18 Journal of Pain and SymptomManagement

Vol. 7 No. 1 January 1992

A Survey Examining Pain Control Joan Hamilton, RN, and Linda Edgar, RN Victoria General Hospital (J.H.), Halifax, Nova Scotia, and Sir Mortimer B. Davis Jewish GeneralHospital (L.E.), Montreal, Quebec, Canada

Three hundred and eighteen (318) nursing staff members at an acute care teaching hospital in Montreal, Canada, were surveyed to identify their knowledge of pain assessmentand management. Two pain instruments were combined and adapted for use. The&al instrument consisted @imurily of truelfabseresponses and took about 10 min to complete. The mean score was 63.9%. Gverall resuhs indicated that nurses la&d knowledge and understanding of opioid addiction, equivalent dosing, properties of opioids, and d@rences in acute and chronic pain. No statistically si&icant d@erences were found in the scores b level of educational preparation or by years of experience. Presentation of the results unit by unit demonstrated that the instrument is suitable as an educational tool as well as an eflective strategy to introduce nursing staff to nursing research. J Pain Symptom Manage 1992;?;18-26. Key wmdr Pain control, nurses’ knowledge

Introduction Few published studies examining nurses’ knowledge and attitudes about pain control have included a complete study questionnaire and results . ‘~3*6,‘1-9 Th e present study was performed to 1) systematically identify the pain assessment and management knowledge base of bedside nursing staff to identify specific learning needs, 2) resensitize nursing staff to pain management content, and 3) provide health care professionals who are interested in pain management with a quick survey instrument and comparison results. The authors were interested in examining nurses’ knowledge and A&es-sreprintrequeststo: Joan Hamilton, RN, 3206 Pennington Street, Halifax, Nova Scotia, Canada, B3L 4A9.

Acceptedfor publication:August 6,

1991.

0 U.S. Cancer Pain Relief Committee, 1992 Pttblished by Else&r, New York, New York

understanding of pain physiology md assessment, and of the general principles of pharmacologic and nonpharmacologic intervention as opposed to focusing primarily on attitudes and beliefs about pain control. On reviewing the literature, it became evident that knowledge, attitudes, beliefs, and practices of pain assessment and management have not usually been examined separately from each other, probably because they have not been viewed as consisting of mutually exclusive content areas. Moreover, most studies have focused either on postoperative pain or pain of chronic malignant disease and not on general pain-control principles. Over the years, many studies have been conducted examining nurses’ involvement in pain control, using a number of different approaches depending on the perspectives and overall aims of the research. Most researchers have exam-

Vol.

7 No.

I _banumy

I992

AJuises’ Knowledge

ined a combination of different issues in the same study. Research studies have examined the nurses’ beliefs about the incidence of patients in pain;5.‘os’ ’ the compatison of patient and nurse perceptions;5*1’-‘3 knowledge of the physiology of pain;r4”’ philosophy, attitudes, and beliefs about pain control;‘*g current practice;‘*s knowledge of drug therapy and side effects;s.‘*” and the effectiveness of educational programs.4*‘“*‘7 Of the many studies in the literature, three have contained a portion or a majority of knowledge questions reiating to narcotic use and side effects, and specifically reviewed the responses to these questions. The first study was conducted in the United States by Weis and colleagues.’ In this study, 70 nurses working on surgical, orthopedic, and gynecology wards responded to a mail-back multiple-choice questionnaire as one part of a larger study on postoperative analgesic care, over& goals of the treatment of pain, and the nurses’ opinion as to whether pain control was adequate. Of the questions to determine knowledge of analgesic use, results indicated that nurses had inaccurate ideas about tbe likelihood of addiction, respiratory depression, and “potentiators” of analgesics. A Canadian study conducted in 1987 by WattWatson’ sampled 106 graduate nurses (diploma and BScN) from medical or neuroscience settings, and 10 1 second and third year baccalaureate nursing students attending pain education programs. The aim of the study was to examine the nurses’ knowledge base about pain assessment and narcotic administration. The questionnaire consisted primarily of 18 questions using true/false, multiple choice and fill in the blank formatting. Watt-Watson also found a lack of knowledge about pain assessment and narcotic administration. The incidence of addiction was overestimated and the sample did not know equianalgesic doses or the correct duration of action of commonly used narcotics. 1 he third study was done most recently by McCaffery et al.’ Responses from a pretest questionnaire collected from a series of pain workshops in 14 states provided data to determine current nursing knowledge of opioid analgesic drugs and incidence of psychological dependence. A total of 2459 nurses (the vast majority of which were registered nurses) made up the sample. Respondents were divided into

of

Pain Control

19

two groups--basic an advanced learners. Advanced Iearners had pain education course. A s examined the nurses’ know classification of seven a the nurse to identify the drug as a narcotic or nonnarcotic. The Past question examined the nurses’ knowledge of drug addiction. Results indicated that nurses lacked knowledge of opioid classification of the seven drugs. Less than 25% of the sample correctly identified the frequency of psychological dependence. Several of the results from the study by McCaffery and colleagues’ can be compared directly with results of the present study because identical questions were asked. Qnly similarities in results can be drawn with the other two studies. The use of the same research instrument would have permitted direct comparisons across settings and provided more useful comparative data and feedback.

ect Se A cross-sectional study was conducted in a 612&d university teaching hospital in Montreal, Quebec, Canada from August 1989 to December 1989. Twenty-two nursing units ranging in size from 6 to 38 beds participated in the study. The psychiatric and obstetric units were excluded due to financial constraints. Both these units are distinct groups and could be separated easily from other clinical areas. Each head nurse was responsible for giving the questionnaire to the nursing staff on his/her unit. The nurses returned the questionnaires anonymously via a designated envelope on the unit over the 3-wk period of data collection.

The self-administered Pain Control Survey instrument was a combination and revision of two instruments obtained from Margo McCaffery, a well-known nursing expert in pain assessment and management. Page one of the ques(Figure 1) examines opioid tionnaire classification and opioid effects. This part of the instrument’s development is described in McCaffery and colleagues.’ Page two consists of 20 true/false statements developed by McCaffery

Jcnwnal of Pain and Symptom Management -

Hamilton and Edgar

20

PAIN CONTROL SURVEY General Information

About You Date:

Please circle or fill in the blank RN (Diploma) RN I(Bacheior’s) Levei o/Preparation: RN (Master’s) Other RNA Student Nurse Years qf E+e&nce Clinical hea:

Age:

54

NARCOTIC/OPlOID

CLASSIFICATION

Based on the PHARMACOLOGICAL DEFINITION of a narcotidopioid please indicate what you know about the following:

analgesic. not on government

laws or regulations,

CIRCLE ONE of these 3 answers:

DRUG Amitriptyiine Codeine Heroin Hydromorphine (Diiaudid) Indomethacin (Indocid) Mepexidine (Demeroi) Morphine Pentazocine (Talwin) Empracet 30

Not Not Not Not Not Not Not Not Not

Narcotic Narcotic Narcotic Narcotic Narcotic Narcotic Narcotic Narcotic Narcotic NARCOTIC/OPIOID

1.

.-

a a a a a a a a a

narcotic narcotic narcotic narcotic narcotic narcotic narcotic narcotic narcotic

Not Not Not Not Not Not Not Not Not

sure/Don’t sure/Don’t sure/Don’t sure/Don’t sure/Don’t sure/Don’t sure/Don’t sure/Don’t sure/Don’t

know know know know know know know know know

EFFECTS

Usingthe

definition below, how Iikeiy is it that narcotidopioid addiction will occur as a result of treating pain with narcotic analgesics? Circle one number closest to what you consider the correct answer:

25% 10% 15% 20% 30% 50% 75% 100% 1% 5% O.Ol). Although the correlation (Pearson’s 7) is negative, suggesting that total scores decreased with years of experience, the magnitude of r is so small that a value of r = 0 is likely to lie within the confidence limits of this estimate. The trend is, therefore, as likely to be in the opposite direction in terms of years of experience affecting total score. No statistically significant difference was found between the total mean score by educational preparation group (F = 0.9123, p >O.Ol).

The first part of the questionnaire asked the respondent to identify which of 9 drugs were opioids. Table 2 illustrates the results of this classification for the total sample. Chi-square analysis was us~.dto compare drug classifications between the present study and that of McCaffery and colleagues’ (Table 3). Responses of subjects from both studies were correct most often with morphine and least often with pentazocine (Talwin). Nursing knowledge of the correct classification of one drug is not likely to be totally independent of the knowledge of the other drug classifications. As a result, and due to the multiple testing effect, the critical p value for x2 in Table 3 was determined by dividing 0.01 bv the number of tests performed (i.e., 5); thus, the criticalp value for Table 3 is 0.002. The comparison revealed

The question most poorly answered was the one on equivalent dosing. Only 37 (11.6%) of 297 nursing staff members were aware that the relative potency of oral to intramuscular meperidine is four to one. Thirty-one point one

percent indicated that 75 mg of intramuscular meperidine is equivalent to 150 mg; 25.8% circled 100 mg; 24.8% circled 75 mg; and 6.6% of the sample did not respond to the question. The last question on page one of the survey Table 2

Survey

Answers-Narcotic’Opioid Classification” Not a

Narcotic %

Drug

narcotic %

Not surei don’t know %

Unanswered %

2.5

73.0 2.2

17.3

7.2

Heroin Hydromorphine (Dilaudid)

96.5 91.5 76.7

3.5 12.9

1.9 5.7

1.3 3.1

Indomethacin Meperidine Morphine

3.8 97.5 K-i

89.3 0.6 -

2.8 -0.3

15.4 5.0

4.4 0.6

Amitriptyline Codeine

(Indocid)

Pentazocine (Talwin) Empracet 30 “Correct responses are

7s.i 918 1

underlined.

-

4.7 4.1 1.6 1.9 4.1 2.5

Vol. 7 No. 1 Januavy 199.2

Nurses’ Knowledge of Pain Control

23

Table 3 Percentage d Correct Res

pioid Classification in the nited States Nurses

Present study (.W = 318)

Qpioid Codeine Heroin Meperidine Morphine Pentazocine (df= 1)

96.5 91.5 97.2 98.1 76.1

(N (iv (N (iV (N

McCaffery et al. study (iv = 2,459)

== 307) = 291) = 310) = 312) = 242)

89 75 93 98 35

asked about the ceiling on the dosage of morphine. Less than one-half of the respondents (44.9%, N = 135) circled the correct response, while 52.2% (IV = 166) of nurses responded incorrectly, and 5.3% (IV = 17) of subjects did not reply. Table 5 lists the coaTect responses to the first page of the survey. Listed in Table 6 are the correct responses and the results to the twenty true/false statements of the second page.

Although nursing staff tended to score highly in identifying which drugs were and were not opioids, knowledge about some principles of opioid pharmacology (addiction, ceiling effect, equivalent dosing, and respiratory depression) was generally weak. Nursing staff members appear to have a sound knowledge base in some areas: the patient is the authority about his/her pain, pain cannot be compared, patients should not endure pain before receiving analgesics, Table 4 Survey Answers-Likeliiood of Opioid Addiction

Response option