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Nursing students’ knowledge of and views about children in pain
Article
Nursing students’ knowledge of and views about children in pain Sanna Salanterä and Sirkka Lauri
It is important to evaluate the outcomes of the given education to gain knowledge about the abilities of our students to meet the needs of nursing practice. Pain associated with different illnesses and procedures is one of the most common symptoms that children experience in the hospital. The purpose of this study was to evaluate the views and knowledge base of graduating nursing students in the area of taking care of children in pain. The data were collected with a purpose-designed Likert-type instrument from all nursing students that graduated during one year from the child nurse specializing program in Finland (n=85), with a response rate of 86%. Results indicate that students have mainly positive views and attitudes towards taking care of children in pain. The views and attitudes differ when older and younger students and students from different schools are compared. Students lack knowledge especially in the area of pain medications as well as in the assessment of pain. In the knowledge section, the results did not differ greatly when different schools, younger and older students or previous working experience and no working experience were compared. In some of the researched schools, many of the students felt a lack of confidence about their knowledge. There is a need for more detailed education in the area of taking care of children with pain. © 2000 Harcourt Publishers Ltd
Sanna Salanterä RN, PhD Assistant Professor, Sirkka Lauri PhD, RN, Professor, Department of Nursing Science, 20014 University of Turku, Finland. Tel.: +358 2 333 8409; Fax: +358 2 333 8400; E-mail [email protected] (Requests for offprints to SS) Manuscript accepted: 2 March 2000
Introduction and literature review As the knowledge base about taking care of pain in children grows, there is a growing interest in the extent of nurses and nursing students’ knowledge of the subject as well as what kind of attitudes and views they have. Developing a sound knowledge base during education is important and helps the nurse to proceed from beginner status to expert status in nursing. There is some research available about the knowledge base and attitudes that nurses have but far less about the knowledge base of nursing students and even less in the area of children’s nursing. This study set out to find out what kind of knowledge base and views nursing students
© 2000 Harcourt Publishers Ltd doi:10.1054/nedt.2000.0472, available online at http://www.idealibrary.com on
specializing in children’s care have about pain in children and taking care of children in pain when their nursing education is complete. Several studies indicate that nurses lack knowledge about taking care of pain (Ketovuori 1987; Hamilton & Edgar 1992; Caty et al. 1995; Clarke et al. 1996; Closs 1996; Kubecka et al. 1996; Lebovits et al. 1997; Salanterä et al. 1999). There are also studies which conclude that nurses still have misconceptions, false beliefs and attitudes that mediate against proper pain care (Ferrell et al. 1995; Clarke et al. 1996; Lebovits et al. 1997; Salanterä 1999). These results pertain to other groups of health care professionals as well (Ferrell et al. 1995; Mercadente & Salvaggio 1996; Lebovits et al. 1997). On the other hand, more recent research shows that nurses have a wider
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repertoire of knowledge than they actually use in assessing pain (Seymour et al. 1997), that nurses are better informed and more aware about children in pain than has been previously suggested, and that pain myths are not widespread (Collier & Pattison 1997). As pain is one of the most common symptoms that patients have, it is obvious that in nursing education this subject should be well covered and students should have a good knowledge base when their studies are complete. In McCaffery and Ferrell’s (1996) study, the results showed that students already have strong attitudes and beliefs about pain and taking care of pain before entering nursing school. Studies to indicate how these attitudes change in the course of nursing education are not available. Diekmann and Wassem (1991) conducted a survey of nursing students’ knowledge of cancer pain control and found out that the results reflected poor knowledge about the prevalence of cancer pain and management. In Sheehan et al.’s (1992) study, 82 baccalaureate student nurses had a realistic perspective about the severity and prevalence of cancer pain and psychological dependence but still they had specific knowledge deficits and negative attitudes towards cancer pain management. The level of education seems to have an effect on students’ beliefs and perceptions. In Margolius et al.’s (1995) survey of 228 nurses, they found that those nurses who had lower education and provided the most direct care held the most misconceptions about effective pain management for children. Price (1992) studied 17 second-year general nursing students, who had just completed their paediatric secondment, with a self-administered questionnaire. The results showed that students’ definitions of pain concentrated mainly on the physical effects of pain. Also, nursing faculty knowledge of and beliefs about pain can be less than optimal, as shown by a survey conducted of 14 baccalaureate nursing schools in the USA. In the same study, the results showed that many nursing curriculum contents related to pain were inadequate. (Ferrell et al. 1995). As several studies show, nurses, nursing teachers, and nursing students have misconceptions, and lack of knowledge about taking care of pain in adults and cancer patients in particular. It is important to know whether this
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is the case with nursing students who will be working with children.
Purpose of the study and research questions The aim of this study was to explore nursing students’ knowledge and views of, as well as their opinions about their education in taking care of children in pain during their last semester as nursing students. The following research questions were asked: 1. How do nursing students evaluate their knowledge of and abilities in nursing children in pain and treating pain in children? 2. What are nursing students’ views of children in pain and pain in children? 3. What is the extent of nursing students’ knowledge about children in pain and pain in children? 4. What kind of children’s pain assessment and pain management methods are taught in nursing education? 5. Do students knowledge, views or opinions differ according to their age, working experience and place of education?
Materials and methods The target population consisted of all such nursing students who graduated during one year in Finland in the specialization field of children’s nursing (n=85). The questionnaire was sent to all the students via their teachers. Altogether, 73 students completed the questionnaire, which makes a response rate of up to 86%. The instruments were well filled and the number of missing answers per item was two at the most. Students were from four different nursing colleges situated in different parts of the country. The education of these nurses lasts three-and-ahalf years after high-school education, of which two-and-a-half years is devoted to general nursing education and one year to specialist child care. The data were collected during the last month of the course. About 97% of the nursing students in Finland are female. Respondents were not asked their gender in this questionnaire to ensure full anonymity. The age of the respondents ranged from 21 to 45 and mean age was 26 years (SD 5.9)
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Students’ knowledge of and views about children in pain
and median 24 years, which is equivalent to the mean age of nursing students in general in Finland. Eleven students had a previous degree in the field of health care (nursing assistant). Almost half of the students (45%) had some working experience in the field of health care. The mean length of this experience was 2 years (SD 2.5). Most of the working experience was in the position of nursing assistant (77%). The questionnaire consisted of a demographic data sheet, 82 items about knowledge and views of pain in children and children in pain, questions about the assessment methods, and non-pharmacological pain management methods that are taught during the nursing course as well as questions regarding students’ own opinions about their education, knowledge of and ability to take care of children in pain. The five-point Likert-type scale for the items ranged from ‘Agree’, through ‘Agree to some extent’, ‘Don’t know’, ‘Disagree to some extent’ to ‘Disagree’. In the section where students stated their own opinion about their knowledge of and possibilities for taking care of pain in children, the scale ranged from ‘Good’ through, ‘Fairly good’, ‘Don’t know’, ‘Fairly poor’ to ‘Poor’. Knowledge scores were expressed as a percentage of correct answers out of the possible total. The answers ‘Agree’ and ‘Agree to some extent’ or, when the item was incorrect, ‘Disagree’ or ‘Disagree to some extent’ were scored as correct answers and were worth one point, while other options were scored as zero. The items concerning students’ views were scored similarly so that the answers stating views that were supportive to good pain assessment and management in children were scored as one and counterproductive and ‘don’t know’ options were scored as zero. The instrument used in this study was designed in parallel with one designed for nurses and they were both based on the existing research literature on children’s pain mainly in the field of nursing. For concept, content and construct validity, the instrument was reviewed by a group of five nurses who were experts in taking care of children in pain. These experts had at least 10 years of practical experience, they had been identified as experts by their superiors and they had all been involved in research development programmes in the field of pain. The other expert group consisted of five nurses with Master’s
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degrees in nursing science. Both groups assessed the validity, readability and language of each item. The instrument was also reviewed by a paediatrician and an anaesthesiologist. Then the revised instrument was pilot-tested with a group of 10 nurses. After this, the instrument was finalized. The homogenety of items measuring views and knowledge was tested using Cronbach’s α coefficient for the views and knowledge scale and Kuder-Richardson 20-formula for the dichotomous knowledge scores on non-pharmacological and pharmacological pain management. The α-coefficient was 0.64, which is slightly below an acceptable level of good reliability (0.7) of a new instrument, and the Kuder-Richardson 20-test for the knowledge score was 0.69, indicating fairly good reliability. The descriptive values of items were expressed as means, standard deviations and percentages. The statistical significance of differences between different groups of students on their knowledge scores were tested by Wilcoxon 2-sample test. Independent questions were analysed by Pearson’s χ2 and, if frequencies were small, Fisher’s exact test was applied. P-values less than 0.05 were interpreted as significant. The data were entered twice on the program to avoid errors in data input. The SAS system for Windows, release 6/12/1996, was used for data analysis.
Results Students’ opinions about their knowledge of, ability in and possibilities for taking care of children in pain To evaluate the education students had received, they were asked the following three open-ended questions:(1) What kind of teaching have you received during your education on children’s pain? (2) What kind of literature have you recently read on children’s pain?; and (3) What kind of education would you like to have on children’s pain? The answers were content analysed and categorized. In the first question, 25 (34%) of the 73 students felt their education had been superficial, 23 (32%) thought that they had received basic knowledge on the subject, and 10 students (14%) described their education on the subject as varied and comprehensive. A few
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Students’ knowledge of and views about children in pain
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Fig. 1 Percent of students who felt their knowledge, abilities or possibilities were good or fairly good in areas of taking care of children in pain.
students felt their education had been too theoretical. The remaining responses were too heterogeneous to be formed into categories. The answers to the second question were divided into five main categories. The students had mainly read about children’s pain in the chapters of a book on children’s nursing (mentioned by 25 students), in professional journals (22), and in magazines (17). Eleven students mentioned a scientific journal and eight students a research report as sources of information. The remaining answers referred to individual sources such as videos, abstracts, a book or notes on lectures. The students were mainly keen to learn more about pain medication (mentioned by 38 students), pain assessment (16), pain alleviation methods (14), and pain experience (9). Only a few students said
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they wanted more education on such subjects as cancer pain, the physiology of pain, the child’s neurological development or how pain emerges. Students felt they had fairly good or good knowledge in many areas of taking care of children in pain. The results of this section are shown in Figure 1. Children’s physical and psychological development were thought to be well mastered but neurological development was not. Students felt that they do not have good knowledge about how pain emerges, nor about pain medication, its side-effects or the possibilities for their institution to offer proper education. The students were divided into two groups according to their opinions so that those who felt their knowledge was good or fairly good always
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Students’ knowledge of and views about children in pain
100%
Percentage of counterproductive answers Percentage of don't know answers Percentage of supportive answers
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Fig. 2 Items with low percentage of supportive answers: (1) A child less than one month of age may be intubated without anaesthesia; (2) Children normally tolerate pain less well than adults do; (3) Children can sleep even they are in severe pain; (4) Chronic pain in children is not easy to ascertain on the basis of changes in vital functions (e.g. heart rate, breathing rate) because those functions do not always react to chronic pain; (5) A calm child who says he or she is experiencing pain is likely to be in pain; (6) Damaged tissue is more sensitive to pain than undamaged tissue; (7) The level of pain suffered by a child can easily be established by giving a placebo; (8) A child who is capable of verbal expression is usually best able to assess his/her own pain; (9) It is difficult to make a distinction between pain and fear in children; (10) The most common reason for the need to increase painkiller dosage in cancer treatment is the progression of the illness and the pain involved; (11) Parents tend to exaggerate their child’s pain.
formed one group and those who felt their knowledge was fairly poor, poor or they could not tell formed the other group and these groups were compared with the demographic data. The school where the students studied had the most significant connection with the answers. In one school, students rated their knowledge significantly poorer than students in the other three schools in the areas of pain medication (χ2=10.2, df=3, P=0.016), and pain alleviation (χ2=8.8, df=3, P=0.031). In another school, students rated the possibility of their school offering proper education in the area of taking care of children in pain lower than students in the other schools (χ2=10.4, df=3, P=0.014). The students who had a previous education in the field of health care were not more confident about their knowledge than those who did not, neither were those who had previous working
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experience in the field of health care. Older students felt their knowledge was good significantly more often in the areas of children’s neurological development (χ2=8.3, df=1, P<0.001) and in the area of pain alleviation methods (χ2=8.6, df=1, P<0.001) than younger students.
Nursing students’ views about taking care of children in pain There were 40 items in the questionnaire that measured students’ views about taking care of children in pain. These items measured nursing students’ beliefs and attitudes towards certain aspects of children in pain. Students had an average of 80% (SD 8.4) in such answers that were supportive to effective care and the median was as high as 83%, i.e. 32 answers out of 40. From the 73 students, 38 (52%) had over 80% of
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Table 1
Student characteristics and knowledge scores Knowledge scores on: Non-pharmacological pain management (9 items)
General aspects of pharmacological pain (6 items)
Anti-inflammatory pain medication (8 items)
Opiates (6 items)
Regional anaesthesia (3 items)
Mean (SD) and
68 % (13.5)
54% (23.0)
49% (22.0)
37% (22.1)
29% (30.9)
median of
median
median
median
median
median
correct answers
67%
50%
50%
33%
33%
NS
NS
NS
χ2=4.9
NS
Student characteristics Age (younger <24,
df = 1
older =>24)
0.027
Previous working experience
NS
NS
NS
NS
NS
NS
NS
χ2 = 10.3
NS
NS
(yes/no) School
df = 3 0.017 NS = non significant; P > 0.05.
such answers that were supportive to effective care of children in pain and only 11 (15%) students had less than 70% of such answers that were considered as supportive to effective care. There were 11 such items where 30% or more of the students chose the answer that could be considered as counterproductive to effective care of children in pain. The distribution of the answers to these 11 items is shown in Figure 2. The scores of these 40 items were compared between the students that had some previous working experience in the field of health care, between younger (<24 years of age) and older (24 or older) students and between students from the four different schools. Previous working experience did not have a significant effect on the students’ answers. There was a difference between younger (<24 years) and older students (≥ 24) in favour of the older students (χ2=4.1, df=1, P=0.043), whose answers were more supportive of effective care of children in pain. The answers of the students differed significantly between the different schools. In one school, the answers were significantly more supportive of effective care of pain than in the other three schools (χ2=12.8, df=3, P=0.005).
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Nursing students’ knowledge of non-pharmacological pain management Nursing students’ knowledge of nonpharmacological pain management was measured with nine items. The mean of correct answers was 68% (SD 13.5%) and median 67% (6 items). Students achieved most correct answers in the following items: ‘In the treatment of pain in children, other methods of alleviating the pain are needed in addition to medication.’ (true, 100% correct answers); ‘Pain in children cannot be totally eliminated by conversation aimed at helping them to relax.’ (true, 93% correct answers). The items that were answered correct the least were: ‘Cold bandages only help if they are placed upon the painful area.’ (false, 25% correct answers) and ‘Massage is a good method of alleviating pain associated with tumours in children.’ (false, 29% correct answers). The significance of the differences between different groups of students was measured as reported before. The associations between the different student characteristics and knowledge scores are seen in Table 1, and the associations between a student’s own opinion about her
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Students’ knowledge of and views about children in pain
Table 2
Student’s own opinion about her knowledge and knowledge scores Knowledge scores on: Non-pharmacological pain management (9 items)
General aspects of pharmacological pain (6 items)
Anti-inflammatory pain medication (8 items)
Opiates (6 items)
Regional anaesthesia (3 items)
About non-pharmacological NS
NS
NS
NS
NS
About pharmacologicalpain management
NS
NS
χ2 = 8.7 df = 2 p = 0.013
NS
NS
About side-effects of pharmacological pain management
NS
NS
χ2 = 12.7 df = 2 0.002
χ2 = 11.7 df = 2 0.003
NS
Student’s view about her school’s possibilities of offering education on children in pain
χ2 = 6.8 df = 2 0.003
NS
NS
NS
NS
Student’s own opinion about her knowledge
NS = non significant; P>0.05.
knowledge and knowledge scores are seen in Table 2. There were nearly significant differences between previous working experience in favour of those who had had some previous experience in the field of health care (χ2=7.9, df=3, P=0.056). No significant differences were found between the students from different schools. In addition, the results were compared in the respect of how well students themselves felt that they knew about non-pharmacological and pharmacological pain management. Groups differed nearly significantly (χ2=5.7, df=2, P=0.056) so that those students who thought their knowledge was good or fairly good also scored highest in the knowledge section. Students that felt their institution offered good possibilities for pain education scored significantly higher than those who thought the possibilities were poor.
Nursing students’ knowledge about pharmacological pain management Knowledge about pharmacological pain management was measured with 23 items, containing six items about general knowledge, eight items about anti-inflammatory pain medication, six items about opiates and three items about regional anaesthesia. The mean (SD) of correct answers in the whole section was 45%
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(17.7), the median being 43%. There were only three items in which over 80% of the students had a correct answer. These items were: ‘Paracetamol (acetaminophen) is well-suited for the treatment of pain in children.’ (true); ‘Pain medication is equally effective whether given before the onset of pain or when the child is already experiencing pain.’ (false); and ‘Long-term continuing opioid (e.g. morphine, petidine) medication almost always causes physiological dependence in child patients.’ (true). There were three items to which less than 20% of the students had answered correctly and these were: ‘Respiratory depression is very rare in children who have received long-term continuing opioid medication.’ (true); ‘Anti-inflammatory drugs do not increase the respiratory effect of opioids.’ (true); and ‘Regional anaesthesia is well-suited for the alleviation of cancer pain.’ (true). The percentage age of correct answers to these items was in all cases 15. When looking at the different sections, students’ knowledge varied greatly. General aspects of pharmacological pain management were not known very well. The mean of correct answers was 54% (23.0) and median was 50%. Knowledge about anti-inflammatory pain management was well known to only half of the students. Knowledge about opiates and regional
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anaesthesia appeared to be even more unfamiliar to the students since the median of correct answers in the area of opiates was 33% (M(SD) = 37(22)) and in the area of regional anaesthesia 33% (M(SD) = 29(31)) respectively. The results of the comparisons between different groups of students indicate that age, previous experience and place of education all had only a minor effect on students’ knowledge. These results are shown in more detail in Table 1. The knowledge scores were also compared with the student’s own opinions about her knowledge. There were not many significant differences between the groups of students. However, students who themselves felt they had good knowledge about pharmacological pain management also scored highest on antiinflammatory pain medications. Furthermore, students who thought their knowledge was good in the area of side-effects of pain medication had most correct answers on anti-inflammatory pain medications as well as on opiates. These results are seen in more detail in Table 2.
Pain assessment and non-pharmacological pain alleviation methods taught during the education Students were asked what types of pain assessment instruments they had been introduced to during their education and how thoroughly they had been taught about these instruments (‘in detail’, ‘in some detail’, ‘don’t know’, ‘superficially’, or ‘not at all’). The instruments in question were ‘Happy – sad faces; Visual Analogue Scale; Pain Ladder; Pain Words; Pain Colours; Body Outline; and any other instrument the student wanted to name. Students found that the Happy–sad faces scale was taught to them quite well, 78% found it either taught in detail or in some detail. The Visual Analogue Scale was likewise adequately introduced to 68% of the students. The other instruments were not as familiar to the students. Pain Words was introduced in some detail to 36% of the students, Body Outline to 20%, Pain Ladder to 18%, and Pain Colours to 14% of the students. Four students additionally mentioned some other instrument. There were no significant differences between the education in different schools in this respect. Nor did the answers differ between those students who had previous
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working experience and those who did not, or between older and younger students. Pain assessment by observing physiological changes occurring in the child was taught in enough detail according to the students; 88% of the students found it was well taught and an additional 12% found that the subject was taught superficially. The results were similar in the area of pain assessment by observing children’s behaviour, 84% of the students thought that the subject was taught in detail or in some detail. The topic of observation of biochemical changes (such as hormonal or metabolism changes) occurring in the child was not as well taught in the opinion of these students. Only 24% of the students thought that it was taught in detail or some detail and 38% found it was taught superficially. As many as 25% of the students thought that the subject of biochemical changes was not covered at all. The student’s age, previous working experience or school did not have a significant connection to the answers. The questionnaire consisted of a list of 20 non-pharmacological pain alleviation methods that are used in practice. Again, the students were asked if they were taught these methods ‘in detail, in some detail, don’t know, superficially, or not at all’. The results of this part of the questionnaire are shown in Figure 3. There were no significant differences between the education level in different schools.
Discussion and conclusions This study gives a wide picture of the present state of education in the area of children’s pain from the students’ point of view. The sample of students was fairly small but it included all the students who graduated during one year in Finland in the Specialism of children’s nursing, which represents the total possible population of that time-period. The age of the subjects of this study equals the normal student population in health care. The response rate was high and no replies had to be omitted. Also, there were very few missing answers, which adds to the reliability of the research. The instrument itself was purpose-designed, and it covered a fairly broad subject. The knowledge received by this type of a questionnaire is often superficial and questions can be semantically misinterpreted. Also, the respondents’ views do not necessarily
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Students’ knowledge of and views about children in pain
p
g
p
100 90 80 70 60 50 40 30 20 10
Fig. 3
Transcutaneous electronic nerve stimulation
Using cassettes for relaxation
Singing to the child
Turning the child's attention to the procedure
Use of warm bandages
Use of humour
Watching videos
Relaxing the muscles
Use of cold bandages
Relaxing breathing
Different pain alleviation methods taught in detail or in some detail in percent.
reflect their real views but what they think or believe are the ‘right’ views. By contrast, the items measuring knowledge may be presumed to measure knowledge. In general, these graduating nursing students had supportive views towards taking care of children in pain. However, as similarly shown in previous research on students (Sheehan et al. 1992) and nurses (Ferrell et al. 1995, Margolius et al. 1995, Kubecka et al. 1996, Lebovits et al. 1997, Salanterä 1999), there were areas where students’ views and attitudes would mediate against proper pain care. The majority of students did not think that children can sleep if they are in pain, half of the students did not think that a calm
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Listening to music
Massage
Using the child's own imagination
Reading to the child
Turning the child's attention away from pain
Smiling to the child
Talking to the child
Rocking
Changing body posture
Being close to the child
0
child who says he or she is experiencing pain is likely to be in pain, and again 40% of the students did not think that a child who is capable of verbal expression would be best able to assess his or her own pain. This kind of view may lead to under-treatment of pain of such children that are quiet and reserved in their expressions and those who do not seem to be in pain, even though they say they are. One-third of the students found it easy to make a distinction between pain and fear and over half of the students did not know that the vital functions do not always react to chronic pain. This kind of view easily oversimplifies the phenomenon of pain. Similar simplifying was reported also in Price’s (1992) study. The views
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differed significantly when the scores of students from different schools and different age groups were compared. This indicates that education might have an effect on students’ attitudes. The results indicate that knowledge about areas such as children’s neurological development, pain as a phenomenon, how it emerges and its effect on children’s systemic functions, pain medication and its side-effects was rated as poor by a large amount of students. Lack of knowledge is reported also in various studies conducted on students (Diekmann & Wassem 1991; Sheehan et al. 1992) and nurses (Caty et al. 1995; Clarke et al. 1996; Closs 1996; Hamilton & Edgar 1992; Ketovuori 1987; Kubecka et al. 1996; Lebovits et al. 1997; Salanterä et al. 1999). It is difficult for a newly graduated nurse to form a picture of the whole process of taking care of children in pain if they feel they lack the basic knowledge of the phenomenon and of how to manage it. Students participating the study had a fairly realistic picture of their knowledge, since those students who felt they lacked knowledge also scored lower in the knowledge test. According to this research, there are only slight differences when knowledge scores of students in different schools, older and younger students or students with or without working experience were compared in both areas – non-pharmacological and pharmacological pain management. Even though the majority of the students thought that they had good knowledge about pain assessment, previous statements show that there are still areas in the assessment that are not well mastered. Older students had more supportive views towards children in pain than younger ones. It can be assumed that the older students have more experience in taking care of children in general and that their experience of life helps them to answer in a supportive way. The most commonly used pain-measurement instruments were familiar to the students. They also found they had good knowledge about pain assessment. Students had a limited knowledge of pain-alleviation methods. There were many methods, such as different types of distraction methods, relaxation methods and massage, warm and cold bandages or TENS, that were unfamiliar to over half of the students. This is an area that should receive more attention during education,
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since pain alleviation is an area where a nurse is the key person. There were differences in the students’ opinions about the level of education in different schools. The level of education may be due to lack of teachers’ knowledge, as Ferrel’s (1995) study indicated. Previous education did not make a difference to students’ answers but students’ age and previous working experience had some effect. It is not enough that students can detect children in pain – they must also have tools to manage this pain. It is also important to know how your actions affect the situation. More emphasis should be placed on the teaching of pain management of children in the education of those nurses who will be working with children. In conclusion, we can say that Finnish nursing students have mainly supportive views towards taking care of children in pain. This result differs somewhat from previous research results concerning nurses (Lebovits et al. 1997; Clarke et al. 1996; Ferrell et al. 1995). It is possible that attitudes change in the course of education. Students in this research lacked some basic knowledge about how pain emerges and how it changes a child’s behaviour and about both painalleviation methods and pharmacological painmanagement methods. Positive views and attitudes are not enough and nurses should also have a solid knowledge base for appropriate judgements. The most important factor responsible for the differences between the students was the received education. Students’ age or working experience were not as significant. The development of nursing education in the area of taking care of children in pain is necessary. Education should support students on systematic utilization of existing nursing and other scientific literature. It should motivate students towards self-learning. All students in this study were specializing in children’s nursing but other types of nurses also take care of children in pain and it would be important in the future to research such future nurses that will work with children but have other types of nursing education. With further testing, the instrument developed for this study may be applicable in other settings as well. References Caty S, Tourigny J, Koren I 1995 Assessment and management of children’s pain in community. Journal of Advanced Nursing 22(4):638–645
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Clarke E B, French B, Bilodeau M L, Capasso V C, Edwards A, Empoliti J 1996 Pain management knowledge, attitudes and clinical practice: The impact of nurses’ characteristics and education. Journal of Pain and Symptom Management 11(1):18–31 Closs S J 1996 Pain and elderly patients: a survey of nurses’ knowledge and experiences. Journal of Advanced Nursing 23(2):237–242 Collier J, Pattison H 1997 Attitudes to children’s pain: exploding the ‘pain myth’. Pediatric Nursing 9(10):15–18 Diekmann J M, Wassem R A 1991 A survey of nursing students’ knowledge of cancer pain control. Cancer Nursing 14(6):314–320 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, Dean G E, Grant M, Coluzzi P 1995 An institutional commitment to pain management. Journal of Clinical Oncology 13(9):2158–2165 Hamilton J, Edgar L 1992 A survey examining nurses’ knowledge of pain control. Journal of Pain and Symptom Management 7(1):18–26 Ketovuori H 1987 Nurses’ and patients’ conceptions of wound pain and the administration of analgesics. Journal of Pain and Symptom Management 2(4):213–218 Kubecka K, Simon J M, Boettcher J H 1996 Pain management knowledge of hospital-based nurses in rural Appalachian area. Journal of Advanced Nursing 23(5):861–867
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Lebovits A H, Florence I, Bathina R, Hunko V, Fox M T, Bramble C Y 1997 Pain knowledge and attitudes of healthcare providers: Practice characteristics differences. The Clinical Journal of Pain 13(3):237–243 Margolius F R, Hudson K A, Michel Y 1995 Beliefs and perceptions about children in pain. Pediatric Nursing 21(2):111–115 McCaffery M, Ferrell B R 1996 Correcting misconceptions about pain assessment and use of opioid analgesics: educational strategies aimed at public concerns. Nursing Outlook 44(4):184–190 Mercadente S, Salvaggio L 1996 Cancer pain knowledge in southern Italy: data from a postgraduate refresher course. Journal of Pain and Symptom Management 11(2):108–115 Price P S 1992 Student nurses’ assessment of children in pain. Journal of Advanced Nursing 17(4):441–447 Salanterä S 1999 Finnish nurses’ attitudes to pain in children. Journal of Advanced Nursing 29(3):727–736 Salanterä S, Lauri S, Salmi T T, Helenius H 1999 Nurses’ knowledge about pharmacological and nonpharmacological pain management in children. Journal of Pain and Symptom Management 18(4):289–299 Seymour E, Fuller B F, Pedersen-Gallegos L, Schwaninger J E 1997 Modes of thought, feeling and action in infant pain assessment by pediatric nurses. Journal of Paediatric Nursing 12(1):32–50 Sheehan D K, Webb A, Bower D, Einsporn R 1992 Level of cancer pain knowledge among baccalaureate student nurses. Journal of Pain and Symptom Management 7(8):478–484
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Nursing students’ knowledge of and views about children in pain Sanna Salanterä and Sirkka Lauri
It is important to evaluate the outcomes of the given education to gain knowledge about the abilities of our students to meet the needs of nursing practice. Pain associated with different illnesses and procedures is one of the most common symptoms that children experience in the hospital. The purpose of this study was to evaluate the views and knowledge base of graduating nursing students in the area of taking care of children in pain. The data were collected with a purpose-designed Likert-type instrument from all nursing students that graduated during one year from the child nurse specializing program in Finland (n=85), with a response rate of 86%. Results indicate that students have mainly positive views and attitudes towards taking care of children in pain. The views and attitudes differ when older and younger students and students from different schools are compared. Students lack knowledge especially in the area of pain medications as well as in the assessment of pain. In the knowledge section, the results did not differ greatly when different schools, younger and older students or previous working experience and no working experience were compared. In some of the researched schools, many of the students felt a lack of confidence about their knowledge. There is a need for more detailed education in the area of taking care of children with pain. © 2000 Harcourt Publishers Ltd
Sanna Salanterä RN, PhD Assistant Professor, Sirkka Lauri PhD, RN, Professor, Department of Nursing Science, 20014 University of Turku, Finland. Tel.: +358 2 333 8409; Fax: +358 2 333 8400; E-mail [email protected] (Requests for offprints to SS) Manuscript accepted: 2 March 2000
Introduction and literature review As the knowledge base about taking care of pain in children grows, there is a growing interest in the extent of nurses and nursing students’ knowledge of the subject as well as what kind of attitudes and views they have. Developing a sound knowledge base during education is important and helps the nurse to proceed from beginner status to expert status in nursing. There is some research available about the knowledge base and attitudes that nurses have but far less about the knowledge base of nursing students and even less in the area of children’s nursing. This study set out to find out what kind of knowledge base and views nursing students
© 2000 Harcourt Publishers Ltd doi:10.1054/nedt.2000.0472, available online at http://www.idealibrary.com on
specializing in children’s care have about pain in children and taking care of children in pain when their nursing education is complete. Several studies indicate that nurses lack knowledge about taking care of pain (Ketovuori 1987; Hamilton & Edgar 1992; Caty et al. 1995; Clarke et al. 1996; Closs 1996; Kubecka et al. 1996; Lebovits et al. 1997; Salanterä et al. 1999). There are also studies which conclude that nurses still have misconceptions, false beliefs and attitudes that mediate against proper pain care (Ferrell et al. 1995; Clarke et al. 1996; Lebovits et al. 1997; Salanterä 1999). These results pertain to other groups of health care professionals as well (Ferrell et al. 1995; Mercadente & Salvaggio 1996; Lebovits et al. 1997). On the other hand, more recent research shows that nurses have a wider
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repertoire of knowledge than they actually use in assessing pain (Seymour et al. 1997), that nurses are better informed and more aware about children in pain than has been previously suggested, and that pain myths are not widespread (Collier & Pattison 1997). As pain is one of the most common symptoms that patients have, it is obvious that in nursing education this subject should be well covered and students should have a good knowledge base when their studies are complete. In McCaffery and Ferrell’s (1996) study, the results showed that students already have strong attitudes and beliefs about pain and taking care of pain before entering nursing school. Studies to indicate how these attitudes change in the course of nursing education are not available. Diekmann and Wassem (1991) conducted a survey of nursing students’ knowledge of cancer pain control and found out that the results reflected poor knowledge about the prevalence of cancer pain and management. In Sheehan et al.’s (1992) study, 82 baccalaureate student nurses had a realistic perspective about the severity and prevalence of cancer pain and psychological dependence but still they had specific knowledge deficits and negative attitudes towards cancer pain management. The level of education seems to have an effect on students’ beliefs and perceptions. In Margolius et al.’s (1995) survey of 228 nurses, they found that those nurses who had lower education and provided the most direct care held the most misconceptions about effective pain management for children. Price (1992) studied 17 second-year general nursing students, who had just completed their paediatric secondment, with a self-administered questionnaire. The results showed that students’ definitions of pain concentrated mainly on the physical effects of pain. Also, nursing faculty knowledge of and beliefs about pain can be less than optimal, as shown by a survey conducted of 14 baccalaureate nursing schools in the USA. In the same study, the results showed that many nursing curriculum contents related to pain were inadequate. (Ferrell et al. 1995). As several studies show, nurses, nursing teachers, and nursing students have misconceptions, and lack of knowledge about taking care of pain in adults and cancer patients in particular. It is important to know whether this
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is the case with nursing students who will be working with children.
Purpose of the study and research questions The aim of this study was to explore nursing students’ knowledge and views of, as well as their opinions about their education in taking care of children in pain during their last semester as nursing students. The following research questions were asked: 1. How do nursing students evaluate their knowledge of and abilities in nursing children in pain and treating pain in children? 2. What are nursing students’ views of children in pain and pain in children? 3. What is the extent of nursing students’ knowledge about children in pain and pain in children? 4. What kind of children’s pain assessment and pain management methods are taught in nursing education? 5. Do students knowledge, views or opinions differ according to their age, working experience and place of education?
Materials and methods The target population consisted of all such nursing students who graduated during one year in Finland in the specialization field of children’s nursing (n=85). The questionnaire was sent to all the students via their teachers. Altogether, 73 students completed the questionnaire, which makes a response rate of up to 86%. The instruments were well filled and the number of missing answers per item was two at the most. Students were from four different nursing colleges situated in different parts of the country. The education of these nurses lasts three-and-ahalf years after high-school education, of which two-and-a-half years is devoted to general nursing education and one year to specialist child care. The data were collected during the last month of the course. About 97% of the nursing students in Finland are female. Respondents were not asked their gender in this questionnaire to ensure full anonymity. The age of the respondents ranged from 21 to 45 and mean age was 26 years (SD 5.9)
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Students’ knowledge of and views about children in pain
and median 24 years, which is equivalent to the mean age of nursing students in general in Finland. Eleven students had a previous degree in the field of health care (nursing assistant). Almost half of the students (45%) had some working experience in the field of health care. The mean length of this experience was 2 years (SD 2.5). Most of the working experience was in the position of nursing assistant (77%). The questionnaire consisted of a demographic data sheet, 82 items about knowledge and views of pain in children and children in pain, questions about the assessment methods, and non-pharmacological pain management methods that are taught during the nursing course as well as questions regarding students’ own opinions about their education, knowledge of and ability to take care of children in pain. The five-point Likert-type scale for the items ranged from ‘Agree’, through ‘Agree to some extent’, ‘Don’t know’, ‘Disagree to some extent’ to ‘Disagree’. In the section where students stated their own opinion about their knowledge of and possibilities for taking care of pain in children, the scale ranged from ‘Good’ through, ‘Fairly good’, ‘Don’t know’, ‘Fairly poor’ to ‘Poor’. Knowledge scores were expressed as a percentage of correct answers out of the possible total. The answers ‘Agree’ and ‘Agree to some extent’ or, when the item was incorrect, ‘Disagree’ or ‘Disagree to some extent’ were scored as correct answers and were worth one point, while other options were scored as zero. The items concerning students’ views were scored similarly so that the answers stating views that were supportive to good pain assessment and management in children were scored as one and counterproductive and ‘don’t know’ options were scored as zero. The instrument used in this study was designed in parallel with one designed for nurses and they were both based on the existing research literature on children’s pain mainly in the field of nursing. For concept, content and construct validity, the instrument was reviewed by a group of five nurses who were experts in taking care of children in pain. These experts had at least 10 years of practical experience, they had been identified as experts by their superiors and they had all been involved in research development programmes in the field of pain. The other expert group consisted of five nurses with Master’s
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degrees in nursing science. Both groups assessed the validity, readability and language of each item. The instrument was also reviewed by a paediatrician and an anaesthesiologist. Then the revised instrument was pilot-tested with a group of 10 nurses. After this, the instrument was finalized. The homogenety of items measuring views and knowledge was tested using Cronbach’s α coefficient for the views and knowledge scale and Kuder-Richardson 20-formula for the dichotomous knowledge scores on non-pharmacological and pharmacological pain management. The α-coefficient was 0.64, which is slightly below an acceptable level of good reliability (0.7) of a new instrument, and the Kuder-Richardson 20-test for the knowledge score was 0.69, indicating fairly good reliability. The descriptive values of items were expressed as means, standard deviations and percentages. The statistical significance of differences between different groups of students on their knowledge scores were tested by Wilcoxon 2-sample test. Independent questions were analysed by Pearson’s χ2 and, if frequencies were small, Fisher’s exact test was applied. P-values less than 0.05 were interpreted as significant. The data were entered twice on the program to avoid errors in data input. The SAS system for Windows, release 6/12/1996, was used for data analysis.
Results Students’ opinions about their knowledge of, ability in and possibilities for taking care of children in pain To evaluate the education students had received, they were asked the following three open-ended questions:(1) What kind of teaching have you received during your education on children’s pain? (2) What kind of literature have you recently read on children’s pain?; and (3) What kind of education would you like to have on children’s pain? The answers were content analysed and categorized. In the first question, 25 (34%) of the 73 students felt their education had been superficial, 23 (32%) thought that they had received basic knowledge on the subject, and 10 students (14%) described their education on the subject as varied and comprehensive. A few
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100 90 80 70 60 % 50 40 30 20 10
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Fig. 1 Percent of students who felt their knowledge, abilities or possibilities were good or fairly good in areas of taking care of children in pain.
students felt their education had been too theoretical. The remaining responses were too heterogeneous to be formed into categories. The answers to the second question were divided into five main categories. The students had mainly read about children’s pain in the chapters of a book on children’s nursing (mentioned by 25 students), in professional journals (22), and in magazines (17). Eleven students mentioned a scientific journal and eight students a research report as sources of information. The remaining answers referred to individual sources such as videos, abstracts, a book or notes on lectures. The students were mainly keen to learn more about pain medication (mentioned by 38 students), pain assessment (16), pain alleviation methods (14), and pain experience (9). Only a few students said
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they wanted more education on such subjects as cancer pain, the physiology of pain, the child’s neurological development or how pain emerges. Students felt they had fairly good or good knowledge in many areas of taking care of children in pain. The results of this section are shown in Figure 1. Children’s physical and psychological development were thought to be well mastered but neurological development was not. Students felt that they do not have good knowledge about how pain emerges, nor about pain medication, its side-effects or the possibilities for their institution to offer proper education. The students were divided into two groups according to their opinions so that those who felt their knowledge was good or fairly good always
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Students’ knowledge of and views about children in pain
100%
Percentage of counterproductive answers Percentage of don't know answers Percentage of supportive answers
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2
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6 Items
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Fig. 2 Items with low percentage of supportive answers: (1) A child less than one month of age may be intubated without anaesthesia; (2) Children normally tolerate pain less well than adults do; (3) Children can sleep even they are in severe pain; (4) Chronic pain in children is not easy to ascertain on the basis of changes in vital functions (e.g. heart rate, breathing rate) because those functions do not always react to chronic pain; (5) A calm child who says he or she is experiencing pain is likely to be in pain; (6) Damaged tissue is more sensitive to pain than undamaged tissue; (7) The level of pain suffered by a child can easily be established by giving a placebo; (8) A child who is capable of verbal expression is usually best able to assess his/her own pain; (9) It is difficult to make a distinction between pain and fear in children; (10) The most common reason for the need to increase painkiller dosage in cancer treatment is the progression of the illness and the pain involved; (11) Parents tend to exaggerate their child’s pain.
formed one group and those who felt their knowledge was fairly poor, poor or they could not tell formed the other group and these groups were compared with the demographic data. The school where the students studied had the most significant connection with the answers. In one school, students rated their knowledge significantly poorer than students in the other three schools in the areas of pain medication (χ2=10.2, df=3, P=0.016), and pain alleviation (χ2=8.8, df=3, P=0.031). In another school, students rated the possibility of their school offering proper education in the area of taking care of children in pain lower than students in the other schools (χ2=10.4, df=3, P=0.014). The students who had a previous education in the field of health care were not more confident about their knowledge than those who did not, neither were those who had previous working
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experience in the field of health care. Older students felt their knowledge was good significantly more often in the areas of children’s neurological development (χ2=8.3, df=1, P<0.001) and in the area of pain alleviation methods (χ2=8.6, df=1, P<0.001) than younger students.
Nursing students’ views about taking care of children in pain There were 40 items in the questionnaire that measured students’ views about taking care of children in pain. These items measured nursing students’ beliefs and attitudes towards certain aspects of children in pain. Students had an average of 80% (SD 8.4) in such answers that were supportive to effective care and the median was as high as 83%, i.e. 32 answers out of 40. From the 73 students, 38 (52%) had over 80% of
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Table 1
Student characteristics and knowledge scores Knowledge scores on: Non-pharmacological pain management (9 items)
General aspects of pharmacological pain (6 items)
Anti-inflammatory pain medication (8 items)
Opiates (6 items)
Regional anaesthesia (3 items)
Mean (SD) and
68 % (13.5)
54% (23.0)
49% (22.0)
37% (22.1)
29% (30.9)
median of
median
median
median
median
median
correct answers
67%
50%
50%
33%
33%
NS
NS
NS
χ2=4.9
NS
Student characteristics Age (younger <24,
df = 1
older =>24)
0.027
Previous working experience
NS
NS
NS
NS
NS
NS
NS
χ2 = 10.3
NS
NS
(yes/no) School
df = 3 0.017 NS = non significant; P > 0.05.
such answers that were supportive to effective care of children in pain and only 11 (15%) students had less than 70% of such answers that were considered as supportive to effective care. There were 11 such items where 30% or more of the students chose the answer that could be considered as counterproductive to effective care of children in pain. The distribution of the answers to these 11 items is shown in Figure 2. The scores of these 40 items were compared between the students that had some previous working experience in the field of health care, between younger (<24 years of age) and older (24 or older) students and between students from the four different schools. Previous working experience did not have a significant effect on the students’ answers. There was a difference between younger (<24 years) and older students (≥ 24) in favour of the older students (χ2=4.1, df=1, P=0.043), whose answers were more supportive of effective care of children in pain. The answers of the students differed significantly between the different schools. In one school, the answers were significantly more supportive of effective care of pain than in the other three schools (χ2=12.8, df=3, P=0.005).
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Nursing students’ knowledge of non-pharmacological pain management Nursing students’ knowledge of nonpharmacological pain management was measured with nine items. The mean of correct answers was 68% (SD 13.5%) and median 67% (6 items). Students achieved most correct answers in the following items: ‘In the treatment of pain in children, other methods of alleviating the pain are needed in addition to medication.’ (true, 100% correct answers); ‘Pain in children cannot be totally eliminated by conversation aimed at helping them to relax.’ (true, 93% correct answers). The items that were answered correct the least were: ‘Cold bandages only help if they are placed upon the painful area.’ (false, 25% correct answers) and ‘Massage is a good method of alleviating pain associated with tumours in children.’ (false, 29% correct answers). The significance of the differences between different groups of students was measured as reported before. The associations between the different student characteristics and knowledge scores are seen in Table 1, and the associations between a student’s own opinion about her
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Students’ knowledge of and views about children in pain
Table 2
Student’s own opinion about her knowledge and knowledge scores Knowledge scores on: Non-pharmacological pain management (9 items)
General aspects of pharmacological pain (6 items)
Anti-inflammatory pain medication (8 items)
Opiates (6 items)
Regional anaesthesia (3 items)
About non-pharmacological NS
NS
NS
NS
NS
About pharmacologicalpain management
NS
NS
χ2 = 8.7 df = 2 p = 0.013
NS
NS
About side-effects of pharmacological pain management
NS
NS
χ2 = 12.7 df = 2 0.002
χ2 = 11.7 df = 2 0.003
NS
Student’s view about her school’s possibilities of offering education on children in pain
χ2 = 6.8 df = 2 0.003
NS
NS
NS
NS
Student’s own opinion about her knowledge
NS = non significant; P>0.05.
knowledge and knowledge scores are seen in Table 2. There were nearly significant differences between previous working experience in favour of those who had had some previous experience in the field of health care (χ2=7.9, df=3, P=0.056). No significant differences were found between the students from different schools. In addition, the results were compared in the respect of how well students themselves felt that they knew about non-pharmacological and pharmacological pain management. Groups differed nearly significantly (χ2=5.7, df=2, P=0.056) so that those students who thought their knowledge was good or fairly good also scored highest in the knowledge section. Students that felt their institution offered good possibilities for pain education scored significantly higher than those who thought the possibilities were poor.
Nursing students’ knowledge about pharmacological pain management Knowledge about pharmacological pain management was measured with 23 items, containing six items about general knowledge, eight items about anti-inflammatory pain medication, six items about opiates and three items about regional anaesthesia. The mean (SD) of correct answers in the whole section was 45%
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(17.7), the median being 43%. There were only three items in which over 80% of the students had a correct answer. These items were: ‘Paracetamol (acetaminophen) is well-suited for the treatment of pain in children.’ (true); ‘Pain medication is equally effective whether given before the onset of pain or when the child is already experiencing pain.’ (false); and ‘Long-term continuing opioid (e.g. morphine, petidine) medication almost always causes physiological dependence in child patients.’ (true). There were three items to which less than 20% of the students had answered correctly and these were: ‘Respiratory depression is very rare in children who have received long-term continuing opioid medication.’ (true); ‘Anti-inflammatory drugs do not increase the respiratory effect of opioids.’ (true); and ‘Regional anaesthesia is well-suited for the alleviation of cancer pain.’ (true). The percentage age of correct answers to these items was in all cases 15. When looking at the different sections, students’ knowledge varied greatly. General aspects of pharmacological pain management were not known very well. The mean of correct answers was 54% (23.0) and median was 50%. Knowledge about anti-inflammatory pain management was well known to only half of the students. Knowledge about opiates and regional
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anaesthesia appeared to be even more unfamiliar to the students since the median of correct answers in the area of opiates was 33% (M(SD) = 37(22)) and in the area of regional anaesthesia 33% (M(SD) = 29(31)) respectively. The results of the comparisons between different groups of students indicate that age, previous experience and place of education all had only a minor effect on students’ knowledge. These results are shown in more detail in Table 1. The knowledge scores were also compared with the student’s own opinions about her knowledge. There were not many significant differences between the groups of students. However, students who themselves felt they had good knowledge about pharmacological pain management also scored highest on antiinflammatory pain medications. Furthermore, students who thought their knowledge was good in the area of side-effects of pain medication had most correct answers on anti-inflammatory pain medications as well as on opiates. These results are seen in more detail in Table 2.
Pain assessment and non-pharmacological pain alleviation methods taught during the education Students were asked what types of pain assessment instruments they had been introduced to during their education and how thoroughly they had been taught about these instruments (‘in detail’, ‘in some detail’, ‘don’t know’, ‘superficially’, or ‘not at all’). The instruments in question were ‘Happy – sad faces; Visual Analogue Scale; Pain Ladder; Pain Words; Pain Colours; Body Outline; and any other instrument the student wanted to name. Students found that the Happy–sad faces scale was taught to them quite well, 78% found it either taught in detail or in some detail. The Visual Analogue Scale was likewise adequately introduced to 68% of the students. The other instruments were not as familiar to the students. Pain Words was introduced in some detail to 36% of the students, Body Outline to 20%, Pain Ladder to 18%, and Pain Colours to 14% of the students. Four students additionally mentioned some other instrument. There were no significant differences between the education in different schools in this respect. Nor did the answers differ between those students who had previous
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working experience and those who did not, or between older and younger students. Pain assessment by observing physiological changes occurring in the child was taught in enough detail according to the students; 88% of the students found it was well taught and an additional 12% found that the subject was taught superficially. The results were similar in the area of pain assessment by observing children’s behaviour, 84% of the students thought that the subject was taught in detail or in some detail. The topic of observation of biochemical changes (such as hormonal or metabolism changes) occurring in the child was not as well taught in the opinion of these students. Only 24% of the students thought that it was taught in detail or some detail and 38% found it was taught superficially. As many as 25% of the students thought that the subject of biochemical changes was not covered at all. The student’s age, previous working experience or school did not have a significant connection to the answers. The questionnaire consisted of a list of 20 non-pharmacological pain alleviation methods that are used in practice. Again, the students were asked if they were taught these methods ‘in detail, in some detail, don’t know, superficially, or not at all’. The results of this part of the questionnaire are shown in Figure 3. There were no significant differences between the education level in different schools.
Discussion and conclusions This study gives a wide picture of the present state of education in the area of children’s pain from the students’ point of view. The sample of students was fairly small but it included all the students who graduated during one year in Finland in the Specialism of children’s nursing, which represents the total possible population of that time-period. The age of the subjects of this study equals the normal student population in health care. The response rate was high and no replies had to be omitted. Also, there were very few missing answers, which adds to the reliability of the research. The instrument itself was purpose-designed, and it covered a fairly broad subject. The knowledge received by this type of a questionnaire is often superficial and questions can be semantically misinterpreted. Also, the respondents’ views do not necessarily
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Students’ knowledge of and views about children in pain
p
g
p
100 90 80 70 60 50 40 30 20 10
Fig. 3
Transcutaneous electronic nerve stimulation
Using cassettes for relaxation
Singing to the child
Turning the child's attention to the procedure
Use of warm bandages
Use of humour
Watching videos
Relaxing the muscles
Use of cold bandages
Relaxing breathing
Different pain alleviation methods taught in detail or in some detail in percent.
reflect their real views but what they think or believe are the ‘right’ views. By contrast, the items measuring knowledge may be presumed to measure knowledge. In general, these graduating nursing students had supportive views towards taking care of children in pain. However, as similarly shown in previous research on students (Sheehan et al. 1992) and nurses (Ferrell et al. 1995, Margolius et al. 1995, Kubecka et al. 1996, Lebovits et al. 1997, Salanterä 1999), there were areas where students’ views and attitudes would mediate against proper pain care. The majority of students did not think that children can sleep if they are in pain, half of the students did not think that a calm
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Listening to music
Massage
Using the child's own imagination
Reading to the child
Turning the child's attention away from pain
Smiling to the child
Talking to the child
Rocking
Changing body posture
Being close to the child
0
child who says he or she is experiencing pain is likely to be in pain, and again 40% of the students did not think that a child who is capable of verbal expression would be best able to assess his or her own pain. This kind of view may lead to under-treatment of pain of such children that are quiet and reserved in their expressions and those who do not seem to be in pain, even though they say they are. One-third of the students found it easy to make a distinction between pain and fear and over half of the students did not know that the vital functions do not always react to chronic pain. This kind of view easily oversimplifies the phenomenon of pain. Similar simplifying was reported also in Price’s (1992) study. The views
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Students’ knowledge of and views about children in pain
differed significantly when the scores of students from different schools and different age groups were compared. This indicates that education might have an effect on students’ attitudes. The results indicate that knowledge about areas such as children’s neurological development, pain as a phenomenon, how it emerges and its effect on children’s systemic functions, pain medication and its side-effects was rated as poor by a large amount of students. Lack of knowledge is reported also in various studies conducted on students (Diekmann & Wassem 1991; Sheehan et al. 1992) and nurses (Caty et al. 1995; Clarke et al. 1996; Closs 1996; Hamilton & Edgar 1992; Ketovuori 1987; Kubecka et al. 1996; Lebovits et al. 1997; Salanterä et al. 1999). It is difficult for a newly graduated nurse to form a picture of the whole process of taking care of children in pain if they feel they lack the basic knowledge of the phenomenon and of how to manage it. Students participating the study had a fairly realistic picture of their knowledge, since those students who felt they lacked knowledge also scored lower in the knowledge test. According to this research, there are only slight differences when knowledge scores of students in different schools, older and younger students or students with or without working experience were compared in both areas – non-pharmacological and pharmacological pain management. Even though the majority of the students thought that they had good knowledge about pain assessment, previous statements show that there are still areas in the assessment that are not well mastered. Older students had more supportive views towards children in pain than younger ones. It can be assumed that the older students have more experience in taking care of children in general and that their experience of life helps them to answer in a supportive way. The most commonly used pain-measurement instruments were familiar to the students. They also found they had good knowledge about pain assessment. Students had a limited knowledge of pain-alleviation methods. There were many methods, such as different types of distraction methods, relaxation methods and massage, warm and cold bandages or TENS, that were unfamiliar to over half of the students. This is an area that should receive more attention during education,
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since pain alleviation is an area where a nurse is the key person. There were differences in the students’ opinions about the level of education in different schools. The level of education may be due to lack of teachers’ knowledge, as Ferrel’s (1995) study indicated. Previous education did not make a difference to students’ answers but students’ age and previous working experience had some effect. It is not enough that students can detect children in pain – they must also have tools to manage this pain. It is also important to know how your actions affect the situation. More emphasis should be placed on the teaching of pain management of children in the education of those nurses who will be working with children. In conclusion, we can say that Finnish nursing students have mainly supportive views towards taking care of children in pain. This result differs somewhat from previous research results concerning nurses (Lebovits et al. 1997; Clarke et al. 1996; Ferrell et al. 1995). It is possible that attitudes change in the course of education. Students in this research lacked some basic knowledge about how pain emerges and how it changes a child’s behaviour and about both painalleviation methods and pharmacological painmanagement methods. Positive views and attitudes are not enough and nurses should also have a solid knowledge base for appropriate judgements. The most important factor responsible for the differences between the students was the received education. Students’ age or working experience were not as significant. The development of nursing education in the area of taking care of children in pain is necessary. Education should support students on systematic utilization of existing nursing and other scientific literature. It should motivate students towards self-learning. All students in this study were specializing in children’s nursing but other types of nurses also take care of children in pain and it would be important in the future to research such future nurses that will work with children but have other types of nursing education. With further testing, the instrument developed for this study may be applicable in other settings as well. References Caty S, Tourigny J, Koren I 1995 Assessment and management of children’s pain in community. Journal of Advanced Nursing 22(4):638–645
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Students’ knowledge of and views about children in pain
Clarke E B, French B, Bilodeau M L, Capasso V C, Edwards A, Empoliti J 1996 Pain management knowledge, attitudes and clinical practice: The impact of nurses’ characteristics and education. Journal of Pain and Symptom Management 11(1):18–31 Closs S J 1996 Pain and elderly patients: a survey of nurses’ knowledge and experiences. Journal of Advanced Nursing 23(2):237–242 Collier J, Pattison H 1997 Attitudes to children’s pain: exploding the ‘pain myth’. Pediatric Nursing 9(10):15–18 Diekmann J M, Wassem R A 1991 A survey of nursing students’ knowledge of cancer pain control. Cancer Nursing 14(6):314–320 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, Dean G E, Grant M, Coluzzi P 1995 An institutional commitment to pain management. Journal of Clinical Oncology 13(9):2158–2165 Hamilton J, Edgar L 1992 A survey examining nurses’ knowledge of pain control. Journal of Pain and Symptom Management 7(1):18–26 Ketovuori H 1987 Nurses’ and patients’ conceptions of wound pain and the administration of analgesics. Journal of Pain and Symptom Management 2(4):213–218 Kubecka K, Simon J M, Boettcher J H 1996 Pain management knowledge of hospital-based nurses in rural Appalachian area. Journal of Advanced Nursing 23(5):861–867
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Lebovits A H, Florence I, Bathina R, Hunko V, Fox M T, Bramble C Y 1997 Pain knowledge and attitudes of healthcare providers: Practice characteristics differences. The Clinical Journal of Pain 13(3):237–243 Margolius F R, Hudson K A, Michel Y 1995 Beliefs and perceptions about children in pain. Pediatric Nursing 21(2):111–115 McCaffery M, Ferrell B R 1996 Correcting misconceptions about pain assessment and use of opioid analgesics: educational strategies aimed at public concerns. Nursing Outlook 44(4):184–190 Mercadente S, Salvaggio L 1996 Cancer pain knowledge in southern Italy: data from a postgraduate refresher course. Journal of Pain and Symptom Management 11(2):108–115 Price P S 1992 Student nurses’ assessment of children in pain. Journal of Advanced Nursing 17(4):441–447 Salanterä S 1999 Finnish nurses’ attitudes to pain in children. Journal of Advanced Nursing 29(3):727–736 Salanterä S, Lauri S, Salmi T T, Helenius H 1999 Nurses’ knowledge about pharmacological and nonpharmacological pain management in children. Journal of Pain and Symptom Management 18(4):289–299 Seymour E, Fuller B F, Pedersen-Gallegos L, Schwaninger J E 1997 Modes of thought, feeling and action in infant pain assessment by pediatric nurses. Journal of Paediatric Nursing 12(1):32–50 Sheehan D K, Webb A, Bower D, Einsporn R 1992 Level of cancer pain knowledge among baccalaureate student nurses. Journal of Pain and Symptom Management 7(8):478–484
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