Original Article Enhancing Knowledge and Attitudes in Pain Management: A Pain Management Education Program for Nursing Home Staff ---


From the School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong. Address correspondence to Mimi Mun Yee Tse, PhD, Assistant Professor, School of Nursing, Hong Kong Polytechnic University, Hong Kong. E-mail: [email protected] Received November 4, 2011; Revised March 30, 2012; Accepted March 30, 2012. Supported by Cadenza: a Jockey Club Initiative for Seniors, Hong Kong Jockey Club Charities Trust. 1524-9042/$36.00 Ó 2014 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2012.03.009

Mimi Mun Yee Tse, PhD, and Suki S. K. Ho, MSc


The aim of the study was to examine the effectiveness of a pain management program (PMP) in enhancing the knowledge and attitudes of health care workers in pain management. Many nursing home residents suffer from pain, and treatment of pain is often inadequate. Failure of health care workers to assess pain and their insufficient knowledge of pain management are barriers to adequate treatment. It was a quasiexperimental pretest and posttest study. Four nursing homes were approached, and 88 staff joined the 8-week PMP. Demographics and the knowledge and attitudes regarding pain were collected with the use of the Nurse’s Knowledge and Attitudes Survey Regarding Pain–Chinese version (NKASRP-C) before and after the PMP. A deficit in knowledge and attitudes related to pain management was prominent before the PMP, and there was a significant increase in pain knowledge and attitudes from 7.9 ± SD 3.52 to 19.2 ± SD4.4 (p < .05) after the 8-week PMP. A PMP can improve the knowledge and attitudes of nursing staff and enable them to provide adequate and appropriate care to older persons in pain. PMPs for nurses and all health care professionals are important in enhancing care for older adults and to inform policy on the provision of pain management. Ó 2014 by the American Society for Pain Management Nursing

Pain is common among older residents of nursing homes and can lead to adverse effects, including a decrease in the activities of daily living and quality of life. It has been found that 50% of older people living in the community are experiencing chronic pain, and this number increases to 80% in the nursing home population (American Geriatrics Society, 1998). In Hong Kong, the prevalence of pain among older adults was 50% (Chung & Wong, 2007). Pain in older adults tends to be constant in nature and moderate to severe in intensity, lasting for several years. Examples of chronic pain conditions that are common in adults of advanced age include osteoarthritis and musculoskeletal pain, low back pain, cancer, Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 2-11

Pain Management Education for Nursing Home Workers

poststroke pain, and diabetic peripheral neuropathy (American Society for Pain Management Nursing, 2011). The negative impact of chronic pain in older adults mainly takes the form of impaired quality of life, depression and suicide risk, anxiety, poor sleep, disturbed appetite, weight loss, cognitive impairment, and impaired functional mobility and activities of daily living (Schofied & Drago, 2007). Pain tends to be underreported by older adults. Reasons include the misinterpretation of pain sensations, difficulty in using pain assessment scales (particularly for cognitively impaired older adults), false beliefs that pain is to be expected as part of aging, and false beliefs that pain should be tolerated instead of seeking treatment and cure (American Society for Pain Management Nursing, 2011; Schofield, 2006). To make matters worse, the majority of oral analgesics are written on an ‘ as-needed’’ basis and the patients have to make a request to the nurse before they can have the medications for pain. Given that older adults believe that pain is a part of aging and have a low expectation for pain relief (Brown, Bowman, & Eason, 1999), they may be hesitant to report pain to the nurse and request analgesics. In long-term care facilities/nursing home care services for older persons, the health care team is composed of registered nurses (RNs), enrolled nurses (ENs), health workers (HWs), and personal care workers (PCWs). As such, direct patient care, including bathing, feeding, and activities of daily living, are carried out by HWs and PCWs. It is noted that educational preparation and nursing care training for both HWs and PCWs is not very advanced. Secondary school graduates can apply for an HW post and receive 260 hours of nursing care training, and primary school leavers can apply for a PCW position and receive only 70 hours of basic nursing care training. The nursing care training mainly focuses on patient care skills, including showering, feeding, and patient transfer. Upon completion of their training, they receive a practicing certificate issued by the Social Service Department. There is hardly any pain management training for either HWs or PCWs in the nursing care training course (Hong Kong St. John’s Ambulance, 2005; Hong Kong Council of Social Service, 2009). A competent nursing staff should have the ability and skill to make accurate physical and psychologic assessments and to provide appropriate nursing care to patients. Indeed, nursing a patient in pain is a challenging task and requires up-to-date knowledge, skilled interventions, and attitudes that convey trust, care, and belief in what the patients state (Matthews & Malcolm, 2007). It is necessary for nurses, HWs, and PCWs to provide their


patients with informed pharmacologic and nonpharmacologic strategies for effective pain management. It is noted that the skills required to provide effective interventions in pain treatment facilities are not gained in the initial training of the core professions, including nurses, physiotherapists, psychologists, occupational therapists, and medical personnel (International Association for the Study of Pain, 1997). Indeed, it is of concern that nurses and health care workers have inadequate knowledge and attitudes regarding pain management (Liu, So, & Fong, 2008; Matthews & Malcolm, 2007; Takai, Yamamoto-Mitani, Okamoto, Koyama, & Honda, 2010). Likewise, HWs and PCWs, who are mainly responsible for direct patient care and assisting with the drug administration in nursing homes, receive inadequate education preparation, especially in pain management (Liu, So, & Fong, 2008; Sloman, Ahern, Wright, & Brown, 2001; Tse & Chan, 2004). Therefore, the present study investigated the effectiveness of a pain management program (PMP) in changing health care providers’ knowledge of and attitudes to pain management.

AIM AND RESEARCH QUESTIONS The aim of the study was to examine the effectiveness of a PMP in enhancing knowledge of and attitudes to pain management among health care workers. The objectives were: to investigate knowledge levels and attitudes regarding pain management among health care providers in nursing homes; to investigate the effectiveness of an intensive and comprehensive pain management program (PMP) in improving the knowledge and attitudes of the health care workers; and to examine the relationships between the demographics, practice descriptors, and education of the nursing staff and their knowledge of and attitudes to pain management.

METHODS Design and Sample It was a quasiexperimental pretest and posttest design. After approval was obtained from the Ethics Committee of the university, four nursing homes were approached and the staff invited to join an 8-week PMP. An information sheet was given to them to explain the process and procedure of the PMP, and their written consent was obtained. The study was conducted in October 2008 and February 2010. These nursing homes served 140-200 patients and had 15-40 health care providers. Eighty-eight health care providers joined the PMP, and they were invited to complete the Nurse’s Knowledge and Attitudes Survey Regarding Pain–Chinese version (NKASRP-C)


Tse and Ho

questionnaire for their knowledge and attitudes to pain management before and after the PMP. Intervention: 8-Week Pain Management Program The PMP was designed and taught by the research team, including RNs and a physiotherapist, and the content was focused on common types of pain in nursing homes, pain assessment, pharmacology, drug addiction and dependence, side effects, and nonpharmacologic management strategies (Table 1). To maximize the participation of the staff, there were two concurrent 1-hour sessions per week over 8 weeks. Fifteen out of 88 participants attended 100% of the program, and the majority (68 participants) attended from 62.5%87.5% of the sessions; five participants attended 25% of the course. To cater for those who could not attend the PMP owing to leave and shift duties, we offered several make-up classes and the participation for these classes was very satisfactory, giving a total participation of 90%-95% for the entire 8-week PMP. Interactive Learning Methods The PMP aimed at translating behavioral intentions into practice. According to Huang’s (2002) and Knowles’ (1998) adult learning principles, adults are

motivated to learn information in which they understand the purpose and the practical applications; also, they want to take control of their learning process and learning from their own and others’ experiences. Therefore, the program used the belief-attitude dynamic in planning teaching and learning activities for nursing staff (Liao, Chen, & Yen, 2006). The PMP consisted of reality- and clinic-based scenarios that reflected problems with pain among older persons in general and among older residents in nursing homes in particular. During class attendance, nursing staff were given a practical session to assess the residents’ pain and monitor the effects and side effects of drug therapy. In this way, nursing staff could directly apply the knowledge gained from the PMP to the older adults. Group discussion and face-to-face interactions were used. In addition, exercise classes were given by a physiotherapist to help the health care providers to perform stretching and strengthening exercises for their health. Pharmacologic and nonpharmacologic pain management methods were introduced, with information gathered from various pain textbooks and websites; also, the research team produced scenario-based video clips regarding pain assessment and pain management and broadcast these in class to stimulate discussion and understanding of the pain management concepts.

TABLE 1. Content of the 8-Week Integrated Pain Management Program Week

Pain Program for Staff (2 Concurrent Sessions Weekly)


 Report on residents’ pain condition of and nurses’ knowledge of pain  Review of the top five wrong answers on the nurse questionnaire  Definition of pain, the neurophysiologic process of pain, and misconceptions of pain  Pain assessment  Use of analgesic in mild pain relief, effects, and side-effects, e.g., NSAIDs, and aspirin  Abdominal examination  Introduce moderate to severe pain relief, effects, and side effects, e.g., codeine, morphine  Neurologic examination  Psychologic well-being situation in nursing homes and how pain can affect it  Integrate various nondrug strategies for pain relief  Anatomy and cause of knee and back pain, pain assessment and treatment  Nurses’ exercises for knee and back pain relief  Anatomy and cause of shoulder pain, shoulder pain assessment and treatment  Nurses’ exercises for shoulder pain relief  Revision and reflection on the pain program  Questionnaire and short interview

2 3 4 5 6 7 8

Activity  Sharing the knowledge  Discussion  Interactive group activities  Pain assessment assignment 1  Interactive group activities  Pain assessment assignment 2  Interactive group activities  Clinic-based scenario discussion  Interactive group activities  Interactive group activities, skills, and practices  Video clip playing  Discussion  Interactive group activities, skills, and practices

Pain Management Education for Nursing Home Workers

Procedure The research team distributed the questionnaires, and staff were invited to attend a group interview to see whether they had any problems in understanding the NKASRP-C and to share their self-perceived knowledge and experience in caring for older persons with pain. They were then invited to join the 8-week PMP accordingly. On completion of the PMP, they were invited to complete the NKASRP-C questionnaire and attend a group interview to give feedback and comments regarding the PMP. Instruments The self-administered questionnaire consisted of two parts: 1) the participants’ demographic data sheet, which included age, sex, rank, educational level, work experience in years, specialty experience, frequency in management of elderly in pain, and attendance in courses dealing with pain; and 2) the NKASRP-C. The original NKASRP was developed by Ferrell and McCaffery in 1987 and translated into Chinese by Tse and Chan (2004). The content validity index was 0.87 and the test-retest reliability was 0.81 (Spearman r coefficient). It consists of 25 items: 16 true/false questions and 9 multiple-choice questions. One point is gained for 1 correct answer. The total maximum score is 25. The higher the score, the better the knowledge of and attitudes to pain management. Data Analysis The data collected from the HKASRP-C questionnaire were calculated and analyzed with the use of SPSS software. The short interviews were tape recorded and transcribed verbatim. The transcribed text was analyzed by qualitative content analysis (Berg, 2001). The transcribed interviews were read repeatedly to obtain an overall understanding of the data. Sentences or parts of sentences were identified as meaningful units in each interview text. The meaningful units were then categorized into themes. Themes were compared and discussed to establish the credibility of the interpretation.

RESULTS Demographic Data The demographic characteristics of the 88 subjects are presented in Table 2. Ninety-seven percent of the participants were female. Most of them (50%) were aged 36-45 years, and 27.3% were aged >45 years. The majority of the participants were PCWs (44.3%), and another substantial group were HWs (29.5%); 13.6% were ENs, followed by 10.2% RNs. More than


TABLE 2. Demographics, Practice Descriptors, and Education of the 88 Participants in the Study (%) Gender Female Male Age, y #25 $26-35 $36-45 >45 Position Registered nurse Enrolled nurse Health worker Personal care worker Non–health care worker Experience after training, y 0-5 $6-10 $11-15 $16-20 $21-25 $30-35 Specialty experience Medicine and geriatrics Operation theater Outpatient department Surgery Orthopedics Pediatrics Oncology Accident and Emergency Neurosurgery Nursing home experience, y 0-5 $6-10 $11-15 $16-20 $21-25 >35 years Educational level Certificate Diploma Undergraduate Postgraduate Attended pain course Yes No Care of patients with pain frequency No Less than once a week Several times a week Once a day More than once a day

97.7 2.3 2.3 20.5 50 27.3 10.2 13.6 29.5 44.3 2.3 46.6 26.1 14.8 5.7 4.5 2.3 7.9 4.5 4.5 3.4 2.3 2.3 1.1 1.1 0 58 23.9 11.4 4.5 1.1 1.1 75 15.9 8 1.1 23.9 76.1 8 27.3 30.7 12.5 21.6

one-half of them (58%) had 0-5 years of nursing home experience. In terms of work experience, 7.9% had experience in the medical and geriatric department, 4.5% in


Tse and Ho

TABLE 3. Demographic Variables and the Total Correct Scores (Pretest and Posttest) Pretest

Age Position Experience after training Specialty experience (M&G) Specialty experience (surgical) Specialty experience (orthopedics) Specialty experience (operating theatre) Specialty experience (A&E) Specialty experience (outpatient dept.) Specialty experience (pediatrics) Nursing home experience Educational level Attended pain course Care of patients with pain frequency



p Value


p Value

0.04 0.52 0.24 0.13 0.09 0.10 0.10 0.00 0.16 0.22 0.07 0.62 0.13 0.04

.74 .00* .03* .23 .42 .34 .34 .96 .14 .04* .52 .00* .22 .75

0.03 0.16 0.02 0.12 0.15 0.12 0.18 0.12 0.21 0.18 0.02 0.21 0.13 0.16

.78 .13 .86 .27 .17 .30 .09 .28 .06 .09 .98 .05* .22 .13

Total correct scores were correlated with the use of Spearman correlation coefficient. *A p value of

Enhancing knowledge and attitudes in pain management: a pain management education program for nursing home staff.

The aim of the study was to examine the effectiveness of a pain management program (PMP) in enhancing the knowledge and attitudes of health care worke...
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