-half felt adequately prepared. Most respondents said that they taught pain management, yet fewer than one-half identified that they used specific pain management guidelines. Faculty demonstrated adequate knowledge of pain assessment, spiritual/cultural issues, and pathophysiology. Areas of weakness were found in medications, interventions, and addiction. Faculty that reported teaching pain management in the classroom and reported more continuing education missed fewer items. Older nursing faculty reported more years of practice, more years of teaching, and more continuing education in pain management than younger faculty. Younger nursing faculty remembered being taught pain management in nursing school and felt more adequately prepared than older nursing faculty. Faculty that reported practicing for longer periods of time felt less prepared in pain management than faculty who practiced for shorter periods of time. More continuing education in pain management may be needed for older nurses to meet the recommendations of the Institute of Medicines’ report on relieving pain in the U.S. Ó 2013 by the American Society for Pain Management Nursing Successful pain management remains a challenge for nursing despite the Joint Commission’s mandate authorizing that every patient has a right to have their pain assessed and managed adequately (Joint Commission , 2010). For example, management of acute postoperative pain remains a major problem in hospitalized patients. Lellan (2004) found unacceptable levels of pain reported among Pain Management Nursing, Vol 14, No 4 (December), 2013: pp e226-e235
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postoperative patients in an experimental study that used a pretest-posttest design aimed to investigate their pain experiences. Sauaia, Leber, Erbacher, Abrams, and Fink (2005) found that 51% of a sample of patients reported that their postoperative pain was too much to bear. Those authors concluded that the potential reason may be related to the lack of pain management education in nursing curricula. Ferrell, Viranie, and Grant (2000) evaluated 700 nursing textbooks and reported that pain management was not adequately covered. In addition, MacLaren, Cohen, Larkin, and Shelton (2008) reported a lack of cognitive-behavioral therapy strategies for pain management in nursing courses. Goodrich (2006) found in a convenience sample of baccalaureate nursing students that faculty appeared to have basic knowledge of pain management, but the integration of pain management was inconsistent in the curriculum. Zalon (1995) cited that nurses are given the responsibility to manage pain, yet earlier research has suggested that educational programs may not have adequately prepared nurses on this topic. Barriers to adequate pain management were identified in a study of 180 nurses who worked with surgical patients (Knaggs, 2008). Reasons for not administering adequate pain medications included inadequate assessment of patients’ pain levels. In that study, nurses were using their own assessment of pain levels from nonverbal cues without asking for a self-report. Other reasons included lack of time due to shortage of staff, lack of knowledge of pain medications, patients’ reluctance to ask for medication, and potential opioid side effects (e.g., respiratory depression, excessive sedation, nausea, constipation, hypotension, pruritus, and retention of urine) (Knaggs, 2008). These side effects may cause nurses to use lower opioid dosages and thus inadequately manage pain intensity levels after surgery (Schafheutle, Cantrill, & Noyce, 2001). On graduation, nurses need to be prepared to practice in a safe manner, be accurate in management of medications, and have compassion for patients in a variety of settings Benner, Leonard, & Day (2010). Benner argued that quality education in complex areas is needed to decrease the education-practice gap. Further, nursing educators are responsible to improve patient outcomes through effective teaching methods, and the ability for students to demonstrate knowledge of this content has been identified as a nurse educator competency (Halstead, 2007). From these reported findings, it is unclear whether nursing education and/or curriculums are lacking in pain management strategies, therefore the need to evaluate nursing faculty levels of knowledge in this area is warranted. Therefore, the purpose of the present research study was to examine nursing faculty’s knowledge of
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pain management and explore its relationships with: 1) age; 2) education level; 3) pain management preparation; 4) length of time practicing as a nurse; 5) length of time teaching nursing; 6) time teaching pain management in the classroom; 7) taught pain guidelines in the classroom; and 8) additional continuing education about pain management. Findings from this study may identify areas in need of improvement in educational programs on pain management.
THEORETIC FRAMEWORK The framework of this study was based on King’s (1981) theory of goal attainment. King viewed nursing as an interactive process that leads to attainment of goals. During this interaction, King emphasized the importance of verbal and nonverbal communication. King’s theory is also based on an assumption that a nurse and patient work together to address health issues. Within this framework, the assessment of pain would then depend on: 1) the capacity of the nurse to recognize and communicate with patients about their pain; 2) being aware of the nonverbal communication of pain; and 3) the verbalization of a painful experience. These competencies, therefore, would need to be included when developing a teaching program for nursing students about pain management. The middle-range theory developed by Good and Moore (1996) that used information from an Acute Pain Management Guideline Panel (1992) to develop clinical guidelines for acute pain was also used in the present study. The guidelines were based on pain research with the desired outcome of balanced pain management. Good and Moore’s middle-range theory is similar to King’s model, because it includes the use of patient teaching with an emphasis of mutual goal setting between the nurse and patient for control of pain, assessment of pain on a regular basis, possible pharmacologic treatment, evaluation of side effects of medications, and effectiveness of interventions (Good, 1998).
LITERATURE REVIEW A review of the research literature was done to determine what nurses know about pain management. D’Arcy (2008) surveyed 2,949 working nurses about their knowledge and attitudes regarding pain management. Findings from that study indicated that nurses answered questions at an acceptable level, but areas of concern included pain assessment and the correct usage of opioids. Nurses incorrectly reported that vital signs were an accurate way to assess the amount of pain a person was experiencing, that patients did not give reliable
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reports of pain, and that nurses could be fostering patient addiction to opioids. The author concluded that nurses need more education about pain assessment, pain intensity, and correct dosing of opioids. Wilson (2007) surveyed 43 nurses who worked in oncology/hospice care and 43 nurses who worked in a general setting regarding pain management. The nurses in the oncology group had received education in pain management, and the nurses in the general group had not received pain education outside of their basic nursing education. The results indicated that the oncology/hospice nurses had a better knowledge base of pain management. The author concluded that increased education in pain management improved the knowledge of nurses on pain control; however, the need to evaluate the influence of the work environment was also needed. The findings indicated that the more experienced the nurse, the better their knowledge of pain management. McCaffery and Robinson (2002) used a questionnaire to evaluate 3,282 nurses’ knowledge about pain management. The results indicated that nurses with more experience, nurses who had a master’s degree, and nurses who worked in oncology or hospice had the highest scores. Fewer than one-half of the respondents, however, scored >80%, which the authors determined to be an acceptable score. Little time spent in nursing education on the topic of pain management was cited as a reason for this finding. Polomano et al. (2008) supported that finding and asserted that lack of adequate education may also result in decreased assessment of adverse reactions to pain medications, resulting in overmedication and risks to patient safety. An educational intervention for cognitivebehavioral pediatric pain management was conducted by MacLaren et al. (2008). The aim of the study was to educate students in evidence-based strategies using cognitive-behavioral techniques for pain management in children and to compare the differences in attitudes, knowledge, and the use of cognitive-behavioral management strategies between students who had the educational intervention and a control group who did not have the intervention. The sample included 58 nursing students in their junior year of a baccalaureate nursing program. The tool that was used to evaluate the students’ attitude and knowledge of pain management was the Knowledge and Attitudes of Pain Management Questionnaire. A role-playing scenario was used to assess the students’ ability to use cognitive-behavioral pain management strategies. The researchers found that the implementation of this intervention in a clinical role-play simulation with the training group did increase the use and quality of cognitive-behavioral pain management strategies compared with the
control group; however, the attitudes toward the use of these strategies were changed. A pilot study conducted by Edwards, Nash, Yates, and Walsh (2001) evaluated a pain management intervention program. The sample comprised registered nurses who worked on surgical wards from 21 surgical units in four metropolitan areas. Of the available nurses, 184 nurses completed the survey. Nurses were excluded if they did not complete preintervention and postintervention questionnaires. The instrument used for the study was a Pain Management Survey developed by the study investigators. Their findings suggested that the intervention changed the participants’ beliefs and perceived control regarding the use of opioids for patients in pain. The researchers further concluded that when nurses have self-efficacy and perceived control over the side effects induced by opioid, they are more likely to administer medications and improve pain management outcomes. Ferrell, McGuire, and Donovan (1993) surveyed members of nursing faculty at 14 baccalaureate nursing programs in the United States. The nursing programs included public and private schools. The subjects were full- and part-time faculty who taught pharmacology or clinical courses. The sample included 498 faculty members. The investigators evaluated the faculty beliefs and attitudes about pain, the faculty evaluation of the amount of pain education in the curriculum of their programs, and the effectiveness of pain management in the program. The areas that received the most teaching time were, in descending order, analgesics, interventions that were nonpharmacologic, assessment of pain, the amount of time spent on current research, teaching beliefs, and misconceptions about pain. On average, the faculty rated their curricula as moderately helpful on teaching pain management. Scores for faculty knowledge about pain were lowest on pharmacologic actions and duration of opioid. The highest correct scores were for assessment of pain and use of nonpharmacologic interventions, including cognitive behaviors. Ferrell, McGuire, and Donovan concluded that the hours spent on pain education was not adequate. Lasch, Greenhill, Wilkes, Carr, Lee, and Blanchard (2002) interviewed 72 medical and nursing students. Those researchers sought to corroborate the findings of earlier research that noted deficits in knowledge and attitudes for adequate pain control in nursing faculty, nursing students, medical faculty, and medical students. The research methods included focus groups, in-depth interviews, and observations of participants. The researchers found support for the earlier findings that health care providers lack the knowledge and attitudes that increase effective pain management in
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cancer patients. They also noted that information may not be communicated efficiently during training because faculty and students frequently bring their own attitudes about pain management and addiction into the care of patients in pain. In summary, empirical findings consistently support the hypothesis that pain management continues to be a nursing challenge. Nurses’ education in pain management, area of experience, and time working as a nurse have been identified as factors that increase knowledge of pain management. Nurses with less experience and little education on pain assessment and treatment failed to perform at an adequate level when tested about pain management knowledge. Several studies have indicated the need for enhanced pain management education in nursing curricula to increase the knowledge base of new nurses. Studies have also evaluated knowledge and attitudes of pain management in nursing faculty and found that not enough time is spent on pain management in nursing programs. Faculty knowledge strengths were found in patient assessment and drug therapy, whereas areas needing improvement included opioid efficacy ranges, tolerance, and narcotic dependence. Therefore, further investigation into nursing faculty knowledge and attitudes regarding pain management is needed.
METHODS A descriptive correlational design was used in the present study to examine nursing faculty knowledge of pain management and explore its relationships between: 1) age; 2) education level; 3) pain management preparation; 4) length of time practicing as a nurse; 5) length of time teaching nursing; 6) time teaching pain management in the classroom; 7) taught pain guidelines in the classroom; and 8) additional continuing education about pain management. Sample and Procedures Approval from Oakland University’s Institutional Review Board was obtained before the study was conducted. A convenience sample of nursing faculty in a Midwestern U.S. metropolitan area were recruited for this study. Deans or chairs of nursing departments at 16 colleges and universities with either an associate degree program or a baccalaureate program in the region were contacted by e-mail and given information about the study and asked to participate. The deans and chairs that were willing to participate were asked to determine the number of faculty who may be interested in participating and completing the survey. The researcher delivered that number of surveys to the college or university with self-addressed stamped
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envelopes. An introductory letter was attached to every survey to give the participants the same information and instructions on how to complete the survey. Participants completed the survey in a setting of their choice and were instructed to return the completed survey to the researcher in the self-addressed stamped envelope. Measures A survey was developed to ask about demographic information (age, sex, education level, pain management preparation, clinical experience, length of time teaching, time teaching pain management, if taught pain management practice guidelines). Participants were also asked to provide any additional training or education they may have had since graduation in pain management. An additional training index was computed by adding these variables to give a total score that was used in the bivariate correlation matrix. The Knowledge and Attitudes Survey Regarding Pain (KASRP) (Ferrell & McCaffery, 2006, 2008) tool was used to evaluate the nursing faculty knowledge and attitudes toward pain. The KASRP was originally introduced in 1987 and was revised and updated in 2006 and 2008. Content validity of the KASRP was obtained by pain experts and derived from current standards of pain management. The construct validity was established through the comparison of scores from nurses across various levels of expertise. Test-retest reliability was estimated at r > .80). The items were determined to reflect both attitudes and knowledge with an overall coefficient alpha of 0.85 (Ferrell & McCaffrey, 2008). The KASRP is a self-administered survey that includes 38 questions. The first 21 items are true/false questions, items 22-36 are multiple choice questions, and items 37 and 38 are case studies. This tool was hand scored by the researcher. The number of missed items were computed per participant and included in the bivariate correlation matrix. In other words, lower numbers reflect an increased level of knowledge. Data Analyses Data were analyzed with the use of SPSS version 17.0 computer software, and the level of significance for each test was preset at .05. Analyses for this study included descriptive statistics and bivariate correlations.
RESULTS Sample For this study, 188 surveys were distributed to 16 nursing schools in a Midwestern metropolitan area for nursing faculty to complete. Ninety-six surveys were mailed back to the researcher, for a response rate
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of 51%. On average, the 96 nursing faculty who participated were 53 years of age with a range of 29-74. The majority were female, white, and married and had advanced degrees in nursing. The average length of time that the faculty practiced as an RN was 27 years (range 4-46 years) with 13 years of teaching experience (range 6 months–44 years). Most of the participants reported that they taught pain management in the classroom (62.5%) with an average time spent teaching pain of 5 time spent teaching pain of approximately five percent of class time. The majority of the respondents, however, reported that they did not teach specific pain management guidelines (64.6%; Table 1). Although 72.9% of the sample recalled being taught pain management, fewer than one-half (36.5%)
TABLE 1. Demographic Data of Respondents (n ¼ 96) Characteristics
n
%
Age 52.71 y Sex Male 5 5.2 Female 91 94.8 Race White 92 95.8 Other 3 4.2 Marital status Married 77 80.2 Unmarried couple 2 2.1 Divorced 10 10.4 Separated 1 1.0 Never married 6 6.3 Educational history BSN 5 5.2 MSN 59 61.5 MS in other than nursing 2 2.1 PhD in nursing 18 18.2 DNP, ND, DNSc 3 3.1 Other (PhD student) 1 1.0 EdD 3 3.1 JD 1 1.0 Years of practice as RN 26.9 y Years of teaching 13.26 y How many teach pain management in the classroom No 34 35.4 Yes 60 62.5 Percentage of time teaching 90 5.3 Recall being taught pain management No 25 26 Yes 70 72.9 Felt adequately prepared No 58 60.4 Yes 35 36.5 Teach specific pain management guidelines 64.6 No 62 64.6 Yes 32 33.3
felt adequately prepared on the topic of pain management. To increase their knowledge base regarding pain management, most of the nursing faculty read a journal article (78.1%), attended a meeting (44.8%), or purchased a book (28.1%). Other written responses not included on the survey were related to ‘‘doing their master’s or graduate research projects on the topic of pain management’’ (Table 2). Knowledge and Attitudes of Nursing Faculty For each item of the KASRP, the percentage of faculty who answered the question correctly was calculated. For data display, items were synthesized into six categories of questions on medications (n ¼ 23), pain assessment (n ¼ 8), interventions (n ¼ 3), addiction (n ¼ 3) spiritual/cultural issues (n ¼ 2), and pathophysiology (n ¼ 1; Table 3). On average, faculty scored 31 out of a possible 40 points, or 77.88%. The percentage of participants who scored above the recommended score of 80% (McCaffery & Pasero, 1999) was 42.9%. Among the medication items, 100% of faculty knew that the statement ‘‘Patients should be encouraged to endure as much pain as possible before using an opioid’’ was false. Ninety-nine percent knew that combining analgesics that work differently may result in better pain control with fewer side effects. Only 38.5% knew that aspirin and nonsteriodal antiinflammatory medications were effective for bone cancer, and only 44.8% were aware that research has shown that Phenergan and Vistaril are not reliable potentiators of opioid analgesics. In addition, only 35.4% knew that Vicodin (5 mg hydrocodone plus 500 mg acetaminophen) is approximately equal to 5-10 mg oral morphine. Within the assessment category, 100% of faculty knew that children <11 years old can reliably report pain. Approximately 97% also reported that vital signs were not reliable indicators of pain intensity. Only
TABLE 2. Continuing Education Related to Pain Management (n ¼ 96) Type
n
%
Purchased book Attended conference Took course Conference session Attended a meeting Sought an expert Joined specialty organization Read a journal Other
27 9 21 18 43 8 4 75 9
28.1 9.4 21.9 18.8 44.8 8.3 4.2 78.1 9.4
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TABLE 3. Percentage of Faculty with Correct Responses on Each Question, (n ¼ 96) Test Question Medication category Aspirin and other nonsteroidal antiinflammatory agents are NOT effective analgesics for painful bone metastases. Respiratory depression rarely occurs in patients who have been receiving stable doses of opioids over a period of months. Combining analgesics that work by different mechanisms (e.g., combining an opioid with an NSAID) may result in better pain control with fewer side effects than using a single analgesic agent. The usual duration of analgesia of 1-2 mg morphine IV is 4-5 hours. Research shows that promethazine (Phenergan) and hydroxyzine (Vistaril) are reliable potentiators of opioid analgesics. Opioids should not be used in patients with a history of substance abuse. Morphine has a dose ceiling (i.e., a dose above which no greater pain relief can be obtained). Elderly patients cannot tolerate opioids for pain relief. Patients should be encouraged to endure as much pain as possible before using an opioid. After an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with the individual patient’s response. Vicodin (5 mg hydrocodone þ 500 mg acetaminophen) PO is approximately equal to 5-10 mg morphine PO. Anticonvulsant drugs such as carbamazepine (Tegretol) produce optimal pain relief after a single dose. Benzodiazepines are not effective pain relievers unless the pain is due to muscle spasm. The recommended route of administration of opioid analgesics for patients with persistent cancerrelated pain is ... The recommended route administration of opioid analgesics for patients with brief, severe pain of sudden onset such as trauma or postoperative pain is ... Which of the following analgesic medications is considered the drug of choice for the treatment of prolonged moderate to severe pain for cancer patients? Which of the following IV doses of morphine administered over a 4-hour period would be equivalent to 30 mg oral morphine given q 4 hours? Analgesics for postoperative pain should initially be given ... A patient with persistent cancer pain has been receiving daily opioid analgesics for 2 months. Yesterday the patient was receiving 200 mg/h morphine intravenously. Today he has been receiving 250 mg/h intravenously. The likelihood of the patient developing clinically significant respiratory depression in the absence of new comorbidity is ... The most likely reason a patient with pain would request increased doses of pain medication is ... Which of the following is useful for treatment of cancer pain? The time to peak effect for morphine given IV is ... The time to peak effect for morphine given orally is ... Total medication mean Assessment category Vital signs are always reliable indicators of the intensity of a patient’s pain. Patients may sleep in spite of severe pain. Children <11 years old cannot reliably report pain, so nurses should rely solely on the parent’s assessment of the child’s pain intensity. Giving patients sterile water by injection (placebo) is a useful test to determine if the pain is real. If the source of the patient’s pain is unknown, opioids should not be used during the pain evaluation period, because this could mask the ability to correctly diagnose the cause of the pain. The most accurate judge of the intensity of the patient’s pain is ... Scenario 37a. Andrew is 25 years old, and this is his first day after abdominal surgery. As you enter his room, he smiles at you and continues talking and joking with his visitor. Your assessment reveals the following information: BP ¼ 120/80; HR ¼ 80; RR ¼ 18; on a scale of 0-10 (0 ¼ no pain/discomfort; 10 ¼ worst pain/discomfort) he rates his pain as 8. On the patient’s record you must mark his pain on the scale below. Circle the number that represents your assessment of Andrew’s pain. Patient B: Robert is 25 years old, and this is his first day after abdominal surgery. As you enter his room, he is lying quietly in bad and grimaces as he turns in bed. Your assessment reveals the following information: BP: 120/80; HR ¼ 80; RR ¼ 18; on a scale of 0 to 10 (0 ¼ not pain/discomfort, 10 ¼ worst
% Correct 38.5 76.0 99.0 83.3 44.8 80.2 62.5 96.9 100.0 96.9 35.4 93.8 53.1 59.4 84.4 76.0 53.1 84.4 44.8
95.8 81.3 81.3 67.7 73.4 97.9 92.7 100.0 97.9 66.7 96.9 93.8
96.9 (Continued )
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TABLE 3. Continued Test Question
% Correct
pain/discomfort) he rates his pain as 8. On the patient’s record you must mark his pain on the scale below. Circle the number that represents your assessment of Robert’s pain. Total assessment mean Intervention category Patients who can be distracted from pain usually do not have severe pain. Your assessment, above, is made 2 hours after he received 2 mg morphine IV. Half-hourly pain ratings after the injection ranged from 6 to 8, and he had no clinically significant respiratory depression, sedation, or other untoward side effects. He has identified 2/20 as an acceptable level of pain relief. His physician’s order for analgesia is ‘‘morphine IV 1-3 mg q 1 h PRN pain relief.’’ Check the action you will take at this time. Your assessment, above, is made 2 hours after he received morphine 2 mg IV. Half-hourly pain ratings after the injection ranged from 6 to 8, and he had no clinically significant respiratory depression, sedation, or other untoward side effects. He has identified 2/10 as an acceptable level of pain relief. His physician’s order for analgesia is ‘‘morphine IV 1-3 mg q 1 h PRN pain relief.’’ Check the action you will take at this time. Total intervention mean Addiction category Narcotic/opioid addiction is defined as a chronic neurobiologic disease, characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Using this definition in patients without a history of drug abuse, how likely is it that opioid addiction will occur as a result of treating pain with opioid analgesics? How likely is it that patients who develop pain already have an alcohol and drug abuse problem? After abrupt discontinuation of an opioid, physical dependence is manifested by the following ... Total addiction mean Spiritual/cultural category Patients’ spiritual beliefs may lead them to think that pain and suffering are necessary. Which of the following describes the best approach for cultural considerations caring for patients in pain? Total spiritual/cultural mean Pathophysiology category Because their nervous system is underdeveloped, children <2 years old have decreased pain sensitivity and limited memory of painful experiences. Pathophysiology mean
66.7%, however, knew to give an opioid even if the source of the patient’s pain was unknown. Of the four remaining smaller item categories (interventions, cultural/spiritual, addiction, and pathophysiology) more than one-half of the faculty answered the questions accurately except for the addiction category. Only 45.8% were able to accurately estimate that 5%-15% of patients who develop a pain problem already have an existing alcohol or drug abuse problem. To determine how well the faculty did per category, the mean percentages of correct answers per item within each category were summed and averaged. The total overall mean score for medications (n ¼ 23) was 73.4%, pain assessment (n ¼ 8) 92.9%, interventions (n ¼ 3) 70.5%, addiction (n ¼ 3) 54.9%, spiritual/cultural issues (n ¼ 2) 97.9%, and pathophysiology (n ¼ 1) 88.5%. Bivariate Relationships A specific aim of the present research study was to examine nursing faculty knowledge and application of
92.9 92.7 55.2
63.5
70.5 66.7
45.8 52.1 54.9 97.9 97.9 97.9 88.5 88.5
pain management and explore its relationships with: 1) age; 2) education level; 3) pain management preparation; 4) length of time practicing as a nurse; 5) length of time teaching nursing; 6) time teaching pain management in the classroom; 7) taught pain guidelines in the classroom; and 8) additional continuing education about pain management. Very interesting and significant relationships were found among these study variables. A significant positive correlation was found between age and additional training in pain management (r ¼ 0.32; p < .01). Older nursing faculty reported more continuing education in pain management than the younger faculty. Significant negative correlations were also found between age and remembering being taught pain management in nursing school (r ¼ .29; p < .01) and between age and feeling adequately prepared (r ¼ .28; p < .01). Younger nursing faculty remembered being taught pain management in nursing school and felt more adequately prepared than older nursing faculty (Table 4).
Knowledge and Attitudes of Pain Management
A significant positive correlation was found between education level and years of teaching (r ¼ 0.29; p < .01). Faculty who reported more years of teaching nursing had higher educational levels than faculty who reported less years of teaching. Significant positive correlations were found between length of time practicing nursing and years of teaching (r ¼ 0.53; p < .01) and between length of time practicing nursing and additional training in pain management (r ¼ 0.28; p < .01). Faculty that reported practicing for longer periods of time also taught for longer periods of time and had more continuing education in pain management than faculty that had practiced for shorter periods of time. A negative correlation was found between years of practice and adequate preparation (r ¼ .21; p < .05). Faculty that reported practicing for longer periods of time felt less prepared in pain management than faculty who practiced for shorter periods of time. Significant positive correlations were found between age and years of practice (r ¼ 0.79; p < .05) and between age and years of teaching (r ¼ 0.58; p < .01). Older nursing faculty reported more years of practice and more years of teaching than younger faculty. Faculty that reported teaching for longer periods of time were found to teach pain management significantly less often than faculty who taught for shorter periods of time (r ¼ .25; p < .05). Those faculty who remembered being taught pain management in nursing school reported feeling significantly more adequately prepared than faculty who could not remember being taught pain management (r ¼ 0.24; p < .05). A significant negative correlation was found between feeling adequately prepared to teach pain management and obtaining additional training in pain management (r ¼ .26; p < .05). Faculty that felt adequately prepared sought out less additional training in pain management than faculty who felt inadequately prepared. Significant correlations were found between faculty who taught pain management guidelines and achieving additional training in pain management (r ¼ 0.28; p < .01) and between faculty who taught pain management guidelines and amount of time teaching pain management in the classroom (r ¼ 0.43; p < .01). Faculty who reported teaching pain management guidelines in the classroom had more additional training in pain management and spent longer classroom time teaching pain management than faculty who did not teach pain management guidelines. Faculty that reported teaching pain management in the classroom (r ¼ .24; p < .05) and reported more continuing education had significantly less wrong answers on the KASRP (r ¼ .37; p < .01) than faculty
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who did not teach pain management and reported less continuing education.
DISCUSSION Very interesting and important information regarding the educational backgrounds in pain management among nursing faculty in one large Midwestern metropolitan was found in this study. The age of the majority of participants was 53 years, and many had advanced degrees in nursing. Approximately three-fourths of the participants recalled being taught about pain management in their basic education programs, but fewer than one-half felt adequately prepared on the topic. Most of the participants identified that they taught pain management, but fewer than one-half stated that they did not teach specific pain management guidelines. To increase knowledge of pain management, nursing faculty in the present study reported reading journal articles, attending meetings on the topic, and purchasing books. These findings support earlier research conducted by McCaffery and Robinson (2002) and Polomano et al. (2008) that little time was given within nursing curricula on the topic of pain management in the past and therefore that older faculty may have limited knowledge. These findings may also indicate that students in this region may not be receiving the most current information on pain management based on evidenced-based practice guidelines. The significant positive relationship found between age and additional training may also provides support that older nurses may not have gotten sufficient educational training in pain management. This was further supported with the significant negative association found with age: Younger nursing faculty remembered being taught pain management in nursing school and felt more adequately prepared than older nursing faculty. These findings may indicate that the plethora of research done regarding pain management and the Joint Commissions’ (2011) pain management standards have currently increased pain management education in nursing schools. This study also found that on average, faculty scored 78%, with fewer than one-half scoring the recommended score of >80% on the KASRP. Similar findings also have been reported (d’Arcy, 2008; McCaffery & Robinson, 2002). Faculty in this study demonstrated adequate knowledge levels in the areas of pain assessment, spiritual/cultural issues, and pathophysiology. Areas of weakness were found in medications, interventions, and addiction. Support for these findings was noted in Ferrell et al.’s (1993) study of 498 faculty members. Faculty in the present study also scored
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Voshall, Dunn, and Shelestak
TABLE 4. Correlations Between Study Variables 1
2
3
1. Age 1.0 2. Education level 0.16 3. RN practice 0.80** 0.12 4. Years teaching nursing 0.58** 0.29** 0.53** 5. Teach pain 0.00 0.17 0.03 6. Pain education 0.29** 0.01 0.13 7. Adequate preparation 0.28** 0.10 0.21* 8. Teach pain guidelines 0.18 0.13 0.09 9. Wrong answers 0.08 0.10 0.01 10. Additional training 0.32** 0.14 0.28** 11. Time teaching pain 0.10 0.15 0.16 management
4
5
6
0.15 0.06 0.04 0.18 0.11 0.24* 0.04 0.42** 0.07 0.00 0.24* 0.07 0.10 0.17 0.08 0.25* 0.61** 0.00
7
8
9
10
11
0.03 0.00 0.21 0.26* 0.28** 0.37** 0.09 0.43** 0.09 0.16 1.0
*p < .05 (2 tailed). **p < .01 (2 tailed).
lower on medication questions and higher in assessment, but they were better at identifying nonpharmacologic interventions. Goodrich (2006) reported similar findings in a convenience sample of nursing students and faculty. Faculty in the present study scored highest in questions about assessment and drug therapy and lowest in knowledge about the ceiling effect of opioid medications and the differences between addiction, physical dependency, and drug tolerance. Lack of knowledge in major areas regarding medications was also a concern in this study. Fewer than one-half of the faculty were not aware that aspirin and nonsteroidal antiinflammatory medications were effective for cancer pain. Other questions that were missed by the majority of faculty were that Phenergan and Vistaril are not reliable potentiators of opioid analgesics and on the topic of opioid equivalencies. This lack of knowledge in equivalency doses with opioid has been found in other studies as well (Al-Shaer, Hill, & Anderson, 2011; Lui, 2008; Xue, Schulman-Green, Czaplinski, Harris, & McCorkle, 2007). Matthews and Malcolm (2007) tested nurses working in an orthopedic unit using a modified version of the KASRP and concluded that the nurses may be undertreating pain. In the patient vignette section of the survey, only 29.2% of the nurses identified the correct dose of morphine for a postoperative patient who reported a pain rating of 8 and was smiling, and 45.1% for a similar situation except that the patient was grimacing. In our study, 55% answered the question correctly for the scenario with the patient smiling and 63% for the patient who was grimacing. More correct answers were noted but they were still below the standard of 80%. Finally, faculty that reported more continuing education in pain management and spending more
classroom time teaching pain management did significantly better on the KASRP than faculty who had less continuing education. In addition, faculty who had more continuing education in pain management also reported teaching pain management guidelines in the classroom. Earlier research supports the need for continuing education in pain management. Greenberger et al.’s (2006) study of 1,149 Israeli nursing students and certified nurses found that higher educational levels were the most predictive of higher scores on the older version of the KASRP. What those researchers found most perplexing in that study, however, was that participants with higher scores on the questionnaire also reported that they provided inadequate pain management to patients.
STUDY LIMITATIONS Although very interesting information was obtained from this study, there are limitations. The use of a convenience sample from one region in the U.S. limits the ability to generalize these findings to other populations. In addition, the descriptive correlational research design can only provide significant linkages between study variables, not causality.
CONCLUSION Significant results were found in this study that reflected the participants’ background, knowledge, and attitudes regarding pain management. The Institute of Medicine’s (IOM) report on ‘ Relieving Pain in America’’ (2011) emphasized the need for nursing curricula to improve pain management education based on evidence-based practices. In addition, the IOM specifically defined the role
Knowledge and Attitudes of Pain Management
of nursing to include treating patients with acute and chronic pain in both hospital and outpatient settings. To meet these recommendations, nursing curricula may need to be strengthened in the topic of pain management. Furthermore, the importance of encouraging the use of pain management guidelines must be
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emphasized to provide consistency for nurses entering into clinical practice in all settings. In addition, requirements in obtaining continuing education in pain management may be needed for all nurses to increase knowledge and keep current in pain management protocols.
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