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Nurses' knowledge of pain issues: A survey
Vol. 2 No.4 Fall 1987
Journal of Pain and Symptom Management
207
Original A1ticle
Nurses' Knowledge of Pain Issues: A Survey Judith H. Watt-Watson Department of Nursing, University of Toronto, Toronto, Ontario
Abstract This descriptive study examined the knowledge base, related to pain assessment and narcotic administration, of nurses voluntarily attending pain presentations. Data were collected from 106 graduate nurses and 101 baccalaureate nursing students, using a questionnaire which was administered and collected prior to {he presentation. The majority of registered nurses were graduates of ten years or li/ss and were working in hospital settings. The scores ranged from 13% to 88% (x = 52%, median = 54%, SD = 14), and analysis of variance Was.liDt significant for dilferences among baccalaureate graduates, other graduates, and third-year baccalaureate students. Lack of knowledge about pain assessment and narcotic administration was evident. Graduate and student nurses expressed fntitration with difficulties in pain assessment and inadequate pain relieffor patients. This study points to major problems that need to be addressed in nursing education. J Pain Sympt Manag 1987;2:207-211 Key Words Nurses' knowledge, pain assessment, narcotic admiilistration
Introduction Pain is subjective and difficult to measure. The etiology of pain is not always understood, and relief of pain is too frequently not achieved. Although the physician writes the analgesic orders, the nurse is responsible for contributing to the pain assessment and for administering the drugs. The reluctance of physicians and nurses to administer analgesics, particularly narcotics, has been previously studied. The underestimation of analgesic requirements and lack of analgesic knowledge have been well documented with surgical patients, I medical patients/ and with terminal cancer patients."'" Fear of patient addiction by nurses and doctors has been documented as an important reason for inadequate pain control. ~·4 Some nurses and doctors have Addresss reprint requests to: Judith H. Watt-Watson, l\f5cN, Department of Nursing, Univcrsit}' of Toronto, 50 St. Georgc Strcct, Toronto, Ontario, Canada 1\155 lA1. Accepted for publication: March 19, 1987
indicated that patients were receiving adequate analgesia, although the patients reported that their pain continued to be moderate. 3 ' 5 Despite this research, difficulties in pain assessment, inappropriate narcotic administration, and inadequate pain control have continued. Patients experience considerable pain despite analgesic therapy, and nurses express frustration ,.vith their inadequate asssment of both pain intensity and the subsequent need for analgesia. The purpose of this study was to examine the knowledge base related to pain assessment and narcotic administration of nurses voluntarily attending pain presentations. SpecificaIly, three questions were addressed: • What is the Icvel of knowledge of nurses, both graduates and students, about pain assessment and narcotic administration? • \\7lmt differences exist between nurses' educational preparation and their level of knowledge about pain assessment and narcotic administration?
208
\ fait- \"olson
• What do nurses, both graduates and students, identify as the most difficult nursing issues related to patients experiencing acute or chronic pain?
lV1ethod The sample of 207 subjects participating in this study included 106 graduate nurses (25 ::::: BScN) and 101 baccalaureate students (48 third year, 53 second year). Over a ninemonth period, data were collected from three groups of graduate nurses and two groups of student nurses who voluntarily attended a pain education program. The largest group of graduate nurses (59%) worked in settings related to neurology and neurosurgery, while the remaining graduates worked mainly in medical hospital settings. Their time since graduation ranged from six months to 37 years (x = 12, median = 10, SD = 9). All second and third year students had had some medical-surgical experience with patients experiencing pain. Questionnaires were administered and collected prior to each presentation. The questionn~ire developed for this study (Sec Fig 1) comprised 18 questions assessing specific content about pain assessment and narcotic administration using true/false, multiple choice, and fill-in-the-blank formats. The total score for each instrument was converted to a percentage. Subjects were asked two openended questions to identify (a) the most difficult nursing problem(s) with patients in pain, and (b) current assessment tools and/or approaches.
Results Overall Scores. The total scores for the questionnaire ranged from 13% to 88% with a mean score of 52% (median = 54, SD = 14). Fourteen percent of subjects scored 33% or less, and 48% of subjects scored 50% or less. Only 3% of this sample scored higher than 75% (See Fig 2). Analysis of variance was significant for differences in the score means (see Table I) for the four groups with different education levels (F(3,206) = 9.612, P < 0.000) because of the lower scores of the second year sample (x = 44%, SD = 13). This was expected because of the second year level of formal pain-related
Joumal of Pain and Symplom Management
curriculum and the students' clinical experience. While the mean score for graduate nurses with a baccalaureate or further education (x = 59) was higher than other graduates (X = 55) (see Table 1), this difference was not significant at the 0.05 level of significance using ANOVA. There was no significant difference, using ttests, between years of experience and overall scores for the total sample of graduate nurse subjects. There were no significant associations, using X2 , between the level of education for graduate nurses and scores for any individual questions. Pain Assessment. The majority of subjects (96% RN, 91% students) recognized the importance of patient input in assessing pain, and most (94% RN, 66% students) indiCated that pain severity and duration could not be accurately determined relative to the pain stimulus. Although hospital patients were expected by the majority of subjects to tolerate minimal pain, a large percentage of this sample would encourage patients to increase their tolerance to pain (see Table 2). In assessing pain, the majority of graduates (58%) and students (73%) expected changes in vital signs with chronic pain and did not differentiate chronic from acute pain. It is interesting that while subjects did not believe that malingerers were rare (67% RN, 59% students), the majority indicated that psychogenic pain did hurt and was not the same as malingering (82% RN, 84% students). Qualitative responses indicated that only seven subjects (3%) were using any standard approach to pain assessment such as analogue scales or flow charts. Assessments were described as "not specific," "haphazard," "poor," "very subjective," and "very loosely done." The most difficult nursing problems in pain assessment were cited as judging the intensity of pain and the real need for analgesics, particularly with patients having communication problems and when the patient "seems comfortable," "asleep," or "is not complaining." Assessment of patients with chronic pain was frequently identified as difficult, as was the delineation of contextual issues such as anxiety being related to hospitalization and/or pain. Narcotic administration. A lack of knowledge was evident about narcotic administration and potential side effects, including addiction (see Ta-
Vol. 2 No.4 Fall 1987
209
Nurses' Knowledge of Pain Issues
PLEASE DO NOT PUT YOUR NAME ON THIS FORM NURSING PREPARATION a. RN b. BScN Year(s) graduated
_
c. MScN
_
d.other
_
_
CURRENT EMPLOYMENT a. Hospital: area b. Community: VON _ c. Education: diploma _ d. Other: _
DPH university
Occupational other
_
other
_
_
EXPERIENCE WITH PATIENTS HAVING PAIN Yes No _ PLEASE CHECK WHETHER THE FOLLOWING ARE TRUE (f) OR FALSE (F) 1. Assessment of pain by the health team is more valid than the patient's assessment. 2. The severity and duration of pain have a direct relationship with the pain stimulus. 3. Patients should not be encouraged to develop a high tolerance for pain. 4. Placebos are helpfUl in the treatment of pain problems, including: a. acute pain b. chronic pain c. terminal illness 5. Psychogenic pain really hurts and is not the same as malingering. 6. Malingerers consciously produce their pain symptoms and are rare patients. 7. Oral morphine is as effective as parenteral morphine with equianalg~sic doses. 8. There is no advantage to heroin, orally or parenterally, over current narcotics. PLEASE FILL IN THE BLANKS 9. What percentage of patients \"ith organic pain become addicted to narcotics while in hospital? I O. What is the duration of action for: a. morphine hours b. meperidine (Demerol) hours c. codeine hours d. Dilaudid hours
T T
F F F
T T T T T T T
F F F F F F F
T
_
PLEASE CIRCLE THE OPTION(S) WHICH YOU THINK ARE CORRECT. YOU MAY CHOOSE MORE THAN ONE OPTION. 15. A patient experiencing chronic pain may 11. Which drug(s) at .equianaIgesic doses has the most demonstrate changes in: side effects, eg, addiction, respiratory depression? a. pulse, respirations, blood pressure a. morphine b. meperidine b. mood status c. activity level c. codeine 12. What is the drug of choice for terminally ill d. sleep and eating habits 16. Patients in hospital should usually expect to patients? tolerate: a. meperidine a. no pain b. morphine b. minimal pain c. heroin c. moderate pain d. codeine d, severe pain 13; What is the purpose of PRN in giving pain 17. What is the most difficult problem(s) for you in medications? nursing a patient in pain, either acute or chronic? a. prevent tolerance and addiction 18. How are you assessing pain in your clinical setting? b. decrease respiratory depression c. decrease overdose liability d. for breakthrough pain when titrating narcotics 14. Placebos can be given to patients: a. to see if the pain is real b. who require more medication than necessary c. who are "difficult" and always complaining that treatments don't work d. in controlled research where the patient is told about the possibility of a placebo
Fig 1 Knowledge Surve}'
210
U'atl- Watson
Journal of Pain and Symptom Management
Table 3
Knowledge of Narcotic Administration (n
48Vc
100 !l0
44%
Graduate Nurses
RO Number of Subjects
70 .60 50 40
10
Student Nurses (%)
66
63
33
40
41
21
Placebos arc helpful for patients with: 31 acute pain chronic pain 49 terminal pain 25
51 53 41
Placebos arc used: for research purposes to tell if pairi is real
71 29
More than Hl% ofhospital patients with organic pain become addicted.
20
4Vc
3%
o
-
100
Overall Scores
Fig 2 Frequency of overall scores for total sample.
Table 1
Measures of Central Tendency and Variability of Total Scores and Subscores X Score Total Subscores Graduates-Diploma Graduates-2:BScN Third year BScN students Second year BScN students
n
(%)
SD
207
52
14
81 25 48 53
55 59 54 44
13 15 15 13
PRN medications are given: to prevent tolerance and addiction for breakthrough pain
Table 4
Morphine Meperidine Codeine
Table 2
Graduate Nurses Responses Hospital patients should tolerate: minimal pain moderate pain severe pain Patients should be encouraged to increase their pain tolerance
(%)
63
15
=
71 33
Incorrect Knowledge of the Duration of Action for Specific Narcotics (n = 207)
Narcotic
Responses Related to Pain Tolerance (n
207)
(%)
Respons;s
:~O
=
Graduate Nurses
Student Nurses
(%)
(%)
51 75 23
57 76 55
207)
Student Nurses (%)
70 21
5
o
49
60
ble 3). The incidence of addiction in hospitalized patients with organic pain was stated as greater than 10% by the majority of this sample. Although the rationale for giving placebos was believed by the majority to be for research, one third of subjects believed placebos would determine whether the pain was real.
Knowledge of specific narcotics was lacking, including duration of action( see Table 4). At equianalgesic doses, morphine was believed to have more side effects than either meperidine or codeine (82% RN, 74% students), which may be the reason why morphine was the drug chosen for terminally ill patients by the majority (82% RN, 69% students). Nursing problems identified in managing pain with narcotics included fears of addiction, a lack of knowledge about narcotic doses, side effects and duration, conflict among nurses and between nurses and doctors, and feelings of frustration and helplessness with unsuccessful approaches.
Discussion The educational preparation of graduate nurses and the number of years since gradu-
Vol. 2 No.4 Fall 1987
Nurses' Knowledge of Pain Issues
ation were not significantly related to subjects' overall scores or their scores on individual questions. Misconceptions and lack of knmdedge about pain assessment and narcotic administration were evident for the total sample (X = 52%; see Table 1). Most subjects,were not using any standardized approach to pain assessment, and many expressed their lack of knowledge and skills in this area. The majority of this sample did not view chronic pain as different from acute pain, and chronic pain was frequently identified as a difficult nursing problem. People were expected to increase their tolerance of pain, and 67% of this sample stated patients should expect to experience minimal pain. Similar to nurses in other studies,4.6 the goal of these nurses was to reduce pain rather than relieve it, as only 10% said patients should expect to experience no pain. Nurses have much of the responsibility for the assessment of pain and the subsequent comfort measures. Serious gaps in knowledge have been identified, however, as reflected in this sample's low scores and lack of utilization of assessment tools. While a limitation of this study might be that questionnaire responses may not always coincide with actual practice, this sample was seeking additional knowledge through participation in a pain-focused educational program. In pain management, narcotics are administered by nurses based on their pain assessment and their choice of dose and drug if several are ordered. The majority of this sample overestimated the incidence of addiction ( > 10%) and did not know the equianalgesic doses or correct duration of commonly-used narcotics such as morphine, meperidine, and codeine. One third of the sample believed that "as needed" medications were given to prevent tolerance and addiction, a finding similar to
211
Charap's study3 and that placebos were given to determine if pain was real. Problems in pain management identified by the sample reflect the misconceptions ,and inadequate knowledge stated above. Years of addiction, lack of knowledge about narcotic administration, and interdisciplinary and intradisciplinary conflicts concerning types and amounts of drugs were linked with feelings of frustration and helplessness with unsuccessful . c. approaches. These data suggest that there is a need to include more formal content in nursing curricula on pain assessment approaches and analgesic administration, particularly narcotics.
Acknowledgments This research was partially supported by the Faculty of Nursing. Dean's Development Fund. This research was presented at the American Pain Society meeting in November 1986. The author would like to thank Dr. Jane Graydon for her statistical assistance.
ReferelUes 1. Keeri-Szanto 1\1, Heaman S. Postoperative demand analgesia. Sur Gyn & Obst 1972;134:647-51. 2. !\larks R, Sachar 1\1. Undertreatment of medical inpatients with narcotic analgesics. Ann Int Med 1973;78:173-81. 3. Charap AD. The knowledge, attitudes, and experience of medical personnel treating pain in the terminally ill. !\It Sinai J !\led 1978;45:561-80. 4. Cohen FL. Postsurgical pain relief: patients' status and nurses' medication choices. Pain 1980;9:26574. 5. Rankin 1\1. Use of drugs for pain with cancer patients. Cancer Nursing 1982;5: 181-90. 6. Rankin !\I, Snider B. Nurses' perceptions of cancer patients' pain. Cancer Nursing 1984;1:149-55.
Journal of Pain and Symptom Management
207
Original A1ticle
Nurses' Knowledge of Pain Issues: A Survey Judith H. Watt-Watson Department of Nursing, University of Toronto, Toronto, Ontario
Abstract This descriptive study examined the knowledge base, related to pain assessment and narcotic administration, of nurses voluntarily attending pain presentations. Data were collected from 106 graduate nurses and 101 baccalaureate nursing students, using a questionnaire which was administered and collected prior to {he presentation. The majority of registered nurses were graduates of ten years or li/ss and were working in hospital settings. The scores ranged from 13% to 88% (x = 52%, median = 54%, SD = 14), and analysis of variance Was.liDt significant for dilferences among baccalaureate graduates, other graduates, and third-year baccalaureate students. Lack of knowledge about pain assessment and narcotic administration was evident. Graduate and student nurses expressed fntitration with difficulties in pain assessment and inadequate pain relieffor patients. This study points to major problems that need to be addressed in nursing education. J Pain Sympt Manag 1987;2:207-211 Key Words Nurses' knowledge, pain assessment, narcotic admiilistration
Introduction Pain is subjective and difficult to measure. The etiology of pain is not always understood, and relief of pain is too frequently not achieved. Although the physician writes the analgesic orders, the nurse is responsible for contributing to the pain assessment and for administering the drugs. The reluctance of physicians and nurses to administer analgesics, particularly narcotics, has been previously studied. The underestimation of analgesic requirements and lack of analgesic knowledge have been well documented with surgical patients, I medical patients/ and with terminal cancer patients."'" Fear of patient addiction by nurses and doctors has been documented as an important reason for inadequate pain control. ~·4 Some nurses and doctors have Addresss reprint requests to: Judith H. Watt-Watson, l\f5cN, Department of Nursing, Univcrsit}' of Toronto, 50 St. Georgc Strcct, Toronto, Ontario, Canada 1\155 lA1. Accepted for publication: March 19, 1987
indicated that patients were receiving adequate analgesia, although the patients reported that their pain continued to be moderate. 3 ' 5 Despite this research, difficulties in pain assessment, inappropriate narcotic administration, and inadequate pain control have continued. Patients experience considerable pain despite analgesic therapy, and nurses express frustration ,.vith their inadequate asssment of both pain intensity and the subsequent need for analgesia. The purpose of this study was to examine the knowledge base related to pain assessment and narcotic administration of nurses voluntarily attending pain presentations. SpecificaIly, three questions were addressed: • What is the Icvel of knowledge of nurses, both graduates and students, about pain assessment and narcotic administration? • \\7lmt differences exist between nurses' educational preparation and their level of knowledge about pain assessment and narcotic administration?
208
\ fait- \"olson
• What do nurses, both graduates and students, identify as the most difficult nursing issues related to patients experiencing acute or chronic pain?
lV1ethod The sample of 207 subjects participating in this study included 106 graduate nurses (25 ::::: BScN) and 101 baccalaureate students (48 third year, 53 second year). Over a ninemonth period, data were collected from three groups of graduate nurses and two groups of student nurses who voluntarily attended a pain education program. The largest group of graduate nurses (59%) worked in settings related to neurology and neurosurgery, while the remaining graduates worked mainly in medical hospital settings. Their time since graduation ranged from six months to 37 years (x = 12, median = 10, SD = 9). All second and third year students had had some medical-surgical experience with patients experiencing pain. Questionnaires were administered and collected prior to each presentation. The questionn~ire developed for this study (Sec Fig 1) comprised 18 questions assessing specific content about pain assessment and narcotic administration using true/false, multiple choice, and fill-in-the-blank formats. The total score for each instrument was converted to a percentage. Subjects were asked two openended questions to identify (a) the most difficult nursing problem(s) with patients in pain, and (b) current assessment tools and/or approaches.
Results Overall Scores. The total scores for the questionnaire ranged from 13% to 88% with a mean score of 52% (median = 54, SD = 14). Fourteen percent of subjects scored 33% or less, and 48% of subjects scored 50% or less. Only 3% of this sample scored higher than 75% (See Fig 2). Analysis of variance was significant for differences in the score means (see Table I) for the four groups with different education levels (F(3,206) = 9.612, P < 0.000) because of the lower scores of the second year sample (x = 44%, SD = 13). This was expected because of the second year level of formal pain-related
Joumal of Pain and Symplom Management
curriculum and the students' clinical experience. While the mean score for graduate nurses with a baccalaureate or further education (x = 59) was higher than other graduates (X = 55) (see Table 1), this difference was not significant at the 0.05 level of significance using ANOVA. There was no significant difference, using ttests, between years of experience and overall scores for the total sample of graduate nurse subjects. There were no significant associations, using X2 , between the level of education for graduate nurses and scores for any individual questions. Pain Assessment. The majority of subjects (96% RN, 91% students) recognized the importance of patient input in assessing pain, and most (94% RN, 66% students) indiCated that pain severity and duration could not be accurately determined relative to the pain stimulus. Although hospital patients were expected by the majority of subjects to tolerate minimal pain, a large percentage of this sample would encourage patients to increase their tolerance to pain (see Table 2). In assessing pain, the majority of graduates (58%) and students (73%) expected changes in vital signs with chronic pain and did not differentiate chronic from acute pain. It is interesting that while subjects did not believe that malingerers were rare (67% RN, 59% students), the majority indicated that psychogenic pain did hurt and was not the same as malingering (82% RN, 84% students). Qualitative responses indicated that only seven subjects (3%) were using any standard approach to pain assessment such as analogue scales or flow charts. Assessments were described as "not specific," "haphazard," "poor," "very subjective," and "very loosely done." The most difficult nursing problems in pain assessment were cited as judging the intensity of pain and the real need for analgesics, particularly with patients having communication problems and when the patient "seems comfortable," "asleep," or "is not complaining." Assessment of patients with chronic pain was frequently identified as difficult, as was the delineation of contextual issues such as anxiety being related to hospitalization and/or pain. Narcotic administration. A lack of knowledge was evident about narcotic administration and potential side effects, including addiction (see Ta-
Vol. 2 No.4 Fall 1987
209
Nurses' Knowledge of Pain Issues
PLEASE DO NOT PUT YOUR NAME ON THIS FORM NURSING PREPARATION a. RN b. BScN Year(s) graduated
_
c. MScN
_
d.other
_
_
CURRENT EMPLOYMENT a. Hospital: area b. Community: VON _ c. Education: diploma _ d. Other: _
DPH university
Occupational other
_
other
_
_
EXPERIENCE WITH PATIENTS HAVING PAIN Yes No _ PLEASE CHECK WHETHER THE FOLLOWING ARE TRUE (f) OR FALSE (F) 1. Assessment of pain by the health team is more valid than the patient's assessment. 2. The severity and duration of pain have a direct relationship with the pain stimulus. 3. Patients should not be encouraged to develop a high tolerance for pain. 4. Placebos are helpfUl in the treatment of pain problems, including: a. acute pain b. chronic pain c. terminal illness 5. Psychogenic pain really hurts and is not the same as malingering. 6. Malingerers consciously produce their pain symptoms and are rare patients. 7. Oral morphine is as effective as parenteral morphine with equianalg~sic doses. 8. There is no advantage to heroin, orally or parenterally, over current narcotics. PLEASE FILL IN THE BLANKS 9. What percentage of patients \"ith organic pain become addicted to narcotics while in hospital? I O. What is the duration of action for: a. morphine hours b. meperidine (Demerol) hours c. codeine hours d. Dilaudid hours
T T
F F F
T T T T T T T
F F F F F F F
T
_
PLEASE CIRCLE THE OPTION(S) WHICH YOU THINK ARE CORRECT. YOU MAY CHOOSE MORE THAN ONE OPTION. 15. A patient experiencing chronic pain may 11. Which drug(s) at .equianaIgesic doses has the most demonstrate changes in: side effects, eg, addiction, respiratory depression? a. pulse, respirations, blood pressure a. morphine b. meperidine b. mood status c. activity level c. codeine 12. What is the drug of choice for terminally ill d. sleep and eating habits 16. Patients in hospital should usually expect to patients? tolerate: a. meperidine a. no pain b. morphine b. minimal pain c. heroin c. moderate pain d. codeine d, severe pain 13; What is the purpose of PRN in giving pain 17. What is the most difficult problem(s) for you in medications? nursing a patient in pain, either acute or chronic? a. prevent tolerance and addiction 18. How are you assessing pain in your clinical setting? b. decrease respiratory depression c. decrease overdose liability d. for breakthrough pain when titrating narcotics 14. Placebos can be given to patients: a. to see if the pain is real b. who require more medication than necessary c. who are "difficult" and always complaining that treatments don't work d. in controlled research where the patient is told about the possibility of a placebo
Fig 1 Knowledge Surve}'
210
U'atl- Watson
Journal of Pain and Symptom Management
Table 3
Knowledge of Narcotic Administration (n
48Vc
100 !l0
44%
Graduate Nurses
RO Number of Subjects
70 .60 50 40
10
Student Nurses (%)
66
63
33
40
41
21
Placebos arc helpful for patients with: 31 acute pain chronic pain 49 terminal pain 25
51 53 41
Placebos arc used: for research purposes to tell if pairi is real
71 29
More than Hl% ofhospital patients with organic pain become addicted.
20
4Vc
3%
o
-
100
Overall Scores
Fig 2 Frequency of overall scores for total sample.
Table 1
Measures of Central Tendency and Variability of Total Scores and Subscores X Score Total Subscores Graduates-Diploma Graduates-2:BScN Third year BScN students Second year BScN students
n
(%)
SD
207
52
14
81 25 48 53
55 59 54 44
13 15 15 13
PRN medications are given: to prevent tolerance and addiction for breakthrough pain
Table 4
Morphine Meperidine Codeine
Table 2
Graduate Nurses Responses Hospital patients should tolerate: minimal pain moderate pain severe pain Patients should be encouraged to increase their pain tolerance
(%)
63
15
=
71 33
Incorrect Knowledge of the Duration of Action for Specific Narcotics (n = 207)
Narcotic
Responses Related to Pain Tolerance (n
207)
(%)
Respons;s
:~O
=
Graduate Nurses
Student Nurses
(%)
(%)
51 75 23
57 76 55
207)
Student Nurses (%)
70 21
5
o
49
60
ble 3). The incidence of addiction in hospitalized patients with organic pain was stated as greater than 10% by the majority of this sample. Although the rationale for giving placebos was believed by the majority to be for research, one third of subjects believed placebos would determine whether the pain was real.
Knowledge of specific narcotics was lacking, including duration of action( see Table 4). At equianalgesic doses, morphine was believed to have more side effects than either meperidine or codeine (82% RN, 74% students), which may be the reason why morphine was the drug chosen for terminally ill patients by the majority (82% RN, 69% students). Nursing problems identified in managing pain with narcotics included fears of addiction, a lack of knowledge about narcotic doses, side effects and duration, conflict among nurses and between nurses and doctors, and feelings of frustration and helplessness with unsuccessful approaches.
Discussion The educational preparation of graduate nurses and the number of years since gradu-
Vol. 2 No.4 Fall 1987
Nurses' Knowledge of Pain Issues
ation were not significantly related to subjects' overall scores or their scores on individual questions. Misconceptions and lack of knmdedge about pain assessment and narcotic administration were evident for the total sample (X = 52%; see Table 1). Most subjects,were not using any standardized approach to pain assessment, and many expressed their lack of knowledge and skills in this area. The majority of this sample did not view chronic pain as different from acute pain, and chronic pain was frequently identified as a difficult nursing problem. People were expected to increase their tolerance of pain, and 67% of this sample stated patients should expect to experience minimal pain. Similar to nurses in other studies,4.6 the goal of these nurses was to reduce pain rather than relieve it, as only 10% said patients should expect to experience no pain. Nurses have much of the responsibility for the assessment of pain and the subsequent comfort measures. Serious gaps in knowledge have been identified, however, as reflected in this sample's low scores and lack of utilization of assessment tools. While a limitation of this study might be that questionnaire responses may not always coincide with actual practice, this sample was seeking additional knowledge through participation in a pain-focused educational program. In pain management, narcotics are administered by nurses based on their pain assessment and their choice of dose and drug if several are ordered. The majority of this sample overestimated the incidence of addiction ( > 10%) and did not know the equianalgesic doses or correct duration of commonly-used narcotics such as morphine, meperidine, and codeine. One third of the sample believed that "as needed" medications were given to prevent tolerance and addiction, a finding similar to
211
Charap's study3 and that placebos were given to determine if pain was real. Problems in pain management identified by the sample reflect the misconceptions ,and inadequate knowledge stated above. Years of addiction, lack of knowledge about narcotic administration, and interdisciplinary and intradisciplinary conflicts concerning types and amounts of drugs were linked with feelings of frustration and helplessness with unsuccessful . c. approaches. These data suggest that there is a need to include more formal content in nursing curricula on pain assessment approaches and analgesic administration, particularly narcotics.
Acknowledgments This research was partially supported by the Faculty of Nursing. Dean's Development Fund. This research was presented at the American Pain Society meeting in November 1986. The author would like to thank Dr. Jane Graydon for her statistical assistance.
ReferelUes 1. Keeri-Szanto 1\1, Heaman S. Postoperative demand analgesia. Sur Gyn & Obst 1972;134:647-51. 2. !\larks R, Sachar 1\1. Undertreatment of medical inpatients with narcotic analgesics. Ann Int Med 1973;78:173-81. 3. Charap AD. The knowledge, attitudes, and experience of medical personnel treating pain in the terminally ill. !\It Sinai J !\led 1978;45:561-80. 4. Cohen FL. Postsurgical pain relief: patients' status and nurses' medication choices. Pain 1980;9:26574. 5. Rankin 1\1. Use of drugs for pain with cancer patients. Cancer Nursing 1982;5: 181-90. 6. Rankin !\I, Snider B. Nurses' perceptions of cancer patients' pain. Cancer Nursing 1984;1:149-55.