Research
Impact of an educational pain management programme on nurses’ pain knowledge and attitudes in Kenya Gladys Machira, Hellen Kariuki, Linda Martindale
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I
nadequate treatment of pain is an insidious clinical problem in hospitalised patients (Brown and McCormack, 2006; Bernardi et al, 2007; Silver and Mayer, 2007), with considerable physiological, psychological, emotional, spiritual, and financial consequences. These include slowed healing, a higher rate of complications, anxiety, sleep disturbance, and lowered quality of life (McLeod, 2007; Ruff et al, 2007; Silver and Mayer, 2007; Mehta and Chan, 2008). Research attention has focused on the barriers to pain treatment, including factors related to both health-care providers and patients themselves (Sun et al, 2008; Yildirim et al, 2009). Several studies have indicated that a knowledge deficit is the most important barrier for health professionals in implementing pain management (Borgsteede et al, 2009; Oldenmenger et al, 2009; and Varrassi et al, 2010). In particular, nurses play a critical part in pain management because they deliver direct patient care on a 24-hour basis. However, studies have found that many nurses lack pain management knowledge (Yildirim et al, 2009; Abdalrahim et al, 2011; Tse et al, 2011). For this reason, implementing a pain management programme (PMP) for health professionals, particularly for nurses who act as ‘first-line’ personnel in pain treatment, is a vital strategy in pain management. Previous studies have examined the effects of PMPs on nurses’ pain knowledge and attitudes (Patiraki et al, 2006; Zhang et al, 2008; Abdalrahim et al, 2011; Tse et al, 2011). These concluded that PMPs do have a positive effect on nurses’ pain knowledge and attitudes; however, most of them were carried out in developed countries. In Kenya, some hospitals have provided health professionals with a PMP, but to the authors’ knowledge no studies have explored the effectiveness of PMPs for nurses.
Aim This study aimed to implement and evaluate a PMP for nurses in Kenya. The PMP’s main
International Journal of Palliative Nursing 2013, Vol 19, No 7
Abstract
Introduction: Pain is a common symptom for patients receiving palliative care, but can be relieved by effective pain management. Nurses play a critical part in implementing pain management effectively and must therefore have a solid foundation of knowledge and a positive attitude toward it. Aim: The purpose of this study was to implement and evaluate an educational pain management programme (PMP) for nurses in Kenya. Methods: The effects of the PMP were measured using a quasi-experimental pre–post test design. Twenty seven nurses from two units in a single health institution in Kenya participated in a baseline assessment using the Nurses’ Knowledge and Attitudes Survey Regarding Pain (NKASRP). Nine randomly selected nurses then received 7 hours of focused education. This group completed the assessment again both immediately after and 2 weeks after the PMP. Results: A deficit in knowledge and attitudes related to pain management was prominent at baseline. The nurses who received the PMP scored significantly higher on the NKASRP following the PMP: mean scores were 18.44, 28.00, and 27.56 at baseline, first follow-up, and second follow-up assessment respectively. Conclusion: The PMP appears to be effective in improving nurses’ pain knowledge and attitudes. Key words: Cancer pain l Nurses l Pain tools l Terminal illness l Education l Knowledge and attitudes
component was nurse education about pain management for adult patients with a terminal illness. The study evaluated the effects of the PMP on nurses’ pain knowledge and attitudes.
Design
Materials and methods
A quasi-experimental pre–post test design was used to gather information regarding registered nurses’ pain knowledge and attitudes in patients with terminal illness, and to evaluate the impact of a PMP. A quantitative study was considered appropriate because the phenomenon under investigation is well characterised. Furthermore, as the study sought to understand the current state of Kenyan nurses’ knowledge and attitudes regarding pain in patients with a terminal illness,
Gladys Machira is Lecturer, Kijabe School of Nursing, PO Box 20, Kijabe, Kenya 00220, Kenya; Hellen Kariuki is Lecturer, Department of Medical Physiology, University of Nairobi, Kenya; Linda Martindale is Lecturer and Dissertation Coordinator, School of Nursing and Midwifery, University of Dundee, Scotland Correspondence to: Gladys Machira [email protected]
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❛Several studies have indicated that a knowledge deficit is the most important barrier for health professionals in implementing pain management ...❜
it was necessary for the data generated to be measurable and objective, which is characteristic of data generated from a quantitative study (Polit and Beck, 2004).
Setting Two units/wards from a busy mission hospital in a rural district in Kenya were identified for participation. These two units are the only units in the region with the characteristics required for the study, i.e. units where nurses are already taking care of adult patients with a terminal illness. They are general units that nevertheless admit adult patients for specialist palliative care, as the hospital does not have a specialised in-patient palliative care unit. One of the units was for males and the other for females.
Sample Inclusion criteria were: registered nurses, working in either of the two units, and providing direct patient care during the study period. A total of 31 nurses met the inclusion criteria and were given a baseline knowledge and attitudes questionnaire to complete. Ten of these (every third nurse in a list generated prior to the study) were then randomly selected to receive the research intervention. It was not practical to have all 31 nurses participate in the training, as some had to be left in the ward to provide patient care. This intervention group was surveyed again both immediately after the training and 2 weeks after the training.
Ethical considerations Prior to the commencement of data collection, ethical approval was obtained from both the health-care institute and the Kenyan government, through the National Council of Science and Technology (research permit number NCST/ RRI/12/1/MED-011/19). Further, the researcher (GM) made a sensitisation visit to each unit, which all of the nurses meeting the inclusion criteria attended. During these visits, the researcher clearly explained the purpose and benefits of the study, the selection criteria, that the results would be made available to the part icipants, and that anonymity and confidentiality would be maintained through the use of codes rather than participant names to link the data gathered from the intervention group at the three measurement points.
Data collection The instruments used included a background information form that could be completed in approximately 5 minutes and the Nurses’
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Knowledge and Attitudes Survey Regarding Pain (NKASRP) (Ferrell and McCaffery, 2008), which can be completed in approximately 15–20 minutes. This is a 40-item questionnaire that assesses nurses’ knowledge and attitudes about pain management via 22 true/false questions, 14 multiple-choice questions, and 2 case studies with 2 questions each. To the authors’ knowledge, use of this instrument in Africa has not previously been reported. However, the validity and reliability of the tool has been documented in a number of studies (Patiraki et al, 2006; Zhang et al, 2008; Tse et al, 2011). It was therefore used in this study as there was no evidence for or against its application in the Kenyan setting. Test–retest reliability of the NKASRP was established (r>0.80) by Ferrell and McCaffery (2008) via repeat testing in a continuing education class of staff nurses (n=60). Internal consistency was also established (alpha r>0.70), with items reflecting both knowledge and attitude domains. Content validity was established through review by pain experts, while construct validity was established by comparing the scores of nurses at various levels of expertise (Ferrell and McCaffery, 2008). The NKASRP consists of four subscales: pain knowledge, pain assessment, pain drugs, and pain intervention, with pain intervention assessed through case studies. Each correctly answered item was assigned a score of 1 and each incorrectly answered item was assigned a score of 0. Total scores could therefore range from 0 to 40. A total score higher than 30 indicated that the respondent had a good understanding of pain and appropriate attitudes toward it, whereas a score lower than 20 indicated poor pain knowledge and attitudes. A week after the sensitisation visits, the researcher personally distributed a set of documents (cover letter, consent form, and questionnaire) to all 31 nurses who met the inclusion criteria. The nurses were required to sign the consent form prior to completing the questionnaire. Nurses sampled to participate in the education intervention were informed by the researcher at this point. They were then reminded to formulate a four-digit code (preferably using their birth dates) to enter on the top right-hand side of the top sheet of the document. As the researcher was not stationed in the units during the baseline data collection, different approaches to the collection of the completed questionnaires were explored. The nurses unanimously agreed to hand in the completed questionnaires to either their head ward nurse or the deputy. In order to maintain anonymity and
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Research
International Journal of Palliative Nursing 2013, Vol 19, No 7
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to minimise coercion, the head/deputy nurses did not keep any record of who had or had not returned the questionnaire. This was important as the researcher was a head nurse on one of the units but was away on long leave at the time of data collection. Questionnaires completed at baseline were kept in an envelope that the researcher collected from the head/deputy nurses. A total of 27 questionnaires were completed and returned from the baseline survey and 9 of these had a four-digit code. This process took 2 weeks, after which the PMP was implemented in the intervention group. All of the nurses selected to attend the education programme agreed to participate. In the follow-up assessments, the demographic information form was not included and neither was separate informed consent obtained. The assumption was that once participants signed the initial consent form and placed a code on the questionnaire they were then willing to continue with the study.
Research intervention: the PMP The PMP aimed to improve nurses’ knowledge and attitudes regarding pain and its management. The programme duration was 7 hours and it included lectures, discussions, and group activities. The education comprised an introduction to pain management and information on pain assessment, pharmacological and non-pharmacological pain interventions, and effects of pain on patients and family. The nine nurses all attended the PMP and immediately on finishing they completed the first follow-up questionnaire. The completed questionnaires were handed in to the researcher before the participants departed. A second followup questionnaire was administered 2 weeks post-PMP and handed in to the head/deputy nurses for collection by the researcher. Again, all nine questionnaires were duly completed with their four-digit codes and returned.
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Statistical analysis The lead author examined the data for accuracy prior to entry, checked the entries to correct errors, and then cleaned the data by checking for outliers or numerical values that were not part of the coding scheme before proceeding with the analysis. A variety of methods were used to enable in-depth analysis of the data. The statistical software package SPSS (version 11.5) was used to assist with the data analysis and presentation. Demographic data and data from continuous variables was represented using graphic displays and descriptive statistics. Inferential statistics,
International Journal of Palliative Nursing 2013, Vol 19, No 7
namely the Mann-Whitney U test and the Wilcoxon signed-ranks test, were used to find statistically significant differences in the sample. The rationale for using non-parametric tests was that the data was not normally distributed. Additionally, non-parametric tests are generally used for small sample sizes (Maltby et al, 2007). Further, inferential statistics, namely the Mann-Whitney U test, were used to find any significant associations between the nurses’ demographic characteristics and their baseline NKASRP scores. Wilcoxon signed-ranks tests for continuous variables were used to test for statistically significant differences between the average ranks in the pre- and post-PMP NKASRP scores of the nine nurses who received the intervention, between the two post-tests scores, and between performances on individual items on the NKASRP.
❛The low score at baseline for the nurses ... may be attributed to their having limited access to formal lectures on palliative care or pain management in pre-registration and continuing education.❜
Results
Demographic characteristics The questionnaire was completed by 27 of the 31 nurses (87.1%). The response rate for the intervention group was 90% at baseline and 100% in each of the two follow-up assessments. The baseline group of 27 nurses was 81% female. 59% of the nurses had less than 12 months of nursing experience. 93% had not attended any palliative care course and 89% had not attended any course on pain management for patients with a terminal illness. 81% reported a family member having experienced pain. Demographic characteristics of the intervention group were similar to those noted of the baseline group as a whole, with the exception that 56% of the intervention group had 12 or more months of nursing experience prior to the study vs 40.8% of the baseline group.
NKASRP scores The NKASRP has a maximum score of 40. At baseline, 44% of the nurses scored less than 20, and none scored more than 30 (Figure 1). No statistically significant associations were found between the nurses’ NKASRP scores and their demographic characteristics, namely gender, nursing experience, and previous pain experience among family members. The intervention group obtained a mean score of 18.44 out of 40 at baseline, and 78% of the group scored less than 20 out of 40. At first follow-up the intervention group obtained a mean score of 28.00 out of 40 and all nine of the nurses scored over 20. This improvement in these nurses’ knowledge and attitudes was statistically significant (Table 1). Some common
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8 7 Frequency
6 5
n=27 Mean=19 SD=2.84
4 3 2 1 0
14
16
18
20
22
24
26
Score out of 40
Figure 1. Baseline scores on the Nurses’ Knowledge and Attitudes Survey Regarding Pain. SD, standard deviation Table 1. Intervention group scores on the Nurses’ Knowledge and Attitudes Survey Regarding Pain (n=9) Baseline
First follow-up
Second follow-up
Mean score
18.44
28.00
27.56
Wilcoxon signed-ranks test
Baseline and first follow-up
First and second follow-up
Baseline and second follow-up
P value
0.007
0.572
0.008
misconceptions did persist after the PMP, for example 100% of the nurses answered at baseline and first follow-up that they would not provide morphine to a patient reporting pain but with normal vital signs, and only one nurse (11%) answered this question correctly at second follow-up. At second follow-up the intervention group obtained a mean score of 27.56 out of 40, and all nine nurses again scored over 20. This improvement remained statistically significant (Table 1). No statistically significant difference was found between the first and second follow-up assessments, which suggests that the effect of the PMP was sustained over the 2-week follow-up period (Table 1).
Discussion The most important findings of this study were the relatively low pre-intervention knowledge and attitude scores and the significant improvement in scores after the educational intervention. The findings suggest that Kenyan nurses’ pain knowledge and attitudes are far from ideal. Among the 40 items examined, the mean score for correctly answered items was 19 (47.5%). A knowledge deficit among the sample was noted mainly on issues surrounding the role of placebo
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by injection in pain management. At baseline, 93% of the nurses indicated that giving patients a placebo by injection was a useful test to determine whether their pain was real. A similar observation was made by Lui et al (2008), who reported that 67% of the nurses in their study responded affirmatively to this question. Baseline knowledge deficits detected in this sample of Kenyan nurses were similar to those reported in other international samples (Patiraki et al, 2006; Zhang et al, 2008; Tse et al, 2011). The low score at baseline for the nurses in the present study may be attributed to their having limited access to formal lectures on palliative care or pain management in pre-registration and continuing education. Inadequate pre-registration education on pain management for patients with a terminal illness may affect the level of knowledge and beliefs on the subject among nurses. A pain knowledge deficit among nurses was noted in previous studies as one of the major barriers to effective pain control in patients with a terminal illness (Liu et al, 2007; Sun et al, 2008; Oldenmenger et al, 2009; Varrassi et al, 2010). Pain management did not receive attention in Kenya until the advancement of hospice and palliative care within the past 5 years. It was not until recently that the Kenyan pre-registration nursing curriculum allocated time for palliative care. At present, no nurses have graduated from any nursing school in Kenya having received palliative care training. There is an urgent need to include palliative care in health training to produce nurses who are competent to effectively address the needs of patients with a terminal illness and hence improve their quality of life. The knowledge of and attitudes to pain in patients with a terminal illness improved in the intervention group nurses after the PMP. The mean score on the NKASRP in this group increased from 18.44 pre-test to 28.00 immediately after the PMP and was 27.56 2 weeks later. The outcomes of this study are consistent with the work of other researchers, who have found that a PMP contributes to nurses’ pain knowledge and attitudes in a systematic manner (McAuliffe et al, 2009; Oldenmenger et al, 2009; Tse et al, 2011). Thus, it is imperative that staff continue to build on and develop the knowledge and skills acquired during their training. The fact that there was no statistically significant difference between the NKASRP scores at first and second follow-up assessment suggests that the improved knowledge and attitudes persisted throughout the study follow-up period. The lack of correlation between years of nursing experience and pain knowledge scores
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Research
International Journal of Palliative Nursing 2013, Vol 19, No 7
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noted in this study suggests that knowledge of palliative care and, more specifically, pain management in Kenya has no critical mass that would provide mentorship and affect clinical practice (Donaldson and Carter, 2005; Cunningham et al, 2006; Ferrell et al, 2009; Leighton and Dubas, 2009; Wallace et al, 2009). This suggests the need for formal palliative care training for nurses both pre- and post-registration and as part of continuous professional development (CPD) in clinical practice. The finding that the positive effects of the PMP were maintained is similar to a finding reported by Zhang et al (2008), namely that Chinese nurses improved their pain knowledge following PMP and retained the knowledge gained for at least 3 months. This further supports the need for CPD, as professional development ensures that nurses’ knowledge and skills are kept up to date and remain relevant (Quinn and Hughes, 2007), improving patient care. A discussion on teaching methods is worthwhile. The authors aimed to promote student-led learning, a concept that is gradually gaining popularity in Kenyan training institutions. Thus, lectures and group discussions were favoured. Although lectures are usually perceived as teacher-centred (Quinn and Hughes, 2007), the study used this method as it is a useful way of providing a large amount of information efficiently. Further, small group teaching lends itself to discussion (Quinn and Hughes, 2007), which was useful in the present study as the nurses had vast experience in nursing patients with a terminal illness, which was beneficial in facilitating their learning. These two methods of nurse training were also favoured by two previous studies (Lin et al, 2008; Zhang et al, 2008). To the authors’ knowledge, this was the first study to have used the NKASRP in a developing country. The similarity of the findings to those observed in other studies supports the validity of using the tool in such settings.
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Limitations and recommendations Although the results of this study are promising, several limitations were inherent in the methodology. The sample was drawn from one mission hospital in Kenya and was small because some nurses had to be free to attend to patients. The results may therefore not be generalisable to represent all nurses of all backgrounds across all clinical environments in Kenya. Second, it would have been better to have tested the applicability of the NKASRP to the Kenyan setting in a pilot study before commencing the main study, but this was not feasible. Finally, the study mainly
International Journal of Palliative Nursing 2013, Vol 19, No 7
focused on examining nurses’ knowledge and attitudes in relation to pain management; their actual practice was not examined. Future studies should use larger, multi-centre samples to enhance generalisability, use method triangulation, examine the sustainability of the change in nurses’ pain knowledge and attitudes over a longer period of time, and longitudinally investigate the effects of education on practice.
Implications for practice The study highlighted the fact that palliative care, specifically pain management, in Kenya has no critical mass that would provide mentorship and improve clinical practice. This suggests the need for formal palliative care and specifically pain management training for nurses at pre-registration and as part of CPD within clinical practice.
❛... a wellstructured painmanagement programme for nurses had an immense impact on the pain knowledge and attitudes of a small sample.❜
Conclusion Pain is probably the most common reason patients seek help from health professionals, among whom nurses spend the most time in contact with patients. This study provides information about Kenyan nurses’ knowledge and attitudes in relation to pain management, finding that they are far from optimal. However, a well-structured PMP for nurses had an immense impact on the pain knowledge and attitudes of a small sample. Most of the nurses in the study had no prior palliative care education, indicating that palliative care does not receive sufficient emphasis at pre-registration level and within clinical practice. Strategies for future research and knowledge development have been suggested as means of improving the quality of care and the quality of life of patients JPN with a terminal illness. I● Acknowledgments Gladys Machira would like to acknowledge Betty Ferrell and Margo McCaffery, developers of the Nurses’ Knowledge and Attitudes Survey Regarding Pain tool, for allowing others to use it to improve pain management in their settings. Gladys also wishes to acknowledge Dr Robert Carter of Kijabe hospital for his assistance with initial editorial work on this paper.
Abdalrahim MS, Majali SA, Stomberg MW, Bergbom I (2011) The effect of postoperative pain management program on improving nurses’ knowledge and attitudes toward pain. Nurse Educ Pract 11(4): 250–5 Bernardi M, Catania G, Lambert A, Tridello G, Luzzani M (2007) Knowledge and attitudes about cancer pain management: a national survey of Italian oncology nurses. Eur J Oncol Nurs 11(3): 272–9 Borgsteede SD, Deliens L, Zuurmond WW et al (2009) Prescribing of pain medication in palliative care. A survey in general practice. Pharmacoepidemiol Drug Saf 18(1): 16–23
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Brown D, McCormack B (2006) Determining factors that have an impact upon effective evidence-based pain management with older people, following colorectal surgery: an ethnographic study. J Clin Nurs 15(10): 1287–98 Cunningham SM, Copp G, Collins B, Bater M (2006) Pre-registration nursing students’ experience of caring for cancer patients. Eur J Oncol Nurs 10(1): 59–67 Donaldson H, Carter D (2005) The value of role modelling: Perceptions of undergraduate and diploma nursing (adult) students. Nurse Educ Pract 5(6): 353–9 Ferrell B, McCaffery M (2008) Knowledge and Attitudes Survey Regarding Pain. www.midss.ie/content/ knowledge-and-attitudes-survey-regarding-pain-kasrp (accessed 26 June 2013) Ferrell B, Virani R, Paice JA, Coyle N, Coyne P (2009) Evaluation of palliative care nursing education seminars. Eur J Oncol Nurs 14(1): 74–9 Leighton K, Dubas J (2009) Simulated death: an innovative approach to teaching end-of-life care. Clin Simulat Nurs 5(6): 223–30 Lin PC, Chiang HW, Chiang TT, Chen CS (2008) Pain management: evaluating the effectiveness of an educational programme for surgical nursing staff. J Clin Nurs 17(15): 2032–41 Liu W, Luo A, Liu H (2007) Overcoming the barriers in pain control: an update of pain management in China. Eur J Pain Suppl 1(1): 10–3 Lui LY, So WK, Fong DY (2008) Knowledge and attitudes regarding pain management among nurses in Hong Kong medical units. J Clin Nurs 17(15): 2014–21 Maltby J, Day L, Williams G (2007) Introduction to Statistics for Nurses. Pearson Education Limited, England McAuliffe L, Nay R, O’Donnell M, Fetherstonhaugh D (2009) Pain assessment in older people with dementia: literature review. J Adv Nurs 65(1): 2–10 McLeod R (2007) Goodfellow Symposium 2007. Total pain—physical, psychological and spiritual. www.fmhs. auckland.ac.nz/soph/centres/goodfellow/_docs/total_ pain_handout.pdf (accessed 11 July 2013) Mehta A, Chan LS (2008) Understanding of the concept of “total pain”: a prerequisite for pain control. J Hospice Palliat Nurs 10(1): 26–32 Oldenmenger WH, Sillevis Smitt PA, van Dooren S,
Stoter G, van der Rijt CC (2009) A systematic review on barriers hindering adequate cancer pain management and interventions to reduce them: a critical appraisal. Eur J Cancer 45(8): 1370–80 Patiraki EI, Papathanassoglou ED, Tafas C et al (2006) A randomized controlled trial of an educational intervention on Hellenic nursing staff’s knowledge and attitudes on cancer pain management. Eur J Oncol Nurs 10(5): 337–52 Polit F, Beck T (2004) Nursing Research: Principles and Methods. 7th edn. Lippincott Williams & Wilkins, Philadelphia Quinn FM, Hughes SJ (2007) Quinn’s Principles and Practice of Nurse Education. 5th edn. Nelson Thornes Limited, UK Ruff RL, Ruff SS, Wang X (2007) Persistent benefits of rehabilitation on pain and life quality for nonambulatory patients with spinal epidural metastasis. J Rehabil Res Dev 44(2): 271–8 Silver J, Mayer RS (2007) Barriers to pain management in the rehabilitation of the surgical oncology patient. J Surg Oncol 95(5): 427–35 Sun V, Borneman T, Piper B, Koczywas M, Ferrell B (2008) Barriers to pain assessment and management in cancer survivorship. J Cancer Surviv 2(1): 65–71 Tse MM, Vong SK, Ho SS (2011) The effectiveness of an integrated pain management program for older persons and staff in nursing homes. Arch Gerontol Geriatr 54(2): e203–12 Varrassi G, Marinangeli F, Piroli A, Paladini A, Coaccioli S (2010) Challenges in managing cancer pain. Eur J Pain 4(Suppl 3): 177–80 Wallace M, Grossman S, Campbell S, Robert T, Lange J, Shea J (2009) Integration of end-of-life care content in undergraduate nursing curricula: student knowledge and perceptions. J Prof Nurs 25(1): 50–6 Yildirim Z, Cicek F, Uyar M (2009) Effects of pain education program on pain intensity, pain treatment satisfaction, and barriers in Turkish cancer patients. Pain Manage Nurs 10(4): 220–8 Zhang CH, Hsu L, Zou BR, Li JF, Wang HY, Huang J (2008) Effects of a pain education program on nurses’ pain knowledge, attitudes and pain assessment practices in China. J Pain Symptom Manage 36(6): 616–27
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Impact of an educational pain management programme on nurses’ pain knowledge and attitudes in Kenya Gladys Machira, Hellen Kariuki, Linda Martindale
© 2013 MA Healthcare Ltd
I
nadequate treatment of pain is an insidious clinical problem in hospitalised patients (Brown and McCormack, 2006; Bernardi et al, 2007; Silver and Mayer, 2007), with considerable physiological, psychological, emotional, spiritual, and financial consequences. These include slowed healing, a higher rate of complications, anxiety, sleep disturbance, and lowered quality of life (McLeod, 2007; Ruff et al, 2007; Silver and Mayer, 2007; Mehta and Chan, 2008). Research attention has focused on the barriers to pain treatment, including factors related to both health-care providers and patients themselves (Sun et al, 2008; Yildirim et al, 2009). Several studies have indicated that a knowledge deficit is the most important barrier for health professionals in implementing pain management (Borgsteede et al, 2009; Oldenmenger et al, 2009; and Varrassi et al, 2010). In particular, nurses play a critical part in pain management because they deliver direct patient care on a 24-hour basis. However, studies have found that many nurses lack pain management knowledge (Yildirim et al, 2009; Abdalrahim et al, 2011; Tse et al, 2011). For this reason, implementing a pain management programme (PMP) for health professionals, particularly for nurses who act as ‘first-line’ personnel in pain treatment, is a vital strategy in pain management. Previous studies have examined the effects of PMPs on nurses’ pain knowledge and attitudes (Patiraki et al, 2006; Zhang et al, 2008; Abdalrahim et al, 2011; Tse et al, 2011). These concluded that PMPs do have a positive effect on nurses’ pain knowledge and attitudes; however, most of them were carried out in developed countries. In Kenya, some hospitals have provided health professionals with a PMP, but to the authors’ knowledge no studies have explored the effectiveness of PMPs for nurses.
Aim This study aimed to implement and evaluate a PMP for nurses in Kenya. The PMP’s main
International Journal of Palliative Nursing 2013, Vol 19, No 7
Abstract
Introduction: Pain is a common symptom for patients receiving palliative care, but can be relieved by effective pain management. Nurses play a critical part in implementing pain management effectively and must therefore have a solid foundation of knowledge and a positive attitude toward it. Aim: The purpose of this study was to implement and evaluate an educational pain management programme (PMP) for nurses in Kenya. Methods: The effects of the PMP were measured using a quasi-experimental pre–post test design. Twenty seven nurses from two units in a single health institution in Kenya participated in a baseline assessment using the Nurses’ Knowledge and Attitudes Survey Regarding Pain (NKASRP). Nine randomly selected nurses then received 7 hours of focused education. This group completed the assessment again both immediately after and 2 weeks after the PMP. Results: A deficit in knowledge and attitudes related to pain management was prominent at baseline. The nurses who received the PMP scored significantly higher on the NKASRP following the PMP: mean scores were 18.44, 28.00, and 27.56 at baseline, first follow-up, and second follow-up assessment respectively. Conclusion: The PMP appears to be effective in improving nurses’ pain knowledge and attitudes. Key words: Cancer pain l Nurses l Pain tools l Terminal illness l Education l Knowledge and attitudes
component was nurse education about pain management for adult patients with a terminal illness. The study evaluated the effects of the PMP on nurses’ pain knowledge and attitudes.
Design
Materials and methods
A quasi-experimental pre–post test design was used to gather information regarding registered nurses’ pain knowledge and attitudes in patients with terminal illness, and to evaluate the impact of a PMP. A quantitative study was considered appropriate because the phenomenon under investigation is well characterised. Furthermore, as the study sought to understand the current state of Kenyan nurses’ knowledge and attitudes regarding pain in patients with a terminal illness,
Gladys Machira is Lecturer, Kijabe School of Nursing, PO Box 20, Kijabe, Kenya 00220, Kenya; Hellen Kariuki is Lecturer, Department of Medical Physiology, University of Nairobi, Kenya; Linda Martindale is Lecturer and Dissertation Coordinator, School of Nursing and Midwifery, University of Dundee, Scotland Correspondence to: Gladys Machira [email protected]
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onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on September 30, 2015. For personal use only. No other uses without permission. . All rights r
❛Several studies have indicated that a knowledge deficit is the most important barrier for health professionals in implementing pain management ...❜
it was necessary for the data generated to be measurable and objective, which is characteristic of data generated from a quantitative study (Polit and Beck, 2004).
Setting Two units/wards from a busy mission hospital in a rural district in Kenya were identified for participation. These two units are the only units in the region with the characteristics required for the study, i.e. units where nurses are already taking care of adult patients with a terminal illness. They are general units that nevertheless admit adult patients for specialist palliative care, as the hospital does not have a specialised in-patient palliative care unit. One of the units was for males and the other for females.
Sample Inclusion criteria were: registered nurses, working in either of the two units, and providing direct patient care during the study period. A total of 31 nurses met the inclusion criteria and were given a baseline knowledge and attitudes questionnaire to complete. Ten of these (every third nurse in a list generated prior to the study) were then randomly selected to receive the research intervention. It was not practical to have all 31 nurses participate in the training, as some had to be left in the ward to provide patient care. This intervention group was surveyed again both immediately after the training and 2 weeks after the training.
Ethical considerations Prior to the commencement of data collection, ethical approval was obtained from both the health-care institute and the Kenyan government, through the National Council of Science and Technology (research permit number NCST/ RRI/12/1/MED-011/19). Further, the researcher (GM) made a sensitisation visit to each unit, which all of the nurses meeting the inclusion criteria attended. During these visits, the researcher clearly explained the purpose and benefits of the study, the selection criteria, that the results would be made available to the part icipants, and that anonymity and confidentiality would be maintained through the use of codes rather than participant names to link the data gathered from the intervention group at the three measurement points.
Data collection The instruments used included a background information form that could be completed in approximately 5 minutes and the Nurses’
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Knowledge and Attitudes Survey Regarding Pain (NKASRP) (Ferrell and McCaffery, 2008), which can be completed in approximately 15–20 minutes. This is a 40-item questionnaire that assesses nurses’ knowledge and attitudes about pain management via 22 true/false questions, 14 multiple-choice questions, and 2 case studies with 2 questions each. To the authors’ knowledge, use of this instrument in Africa has not previously been reported. However, the validity and reliability of the tool has been documented in a number of studies (Patiraki et al, 2006; Zhang et al, 2008; Tse et al, 2011). It was therefore used in this study as there was no evidence for or against its application in the Kenyan setting. Test–retest reliability of the NKASRP was established (r>0.80) by Ferrell and McCaffery (2008) via repeat testing in a continuing education class of staff nurses (n=60). Internal consistency was also established (alpha r>0.70), with items reflecting both knowledge and attitude domains. Content validity was established through review by pain experts, while construct validity was established by comparing the scores of nurses at various levels of expertise (Ferrell and McCaffery, 2008). The NKASRP consists of four subscales: pain knowledge, pain assessment, pain drugs, and pain intervention, with pain intervention assessed through case studies. Each correctly answered item was assigned a score of 1 and each incorrectly answered item was assigned a score of 0. Total scores could therefore range from 0 to 40. A total score higher than 30 indicated that the respondent had a good understanding of pain and appropriate attitudes toward it, whereas a score lower than 20 indicated poor pain knowledge and attitudes. A week after the sensitisation visits, the researcher personally distributed a set of documents (cover letter, consent form, and questionnaire) to all 31 nurses who met the inclusion criteria. The nurses were required to sign the consent form prior to completing the questionnaire. Nurses sampled to participate in the education intervention were informed by the researcher at this point. They were then reminded to formulate a four-digit code (preferably using their birth dates) to enter on the top right-hand side of the top sheet of the document. As the researcher was not stationed in the units during the baseline data collection, different approaches to the collection of the completed questionnaires were explored. The nurses unanimously agreed to hand in the completed questionnaires to either their head ward nurse or the deputy. In order to maintain anonymity and
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to minimise coercion, the head/deputy nurses did not keep any record of who had or had not returned the questionnaire. This was important as the researcher was a head nurse on one of the units but was away on long leave at the time of data collection. Questionnaires completed at baseline were kept in an envelope that the researcher collected from the head/deputy nurses. A total of 27 questionnaires were completed and returned from the baseline survey and 9 of these had a four-digit code. This process took 2 weeks, after which the PMP was implemented in the intervention group. All of the nurses selected to attend the education programme agreed to participate. In the follow-up assessments, the demographic information form was not included and neither was separate informed consent obtained. The assumption was that once participants signed the initial consent form and placed a code on the questionnaire they were then willing to continue with the study.
Research intervention: the PMP The PMP aimed to improve nurses’ knowledge and attitudes regarding pain and its management. The programme duration was 7 hours and it included lectures, discussions, and group activities. The education comprised an introduction to pain management and information on pain assessment, pharmacological and non-pharmacological pain interventions, and effects of pain on patients and family. The nine nurses all attended the PMP and immediately on finishing they completed the first follow-up questionnaire. The completed questionnaires were handed in to the researcher before the participants departed. A second followup questionnaire was administered 2 weeks post-PMP and handed in to the head/deputy nurses for collection by the researcher. Again, all nine questionnaires were duly completed with their four-digit codes and returned.
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Statistical analysis The lead author examined the data for accuracy prior to entry, checked the entries to correct errors, and then cleaned the data by checking for outliers or numerical values that were not part of the coding scheme before proceeding with the analysis. A variety of methods were used to enable in-depth analysis of the data. The statistical software package SPSS (version 11.5) was used to assist with the data analysis and presentation. Demographic data and data from continuous variables was represented using graphic displays and descriptive statistics. Inferential statistics,
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namely the Mann-Whitney U test and the Wilcoxon signed-ranks test, were used to find statistically significant differences in the sample. The rationale for using non-parametric tests was that the data was not normally distributed. Additionally, non-parametric tests are generally used for small sample sizes (Maltby et al, 2007). Further, inferential statistics, namely the Mann-Whitney U test, were used to find any significant associations between the nurses’ demographic characteristics and their baseline NKASRP scores. Wilcoxon signed-ranks tests for continuous variables were used to test for statistically significant differences between the average ranks in the pre- and post-PMP NKASRP scores of the nine nurses who received the intervention, between the two post-tests scores, and between performances on individual items on the NKASRP.
❛The low score at baseline for the nurses ... may be attributed to their having limited access to formal lectures on palliative care or pain management in pre-registration and continuing education.❜
Results
Demographic characteristics The questionnaire was completed by 27 of the 31 nurses (87.1%). The response rate for the intervention group was 90% at baseline and 100% in each of the two follow-up assessments. The baseline group of 27 nurses was 81% female. 59% of the nurses had less than 12 months of nursing experience. 93% had not attended any palliative care course and 89% had not attended any course on pain management for patients with a terminal illness. 81% reported a family member having experienced pain. Demographic characteristics of the intervention group were similar to those noted of the baseline group as a whole, with the exception that 56% of the intervention group had 12 or more months of nursing experience prior to the study vs 40.8% of the baseline group.
NKASRP scores The NKASRP has a maximum score of 40. At baseline, 44% of the nurses scored less than 20, and none scored more than 30 (Figure 1). No statistically significant associations were found between the nurses’ NKASRP scores and their demographic characteristics, namely gender, nursing experience, and previous pain experience among family members. The intervention group obtained a mean score of 18.44 out of 40 at baseline, and 78% of the group scored less than 20 out of 40. At first follow-up the intervention group obtained a mean score of 28.00 out of 40 and all nine of the nurses scored over 20. This improvement in these nurses’ knowledge and attitudes was statistically significant (Table 1). Some common
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8 7 Frequency
6 5
n=27 Mean=19 SD=2.84
4 3 2 1 0
14
16
18
20
22
24
26
Score out of 40
Figure 1. Baseline scores on the Nurses’ Knowledge and Attitudes Survey Regarding Pain. SD, standard deviation Table 1. Intervention group scores on the Nurses’ Knowledge and Attitudes Survey Regarding Pain (n=9) Baseline
First follow-up
Second follow-up
Mean score
18.44
28.00
27.56
Wilcoxon signed-ranks test
Baseline and first follow-up
First and second follow-up
Baseline and second follow-up
P value
0.007
0.572
0.008
misconceptions did persist after the PMP, for example 100% of the nurses answered at baseline and first follow-up that they would not provide morphine to a patient reporting pain but with normal vital signs, and only one nurse (11%) answered this question correctly at second follow-up. At second follow-up the intervention group obtained a mean score of 27.56 out of 40, and all nine nurses again scored over 20. This improvement remained statistically significant (Table 1). No statistically significant difference was found between the first and second follow-up assessments, which suggests that the effect of the PMP was sustained over the 2-week follow-up period (Table 1).
Discussion The most important findings of this study were the relatively low pre-intervention knowledge and attitude scores and the significant improvement in scores after the educational intervention. The findings suggest that Kenyan nurses’ pain knowledge and attitudes are far from ideal. Among the 40 items examined, the mean score for correctly answered items was 19 (47.5%). A knowledge deficit among the sample was noted mainly on issues surrounding the role of placebo
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by injection in pain management. At baseline, 93% of the nurses indicated that giving patients a placebo by injection was a useful test to determine whether their pain was real. A similar observation was made by Lui et al (2008), who reported that 67% of the nurses in their study responded affirmatively to this question. Baseline knowledge deficits detected in this sample of Kenyan nurses were similar to those reported in other international samples (Patiraki et al, 2006; Zhang et al, 2008; Tse et al, 2011). The low score at baseline for the nurses in the present study may be attributed to their having limited access to formal lectures on palliative care or pain management in pre-registration and continuing education. Inadequate pre-registration education on pain management for patients with a terminal illness may affect the level of knowledge and beliefs on the subject among nurses. A pain knowledge deficit among nurses was noted in previous studies as one of the major barriers to effective pain control in patients with a terminal illness (Liu et al, 2007; Sun et al, 2008; Oldenmenger et al, 2009; Varrassi et al, 2010). Pain management did not receive attention in Kenya until the advancement of hospice and palliative care within the past 5 years. It was not until recently that the Kenyan pre-registration nursing curriculum allocated time for palliative care. At present, no nurses have graduated from any nursing school in Kenya having received palliative care training. There is an urgent need to include palliative care in health training to produce nurses who are competent to effectively address the needs of patients with a terminal illness and hence improve their quality of life. The knowledge of and attitudes to pain in patients with a terminal illness improved in the intervention group nurses after the PMP. The mean score on the NKASRP in this group increased from 18.44 pre-test to 28.00 immediately after the PMP and was 27.56 2 weeks later. The outcomes of this study are consistent with the work of other researchers, who have found that a PMP contributes to nurses’ pain knowledge and attitudes in a systematic manner (McAuliffe et al, 2009; Oldenmenger et al, 2009; Tse et al, 2011). Thus, it is imperative that staff continue to build on and develop the knowledge and skills acquired during their training. The fact that there was no statistically significant difference between the NKASRP scores at first and second follow-up assessment suggests that the improved knowledge and attitudes persisted throughout the study follow-up period. The lack of correlation between years of nursing experience and pain knowledge scores
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noted in this study suggests that knowledge of palliative care and, more specifically, pain management in Kenya has no critical mass that would provide mentorship and affect clinical practice (Donaldson and Carter, 2005; Cunningham et al, 2006; Ferrell et al, 2009; Leighton and Dubas, 2009; Wallace et al, 2009). This suggests the need for formal palliative care training for nurses both pre- and post-registration and as part of continuous professional development (CPD) in clinical practice. The finding that the positive effects of the PMP were maintained is similar to a finding reported by Zhang et al (2008), namely that Chinese nurses improved their pain knowledge following PMP and retained the knowledge gained for at least 3 months. This further supports the need for CPD, as professional development ensures that nurses’ knowledge and skills are kept up to date and remain relevant (Quinn and Hughes, 2007), improving patient care. A discussion on teaching methods is worthwhile. The authors aimed to promote student-led learning, a concept that is gradually gaining popularity in Kenyan training institutions. Thus, lectures and group discussions were favoured. Although lectures are usually perceived as teacher-centred (Quinn and Hughes, 2007), the study used this method as it is a useful way of providing a large amount of information efficiently. Further, small group teaching lends itself to discussion (Quinn and Hughes, 2007), which was useful in the present study as the nurses had vast experience in nursing patients with a terminal illness, which was beneficial in facilitating their learning. These two methods of nurse training were also favoured by two previous studies (Lin et al, 2008; Zhang et al, 2008). To the authors’ knowledge, this was the first study to have used the NKASRP in a developing country. The similarity of the findings to those observed in other studies supports the validity of using the tool in such settings.
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Limitations and recommendations Although the results of this study are promising, several limitations were inherent in the methodology. The sample was drawn from one mission hospital in Kenya and was small because some nurses had to be free to attend to patients. The results may therefore not be generalisable to represent all nurses of all backgrounds across all clinical environments in Kenya. Second, it would have been better to have tested the applicability of the NKASRP to the Kenyan setting in a pilot study before commencing the main study, but this was not feasible. Finally, the study mainly
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focused on examining nurses’ knowledge and attitudes in relation to pain management; their actual practice was not examined. Future studies should use larger, multi-centre samples to enhance generalisability, use method triangulation, examine the sustainability of the change in nurses’ pain knowledge and attitudes over a longer period of time, and longitudinally investigate the effects of education on practice.
Implications for practice The study highlighted the fact that palliative care, specifically pain management, in Kenya has no critical mass that would provide mentorship and improve clinical practice. This suggests the need for formal palliative care and specifically pain management training for nurses at pre-registration and as part of CPD within clinical practice.
❛... a wellstructured painmanagement programme for nurses had an immense impact on the pain knowledge and attitudes of a small sample.❜
Conclusion Pain is probably the most common reason patients seek help from health professionals, among whom nurses spend the most time in contact with patients. This study provides information about Kenyan nurses’ knowledge and attitudes in relation to pain management, finding that they are far from optimal. However, a well-structured PMP for nurses had an immense impact on the pain knowledge and attitudes of a small sample. Most of the nurses in the study had no prior palliative care education, indicating that palliative care does not receive sufficient emphasis at pre-registration level and within clinical practice. Strategies for future research and knowledge development have been suggested as means of improving the quality of care and the quality of life of patients JPN with a terminal illness. I● Acknowledgments Gladys Machira would like to acknowledge Betty Ferrell and Margo McCaffery, developers of the Nurses’ Knowledge and Attitudes Survey Regarding Pain tool, for allowing others to use it to improve pain management in their settings. Gladys also wishes to acknowledge Dr Robert Carter of Kijabe hospital for his assistance with initial editorial work on this paper.
Abdalrahim MS, Majali SA, Stomberg MW, Bergbom I (2011) The effect of postoperative pain management program on improving nurses’ knowledge and attitudes toward pain. Nurse Educ Pract 11(4): 250–5 Bernardi M, Catania G, Lambert A, Tridello G, Luzzani M (2007) Knowledge and attitudes about cancer pain management: a national survey of Italian oncology nurses. Eur J Oncol Nurs 11(3): 272–9 Borgsteede SD, Deliens L, Zuurmond WW et al (2009) Prescribing of pain medication in palliative care. A survey in general practice. Pharmacoepidemiol Drug Saf 18(1): 16–23
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Brown D, McCormack B (2006) Determining factors that have an impact upon effective evidence-based pain management with older people, following colorectal surgery: an ethnographic study. J Clin Nurs 15(10): 1287–98 Cunningham SM, Copp G, Collins B, Bater M (2006) Pre-registration nursing students’ experience of caring for cancer patients. Eur J Oncol Nurs 10(1): 59–67 Donaldson H, Carter D (2005) The value of role modelling: Perceptions of undergraduate and diploma nursing (adult) students. Nurse Educ Pract 5(6): 353–9 Ferrell B, McCaffery M (2008) Knowledge and Attitudes Survey Regarding Pain. www.midss.ie/content/ knowledge-and-attitudes-survey-regarding-pain-kasrp (accessed 26 June 2013) Ferrell B, Virani R, Paice JA, Coyle N, Coyne P (2009) Evaluation of palliative care nursing education seminars. Eur J Oncol Nurs 14(1): 74–9 Leighton K, Dubas J (2009) Simulated death: an innovative approach to teaching end-of-life care. Clin Simulat Nurs 5(6): 223–30 Lin PC, Chiang HW, Chiang TT, Chen CS (2008) Pain management: evaluating the effectiveness of an educational programme for surgical nursing staff. J Clin Nurs 17(15): 2032–41 Liu W, Luo A, Liu H (2007) Overcoming the barriers in pain control: an update of pain management in China. Eur J Pain Suppl 1(1): 10–3 Lui LY, So WK, Fong DY (2008) Knowledge and attitudes regarding pain management among nurses in Hong Kong medical units. J Clin Nurs 17(15): 2014–21 Maltby J, Day L, Williams G (2007) Introduction to Statistics for Nurses. Pearson Education Limited, England McAuliffe L, Nay R, O’Donnell M, Fetherstonhaugh D (2009) Pain assessment in older people with dementia: literature review. J Adv Nurs 65(1): 2–10 McLeod R (2007) Goodfellow Symposium 2007. Total pain—physical, psychological and spiritual. www.fmhs. auckland.ac.nz/soph/centres/goodfellow/_docs/total_ pain_handout.pdf (accessed 11 July 2013) Mehta A, Chan LS (2008) Understanding of the concept of “total pain”: a prerequisite for pain control. J Hospice Palliat Nurs 10(1): 26–32 Oldenmenger WH, Sillevis Smitt PA, van Dooren S,
Stoter G, van der Rijt CC (2009) A systematic review on barriers hindering adequate cancer pain management and interventions to reduce them: a critical appraisal. Eur J Cancer 45(8): 1370–80 Patiraki EI, Papathanassoglou ED, Tafas C et al (2006) A randomized controlled trial of an educational intervention on Hellenic nursing staff’s knowledge and attitudes on cancer pain management. Eur J Oncol Nurs 10(5): 337–52 Polit F, Beck T (2004) Nursing Research: Principles and Methods. 7th edn. Lippincott Williams & Wilkins, Philadelphia Quinn FM, Hughes SJ (2007) Quinn’s Principles and Practice of Nurse Education. 5th edn. Nelson Thornes Limited, UK Ruff RL, Ruff SS, Wang X (2007) Persistent benefits of rehabilitation on pain and life quality for nonambulatory patients with spinal epidural metastasis. J Rehabil Res Dev 44(2): 271–8 Silver J, Mayer RS (2007) Barriers to pain management in the rehabilitation of the surgical oncology patient. J Surg Oncol 95(5): 427–35 Sun V, Borneman T, Piper B, Koczywas M, Ferrell B (2008) Barriers to pain assessment and management in cancer survivorship. J Cancer Surviv 2(1): 65–71 Tse MM, Vong SK, Ho SS (2011) The effectiveness of an integrated pain management program for older persons and staff in nursing homes. Arch Gerontol Geriatr 54(2): e203–12 Varrassi G, Marinangeli F, Piroli A, Paladini A, Coaccioli S (2010) Challenges in managing cancer pain. Eur J Pain 4(Suppl 3): 177–80 Wallace M, Grossman S, Campbell S, Robert T, Lange J, Shea J (2009) Integration of end-of-life care content in undergraduate nursing curricula: student knowledge and perceptions. J Prof Nurs 25(1): 50–6 Yildirim Z, Cicek F, Uyar M (2009) Effects of pain education program on pain intensity, pain treatment satisfaction, and barriers in Turkish cancer patients. Pain Manage Nurs 10(4): 220–8 Zhang CH, Hsu L, Zou BR, Li JF, Wang HY, Huang J (2008) Effects of a pain education program on nurses’ pain knowledge, attitudes and pain assessment practices in China. J Pain Symptom Manage 36(6): 616–27
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International Journal of Palliative Nursing is very grateful for the advice provided by its pool of dedicated volunteer peer reviewers and always appreciates new offers from experienced clinicians and academics interested in helping out.
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