Nurses’ Knowledge and Attitudes about Pain Assessment and Management in Imam Hussein Medical City in Holy Karbala
Duaa Raad Saied, MScN *, Prof. Khalida Alwan Mansour, PhD**
*Academic Nurse, College of Nursing, University of Baghdad, mail: [email protected]
**Professor, College of Nursing, University of Baghdad, email:
Abstract
Background: Pain is one of the universal medical problems in health institutions. In fact it can directly affect patients' comfort and lifestyle, causing nausea, vomiting, fatigue, stress, lack of control, poor quality of life, and a lack of sexual activity and public relations, also it can lead to poor work performance and daily activities. A descriptive study was conducted to assess nurses‟ knowledge and attitudes about pain assessment and management in imam Hussein medical city in holy Karbala. during the period from 15th November 2020 to 1st January 2021
Methodology: A descriptive design was used to guide this study to assess the nurses’
knowledge and attitude about pain assessment and management. It was conducted at the Imam Hussein medical city in the medical ward, surgical ward, intensive care unit, cardiac care unit and oncology unit, during the period from 15th November, 2020 to 1st January 2021.
Non- probability (purposive) sample of (60) nurses (31) male, (29) female.
Results: The study findings Shows that participants' age group at a level (20-29 years) were (58.3), the majority of participants was male with percentage (51.7)
Findings showed that the total mean score was unacceptable level for all domains, also there is no significant association between nurses' knowledge and attitude about pain assessment and management and their demographic characteristics
Conclusion: Nurses require more knowledge and attitude regarding pain assessment and management
Recommendations: Conduct education programs for nurses who have no experience in assessing and managing of pain, also provide posters, pamphlets, and booklets in the hospitals to improve their knowledge.
Keywords: nurses, knowledge, attitude, pain assessment, pain management.
Introduction
Pain is the most common reason why people visit a healthcare professional. inadequate pain management is the source of major economic and human costs for patients, their families and society.]1[ Alleviation of pain is an important nursing goal embodied in the profession‟s philosophy. ] 2]
Nurses are responsible for regular pain assessment, medication administration, and monitoring of the patient‟s responses. These responsibilities require an understanding of the nature of pain in relation to a patient‟s clinical condition. Although pain control for hospitalized patients is a central issue for all health care providers, major barriers are presented by nurses‟ inadequate knowledge, negative attitudes, insufficient assessment skills, reluctance to act as the patient‟s advocate, and misconceptions. Inadequate pain management reflects inadequate knowledge on the part of nurses. Adequate pain knowledge helps nurses to underpin their practices of pain assessment, medication administration, and monitoring.
Nurses‟ attitudes and beliefs may influence patient care.] 3]
Evidence shows that nurses having adequate knowledge and good attitude of pain may lead to more effective pain management. Nurses who believe in the importance of patient pain relief implement more pain management activities, and nurses with positive attitudes will have the intention and motivation to provide care for a patient with pain.]4]
Pain management is an important part of health care professional (HCPs) practices, particularly for those who treat pain daily basis. To properly manage pain, HCPs must be well-educated and knowledgeable about pain. This starts with a detailed and reliable assessment of pain.in the patient. Pain screening should be a part of a routine assessment, which led the American Pain Society (APS) to declare pain as a "fifth vital sign". Several studies have been conducted to assess the HCPs‟ knowledge and attitudes about pain.]5]
In the United States, according to the Institute of Medicine, chronic pain affects approximately 100 million Americans. This number is higher than the number of diabetes, heart disease and cancer sufferers combined. The cost to the US economy of chronic pain, including healthcare and lost productivity costs, was estimated to be between US $560 and US $635 billion annually. It is important to note that these estimates do not include cancer- related pain ]6]. In Europe, a cross-sectional survey reported that 19% of adults suffered from chronic pain of moderate-to severe intensity and nearly half received inadequate pain management. In Australia, it is expected that one in five Australians will suffer chronic pain in their lifetime, and it is estimated to cost the economy AUD 34 billion per annum. have reported that chronic pain impacts a large proportion of the adult Australian population, including the working age population. 7] ]
Therefore, the importance of this study revolves around assess the pain severity and how to be addressed and manage.
Methodology
A descriptive design was used to guide this study to assess the nurses‟ knowledge and attitude about pain assessment and management. It was conducted at the Imam Hussein medical city in the medical ward, surgical ward, intensive care unit, cardiac care unit and oncology unit, during the period from 15th November, 2020 to 1st January 2021. Non- probability (purposive) sample of (60) nurses (31) male, (29) female. To achieve the study objectives, the researcher use “Knowledge and Attitudes Survey Regarding Pain” (KASRP) tool that comprises two parts:
Part one: Self-administered questionnaire sheet related to demographic characteristics of nurses. This part is consisting the demographic characteristic of nurse (age, gender, education level, years of experience, place of work, training course about pain assessment and management).
Part two: instrument of measuring effectiveness of the instructional program It is adopted the
"Knowledge and Attitudes Survey Regarding Pain” (KASRP) tool ]8]. Revised by Ferrell and McCaffery (1987). It was last updated in 2012 and has undergone updates to reflect existing practice patterns ]9]. Internal consistency reliability is established (alpha r > 0.70) with items reflecting both knowledge and attitude domains as indicated by (39) questions: 22 questions true/false, 15 multiple choice, and two case studies. The score of Knowledge and Attitudes Survey Regarding Pain” (KASRP) was (1) the correct answer value and (0) for the incorrect answer. A level was categorized based on poor, unacceptable, moderate and good level of the knowledge and attitudes about pain assessment and management, Poor (P) level is (0-0,25), Unacceptable (UA) level (0.26-0.50), Moderate (M) level (0.51-0.75), Good (G) level (0.76- 1).
The reliability of the questionnaire is determined through the use test and re-test approach through (10) nurses, determining the reliability based on the Pearson correlation coefficient it was 0.949. After obtaining official approvals from the College of Nursing/
University of Baghdad, the ethical approval of the study is obtained from the Research and Ethics Committee. After which permission is granted to conduct research by the Karbala Health Directorate to ensure their approval and cooperation in collecting data from nurses.
Before data collection the researcher met with the nurses by face-to-face interview and a voluntary verbal agreement was obtained in order to participate in the study. The researcher using the Statistical Package of Social Science (SPSS) version (24) to analyze the data and relation the results of study. The researchers used descriptive and inferential data analysis to obtain results.
Results and Discussion
Discussion of demographic characteristics of nurses in Imam Hussein medical city (Table 1):
Through the data analysis, distribution of demographic variables, reveals that age group of nurses is less than thirty years old accounted for (n=35; 58.3%). These results are consistent with the study conducted at the Bindura Hospital that reported the High percentage (44%) of nurse participants were in the age category of 20-30 years. [10]
The present study reveals that the percentage of male distribution is more than female (n=31;
51.7%), This result is supported study [11] that determine the impact of an in-service educational program on nurses' knowledge and attitudes regarding pain management in an Ethiopian university hospital, the result indicated that the highest percentage (59.5%) is male.
Concerning the level of education, the High percentage (50%) of nurses are graduating from diploma degree, this result agrees with study conducted in Iran reported the high percentage (19
;28.30 %) of nurses graduating from diploma degree. [12]
Regarding the years of experience in nursing the high percentage (23; 38.3) of nurses have experienced (1-5) years, these finding consistent with study [13] that revealed the majority of nurses have experienced (1-5) years with percentage (244 ;39.7%)
According to the training course the most nurses taken training course with percentage (53.3%).
This result consistent with study in emirates that reported over (60%) of participants had received pain management training in the past. [14]
Regarding the place of work in hospital the data analysis present the place of work for nurses is in surgical ward (16.7%), medical ward (16.7%) and intensive care unit (16.7%), cardiac care unit (25%) and oncology unit (25 %). This result consistent with study that report the place work of nurses is an intensive care unit (26.5%), medical ward (29.4%), Oncology ward (9.8%), surgical ward (3.9%), and cardiac care unit (2.9%). [15]
Discussion of the Nurse’s about Knowledge and Attitude domain table (2)
Data analysis of the present study has revealed the assessment level of nurses related to knowledge and attitude domain, the total mean of the score is unacceptable level. This result consistent with study in Saudi Arabia that aim to examine the knowledge and attitudes of nurses regarding pain management. The study findings indicated that nurses recorded a major deficiency in their knowledge regarding assessment and management of pain. The nurses also held incorrect attitudes towards pain assessment and lacked knowledge regarding pharmacological and non- pharmacological interventions. [16]
Discussion of the Nurse’s about pain assessment and management (table 3)
Data analysis of the present study has revealed the assessment level of nurses related to the assessment and management of pain domain, the total mean of the score is an unacceptable level. The current study results consistent with study conducted in Jordan that determine impact of applying brief educational program on nurses' knowledge, attitude, and practices toward pain management. Shows the results of multiple choice (15) questions about pain assessment and management domain, the nurses' responses to all questions in the pre-test phase was at the lowest scores. [17]
Discussion of the Nurse’s about pain assessment and management (table 4)
Data analysis of the present study has revealed the assessment level of nurses about the pain intervention domain, the total mean of the score is a poor level. The current study results concordant with study [18], that showed the result of the two case scenario questions, the correct answer of nurses was unacceptable level with percentage (48%)
Discussion Association between demographic characteristics with all domains (table 5):
The result of the present study indicates that there is no significant association between nurses knowledge and attitude about pain assessment and management and their demographic characteristics (age group, gender, educational level, years of experience, place of work, training course) when analyzed by the t- test and one way ANOVA.
The current study consistent with study [14] conducted in Emirates that determine Impact a pain management program on nurses' knowledge and attitude toward pain, that indicate there is not statistically significant between demographic characteristics and domains of kasrp tool when analyzed by one way ANOVA test.
Conclusion: Nurses require more knowledge and attitude regarding pain assessment and management
Recommendation: Conduct education programs for nurses who have no experience in assessing and managing of pain, also provide posters, pamphlets, and booklets in the hospitals to improve their knowledge.
Table (1) Distribution of demographic data of nurses Demographic
groups
f. %
Gender Male 31 51.7
Female 29 48.3
Total 60 100
Age group 20-29 35 58.3
30-39 14 23.4
40-49 8 13.3
50-60 3 5
Total 60 100
Educational level Nursing school 15 25
Nursing institute 30 50
Nursing college 15 25
Nursing master 0 0
Total 60 100
Years of experience 1-5 23 38.3
6-10 18 30
11-16 9 15
16- above 10 16.7
Total 60 100
Place of work Surgical ward 10 16.7
Medical ward 10 16.7
Intensive care unit 10 16.7 Cardiac care unit 15 25
Oncology unit 15 25
Total 60 100.1
Training No 28 46.7
Yes 32 53.3
Total 60 100
f. = frequency, % = percentage
Table (2): Distribution of the Nurse’s Knowledge and Attitude domain
Knowledge and attitude domain M.S S.D. Ass.
1. Vital signs are always reliable indicators of the intensity of a patient‟s pain
.25 .43 P 2. Because their nervous system is underdeveloped,
children under two years of age have decreased pain sensitivity and limited memory of painful experiences.
.31 .46 UN
3. Patients who can be distracted from pain usually do not have severe pain.
.35 .48 UN 4. Patients may sleep in spite of severe pain. .38 .49 UN 5. Aspirin and other non-steroidal anti-inflammatory agents
are NOT effective analgesics for painful bone metastases.
.35 .48 UN 6. Respiratory depression rarely occurs in patients who
have been receiving stable doses of opioids over a period of months
.43 .49 UN
7. Combining analgesics that work by different mechanisms (e.g., combining an NSAID with an opioid) may result in better pain control with fewer side effects than using a single analgesic agent.
.25 .43 P
8. The usual duration of analgesia of 1-2 mg morphine IV is 4-5 hours.
.41 .49 UN 9. Opioids should not be used in patients with a history of
substance abuse.
.35 .48 UN 10. Elderly patients cannot tolerate opioids for pain relief .35 .48 UN 11. Patients should be encouraged to endure as much pain as
possible before using an opioid.
.21 .41 P 12. Children less than 11 years old cannot reliably report
pain so clinicians should rely solely on the parent‟s assessment of the child‟s pain intensity.
.25 .43 P
13. Patients‟ spiritual beliefs may lead them to think pain and suffering are necessary.
.65 .48 M 14. After an initial dose of opioid analgesic is given,
subsequent doses should be adjusted in accordance with the individual patient‟s response
.31 .46 UN
15. Giving patients sterile water by injection (placebo) is a useful test to determine if the pain is real.
.33 .47 UN 16. Oxycodone 5mg PO is approximately equal to 5-10mg of
morphine PO.
.25 .43 P 17. If the source of the patient‟s pain is unknown, opioids
should not be used during the pain evaluation period, as this could mask the ability to correctly diagnose the cause of pain.
.21 .41 P
18. Anticonvulsant drugs such as gabapentin (Neurontin) produce optimal pain relief after a single dose.
.26 .44 UN
19. Benzodiazepines are not effective pain relievers and are rarely recommended as part of an analgesic regime.
.45 .50 UN 20. Narcotic/opioid addiction is defined as a chronic
neurobiological disease, characterized by behaviors that include one or more of the following
.65 .48 M
21. The term „equianalgesia‟ means approximately equal analgesia and is used when referring to the doses of various analgesics that provide approximately the same amount of pain relief.
.78 .41 G
22. Sedation assessment is recommended during opioid pain management because excessive sedation precedes opioid- induced respiratory depression.
.85 .36 G
Total mean of score Knowledge and attitude domain .39 .08 UN N=number of sample, M.S= Mean of score, S.D=Standard Deviation, ass. =assessment level, P=poor (0-0.25), UN=Un Acceptable (0.26-0.50), M=Moderate (0.51-0.75), G=Good (0.76-1).
Table (3): Distribution of the Nurse’s Knowledge and Attitude about pain assessment and management domain
Pain assessment and management domain
M.S S.D. Ass.
1. The recommended route of administration of opioid analgesics for patients with persistent cancer-related pain is:
.10 .30 P 2. The recommended route of administration of opioid analgesics
for patients with brief, severe pain of sudden onset such as trauma or postoperative pain is:
.71 .45 M
3. Which of the following analgesic medications is considered the drug of choice for the treatment of prolonged moderate to severe pain for cancer patients?
.53 .50 M
4. A 30mg dose of oral morphine is approximately equivalent to: .18 .39 P 5. Analgesics for post-operative pain should initially be given: .50 .50 UN 6. A patient with persistent cancer pain has been receiving daily
opioid analgesics for 2 months:
.33 .47 UN 7. The most likely reason a patient with pain would request
increased doses of pain medication is:
.78 .41 G 8. Which of the following is useful for treatment of cancer pain? .55 .50 M 9. The most accurate judge of the intensity of the patient‟s pain is: .25 .43 P 10. How likely is it that patients who develop pain already have
an alcohol and/or drug abuse problem?
.20 .40 P 11. The time to peak effect for morphine given IV is: .18 .39 P 12. The time to peak effect for morphine given orally is: .23 .42 P 13. Following abrupt discontinuation of an opioid, physical
dependence is manifested by the following:
.13 .34 P 14. Which statement is true regarding opioid induced
respiratory depression?
.26 .44 UN Total mean of score pain assessment and management domain .354 .111 UN N=number of sample, MS= Mean of score, S.D=Standard Deviation, ass.=assessment level, P=poor (0-0.25), UN=Un Acceptable (0.26-0.50), M=Moderate (0.51-0.75), G=Good (0.76-1).
Table (4): Distribution of the Nurse’s Knowledge and Attitude about pain intervention domain
Pain intervention domain
M.S S.D. Ass.
1. On the patients record you must mark his pain on the scale below. Check the number that represents your assessment of Andrew‟s pain
.20 .40 P
2. study post Your assessment, above, is made two hours after he received morphine 2mg IV
.15 .36 P 3. On the patients record you must mark his pain on the
scale below. Check the number that represents your assessment of Roberts‟s pain
.28 .45 UN
4. Your assessment above, is made two hours after he received morphine 2mg IV.
.28 .45 UN Total mean of score pain intervention .22 .21 P N=number of sample, M.S= Mean of score, S.D=Standard Deviation, ass.=assessment level, P=poor (0-0.25), UN=Un Acceptable (0.26-0.50), M=Moderate (0.51-0.75),
G=Good (0.76-1).
Figure (2): distribution of nurses' knowledge and attitude about three domains Table (5): Association between demographic characteristics with all domains
Variables Subgroup Means ± SD test P.
value
Sig.
value
Gender Male .31± .07 t-test= .784 .380 NS
Female
.33± .06
Age group 20-29 .32± .06 F= .959 .418 NS
30-39 .34± .07
40-49 .30± .08
50-60 .30± .02
Educational level
nursing school .3392± .06923 F=.369 .693 NS nursing institute .3229± .06467
nursing college .3198± .07507
years of experience study
1-5 .3308± .06211 F=.302 .824 NS
6-10 .3134± .05444
11-15 .3349± .09176
16-20 .3308± .08421
Place of work study
surgical ward .3583± .06891 F=.874 .485 NS medical ward .3231± .05535
intensive care unit .3154± .08445 Cardiac care unit .3310± .05346 Oncology unit .3094± .07561 Training
course
No .3138± .05930 t-test=
2.043
0.158 NS
Yes .3386± .07417
Total .3262± .06774
N=number of samples, MS= Mean of score, SD=Standard Deviation, t- test=Independent Samples test, F=ANOVA, df=degree of freedom=58, NS= non- significant at p>0.05.
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