|Year : 2021 | Volume
| Issue : 3 | Page : 228-234
Evaluation of Knowledge, Attitude, and Practices of Nurses Regarding Pain Management
Monica Khetarpal, Rashmi Dubey, Samarjit Dey, Prateek Arora
Department of Anaesthesiology, AIIMS, Raipur, Chhattisgarh, India
|Date of Submission||30-May-2021|
|Date of Decision||02-Sep-2021|
|Date of Acceptance||30-Sep-2021|
|Date of Web Publication||29-Dec-2021|
Dr. Rashmi Dubey
Department of Anaesthesiology, AIIMS, G. E. Road, Tatibandh, Raipur - 492 099, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Background: Pain is the primary symptom that brings patients to seek health care and is considered a global health problem. Thus, pain control is a fundamental goal in the management of the hospitalized patients. Despite the development of analgesics and advancement in pain management, the pain remains undermanaged. The untreated pain has a detrimental effect on the patient's quality of life, affects their outcomes, delays recovery, and increases the hospital stay. Nurses play a significant role in pain management as they spend a considerable portion of their time with the patients and deal with all their complaints, including pain. One of the significant obstacles to effective pain management among nurses is their limited knowledge and negative attitudes towards pain management. The primary purpose of this study was to explore nurses' knowledge, attitude, and practices toward pain management. Methods: An online survey was conducted for 224 nurses of various departments to assess their knowledge, attitude, and practices regarding pain management using a 30-item questionnaire in Google Forms. Results: Our survey shows a deficiency in knowledge related to the basics of pain, opioid use, and pain management in the elderly and pediatric age group. Conclusions: It may be prudent to consider training programs regarding opioid use and pain management as a part of continuous education and nursing undergraduate curricula.
Keywords: Attitude, knowledge, nursing, pain management
|How to cite this article:|
Khetarpal M, Dubey R, Dey S, Arora P. Evaluation of Knowledge, Attitude, and Practices of Nurses Regarding Pain Management. Indian J Pain 2021;35:228-34
| Introduction|| |
According to the international association for the study of pain, “pain is defined as an unpleasant sensory and emotional experience associated with actual and potential tissue damage.” It is the most common cause for people seeking medical advice, and yet it is undertreated. The American Pain Society has declared pain as the “fifth vital sign,” and hence screening for pain is made a part of a routine assessment. It is a stressful experience and is a global health problem. Although there is a growing awareness of the causes, advancement, and management of pain, patients still experience intolerable pain that has adverse effects on the patient, impede their response to the treatment, and hampers the physical, emotional, and spiritual dimension of the health.,
Inadequate pain management results from numerous myths and misconceptions about pain and its Inadequate pain management results from numerous myths and misconceptions about pain and its treatment, particularly the fear of using opioids, particularly fear of using opioids., and lack of knowledge in dealing with a specific group of patients, particularly the elderly and the infants., Pain management requires a deeper understanding of the barriers to remedy the deficiencies for proper and optimum management. The education and training of health-care providers is a vital intervention that improves their skills which reflects positively on the patients. For effective pain management, nursing staff must be well-educated and knowledgeable about pain assessment and management techniques. They spend a significant portion of their time with the patients and have a considerable role in the decision-making process. Thus, their limited knowledge of the pain leads to undertreatment of pain, which interferes with the patient's well-being and can alter the patient's quality of life.
Only a few studies evaluate the nurses regarding their knowledge and practices in pain management in India. Therefore, assessing the knowledge and attitude of nurses is essential to improve the pain management process, thereby reducing the associated morbidity and mortality. The study evaluated nurses' knowledge, attitude, and practices working in central India (Chhattisgarh).
| Methods|| |
Two hundred twenty-four nurses from various departments, including general surgery, obstetrics and gynecology, medicine, pediatrics, postanesthesia care unit, and intensive care, participated in the survey. A 30-item questionnaire consisting of “True” or “False” questions; “yes” or “no;” and “multiple-choice” questions was drafted in Google Forms. Google Forms were chosen as it is an easy-to-use platform with a simple user interface and for the ease of tabulating data. It covered the areas of pain management, pain assessment, and the use of analgesics. Nurses were given adequate time to read and understand the questions and then submit their response.
| Results|| |
A total of 224 forms were filled, out of which 63.8% of nurses had an experience of 5 years or less. The majority of the nurses (79.1%) were from surgical wards. Nurses professional characteristics are shown in [Table 1].
A total of 80.3% of respondents acknowledged that they were aware of the WHO pain ladder and 83.4% of nursing staff used a pain scale to assess pain. Regarding the intensity of a patient's pain, 80.3% of the nursing staff had a wrong belief that vital signs are always reliable indicators of pain. A majority (75.7%) falsely believed that, when a patient requests increasing amounts of analgesics to control pain, this usually indicates that the patient is psychologically dependent.
Survey on knowledge regarding opioid use and practices
Most nurses (73.7%) believed that morphine is the drug of choice for severe cancer pain; 64% were correct about the time to peak effect of morphine. Regarding the side effects of opioids, 87.6% were aware that the patients need monitoring for at least 20 min after administration, and 81.4% correctly answered that respiratory depression is the most critical side effect. While doing sedation assessment, 97% correctly answered that sedation precedes opioid-induced respiratory depression, and 71.6% correctly believed that respiratory depression rarely occurs in patients who have been receiving stable doses of opioids for months.
A total of 72% of the nursing staff had a false belief that opioids should not be used in pediatric patients as opioids cause respiratory depression and 56.6% believed that children under 2 years of age have decreased pain sensitivity and limited memory of painful experiences as their nervous system is underdeveloped. Regarding the elderly patients, 55.5% of nurses falsely believed that elderly patients could not tolerate opioids for pain relief. A majority (88.2%) of nurses had a false belief that increasing analgesic requirements are signs that the patient is becoming addicted to the narcotic, and 32.1% of them believed that one-fourth of patients receiving narcotics round the clock become addicted. A total of 81.8% of nurses used intravenous tramadol for pain relief inward, whereas morphine is used only in 10.6% of the patients.
Survey regarding postoperative pain
In this survey, 76.4% of the nursing staff correctly answered that paracetamol injection is beneficial in managing surgical pain, 69.4% of them were aware of the concept of round the clock medication for postoperative pain relief, while 25.2% believed that postoperative pain relief is based on nurse's decisions. Majority of the nurses (92.1%) knew that the intravenous route is the most recommended route for severe sudden postoperative pain. A total of 81.4% of the respondents had a wrong belief that vital signs are always reliable indicators of the intensity of a patient's pain, 60.3% of the participants agreed that the patient is the most reliable source for reporting pain, but 35.5% of them thought that the primary nurse is the best judge of the intensity of the pain. The majority (77.1%) thought using a placebo is essential in determining if the pain is real. This shows that the patients may be undertreated, whereas 21.4% of nurses believed that untreated pain does not delay recovery.
| Discussion|| |
The current study results demonstrated that the majority of the participants knew the use of morphine in severe cancer pain, the time of its peak effects, and typical side effects such as respiratory depression and sedation. Nurses had an awareness of the WHO pain ladder, pain scales. They correctly answered that paracetamol could be used for managing surgical pain, and the intravenous route is the most recommended route for severe sudden postoperative pain [Table 2].
The results of our study demonstrated that the surveyed nurses had limited knowledge of pain management in infants and the elderly. The results are consistent with the prior studies., Pereira Dames et al. found that nurses were unaware of the rating scales for pain assessment and lacked the knowledge for neonatal pain management. New-born infants have an increased sensitivity to pain and are more reactive to pain than older children and adults. However, in our survey, majority of the nursing staff believed that children under 2 years of age have decreased pain sensitivity and limited memory of painful experiences as their nervous system is underdeveloped. Pediatric pain is still high in children, and the use of analgesics is inadequate,, despite protocols for adequate pain control.
In a study by Mędrzycka-Dąbrowska et al., barriers to optimum postoperative pain management in the elderly patients are due to poorly organized systems of care and obstacles in discussing pain management within the team and difficulties experienced by elderly patients in completing pain assessment scales. In another study, the most common barrier for pain management in the elderly was difficulties in identifying the proper doses of the opioids.
The other shortfalls in their knowledge related to several misconceptions about pain and the effects of opioids analgesics are the use of the opioids results in quick addiction, and increasing analgesic requirements are signs that patient is becoming addicted to the narcotic; one-fourth of the nursing staff did not agree with the round the clock medications for pain relief; they had a wrong belief that vital signs are always a reliable indicator of pain; 21% of them believed that untreated pain does not delay recovery. On the survey analysis, we also found nurses were afraid of using opioids due to the side effect of addiction. Morphine is used only in 10.6% of patients in the wards, whereas majority of the nurses use intravenous tramadol for pain relief. Watt-Watson et al. surveyed the number of hours allotted to teaching pain content in the students' curriculum in health science programs. They found that most of them (67.5%) could not delineate the actual designated pain content hours. Their pain society is using this data to raise national awareness of unrelieved pain and the need to develop pain education to ensure that health care workers entering the workforce are competent in pain management. Results of our study emphasize the need to train and educate nursing staff about pain management. Various medical education courses on topics of pain management skills should be started.
| Conclusions|| |
Patients are still hurting because of inadequate knowledge of health-care providers toward pain and its management. Nurses are in the best position to help and improve patient health care. Thus, the undergraduate nursing curriculum should cover pain management as a part of their education and training with the need to develop modules and presentation materials from the health-care professionals with pain education experience. Education and training programs regarding the basics of pain management and opioids use should be implemented by hospitals as a part of continuous medical education. Further studies can be conducted among the nurses in other cities in India, and various training programs should be formulated considering the deficiency of knowledge on the pain management.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Questionnaire|| |
Nurses' knowledge and attitude regarding pain management (questionnaire)
- Type of Hospital
- Intensive care/PACU
- Gynecologists and obstetric
Years after qualifications
- ≤5 years
- 6–10 years
- 10-15 years
- 15 years
Do you know about the WHO pain ladder?
Do you use pain scale to assess pain?
Which injectable opioids do you normally use for pain relief
Do you think that multimodal analgesia may result in better pain control and few side effects?
The most likely reason a patient with pain would request increased doses of pain medication is
- The patient is experiencing increased pain
- The patient is experiencing increased anxiety or depression
- The patient is requesting more staff attention
- The patient's requests are related to addiction
The most accurate judge of the intensity of the patient's pain is
- The treating physician
- The patient's primary nurse
- The patient
- The patient's spouse or family
Analgesics for postoperative pain should initially be given
- Around the clock on a fixed schedule
- Only when the patient asks for the medication
- Only when the nurse determines that the patient has moderate or greater discomfort
The recommended route of administration of opioid analgesics for patients with brief, severe pain of sudden onset such as trauma or postoperative pain is
Which of the following analgesic medications is considered the drug of choice for the treatment of prolonged moderate to severe pain for cancer patients?
The time to peak effect for morphine given IV is
What is the most important side effect of opioids, you watch out for in post-op patients?
- Respiratory depression
Giving patients sterile water by injection (placebo) is a useful test to determine if the pain is real.
Respiratory depression rarely occurs in patients who have been receiving stable doses of opioids over a period of months
Sedation assessment is recommended during opioid pain management because excessive sedation precedes opioid-induced respiratory depression.
Vital signs are always reliable indicators of the intensity of a patient's pain
Because their nervous system is underdeveloped, children under two years of age have decreased pain sensitivity and limited memory of painful experiences
Elderly patients cannot tolerate opioids for pain relief.
When a patient request increasing amounts of analgesics to control pain, this usually indicates that the patient is psychologically dependent
Because narcotics can cause respiratory depression, they should not be used in pediatric patients.
Increasing analgesic requirements are signs that the patient is becoming addicted to the narcotic.
25% of patients receiving narcotics around the clock become addicted.
Acute pain lasts for 20 to 30 days.
Untreated postoperative pain delays recovery
It is a patient's right to expect total postoperative pain relief as a consequence of treatment
Lack of pain expression does not mean lack of pain.
Paracetamol injection is used in managing surgical pain
The side effects of narcotics should be observed at least 20 minute after administration
| References|| |
Aydede M. Defending the IASP definition of pain. Monist 2017;100:439-64.
Stalnikowicz R, Mahamid R, Kaspi S, Brezis M. Undertreatment of acute pain in the emergency department: A challenge. Int J Qual Health Care 2005;17:173-6.
Walid MS, Donahue SN, Darmohray DM, Hyer LA Jr., Robinson JS Jr. The fifth vital sign-what does it mean? Pain Pract 2008;8:417-22.
Eaton LH, Meins AR, Mitchell PH, Voss J, Doorenbos AZ. Evidence-based practice beliefs and behaviors of nurses providing cancer pain management: A mixed-methods approach. Oncol Nurs Forum 2015;42:165-73.
Pereira Dames LJ, Herdy Alves V, Pereira Rodrigues D, De Souza B, Rangel R, Do Valle Andrade Medeiros F, et al.
Nurses' practical knowledge on the clinical management of neonatal pain: A descriptive study. Online Braz J Nurs 2016;15:393-403.
Dahl JH, Portenoy RK. Myths about controlling pain. J Pain Palliat Care Pharmacother 2004;18:55-8.
Carr E. 3 barriers to effective pain management. In: Cox F, editor. Perioperative Pain Management. Chichester, England: Wiley-Blackwell; 2009. p. 45-63.
Mędrzycka-Dąbrowska W, Dąbrowski S, Basinski A, Małecka-Dubiela A. Identification and comparison barriers to assessing and combating acute and postoperative pain in elderly patients in surgical wards of Polish hospitals: A multicenter study. Adv Clin Exp Med 2016;25:135-44.
Mędrzycka-Dąbrowska W, Dąbrowski S, Basiński A. Problems and barriers in ensuring effective acute and post-operative pain management – An international perspective. Adv Clin Exp Med 2015;24:905-10.
Ekim A, Ocakcı AF. Knowledge and attitudes regarding pain management of pediatric nurses in Turkey. Pain Manag Nurs 2013;14:e262-7.
Lunsford L. Knowledge and attitudes regarding pediatric pain in Mongolian nurses. Pain Manag Nurs 2015;16:346-53.
Hiller A, Suominen PK. Pain in children is still under-recognised and undertreated in Scandinavia. Acta Anaesthesiol Scand 2017;61:266-7.
Walther-Larsen S, Pedersen MT, Friis SM, Aagaard GB, Rømsing J, Jeppesen EM, et al.
Pain prevalence in hospitalized children: A prospective cross-sectional survey in four Danish university hospitals. Acta Anaesthesiol Scand 2017;61:328-37.
Murnion BP, Gnjidic D, Hilmer SN. Prescription and administration of opioids to hospital in-patients, and barriers to effective use. Pain Med 2010;11:58-66.
Watt-Watson J, McGillion M, Hunter J, Choiniere M, Clark AJ, Dewar A, et al
. A survey of prelicensure pain curricula in health science faculties in Canadian universities. Pain Res Manag 2009;14:439-44.
[Table 1], [Table 2]