Original Article Jordanian Nurses Knowledge and Attitude Regarding Pain Management ---
From the School of Nursing, Al Al-Bayt University, Mafraq, Jordan. Address correspondence to Mohammad Al Qadire, RN, PhD, Assistant Professor, School of Nursing, Al Al-Bayt University, Mafraq 25113, Jordan. E-mail: [email protected]
aabu.edu.jo Received August 9, 2012; Revised August 18, 2012; Accepted August 20, 2012. 1524-9042/$36.00 Ó 2014 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2012.08.006
Mohammad Al Qadire, RN, PhD, and Murad Al Khalaileh, RN, PhD
Optimal pain management requires knowledgeable and trained nurses. The aim of this study is to investigate nurses’ knowledge and attitudes regarding pain treatment in Jordan. The sample included 211 nurses from 4 hospitals in Jordan. The Nurses’ Knowledge and Attitudes Survey Regarding Pain was used to measure the nurses’ pain management knowledge and attitudes. Data were analyzed using descriptive statistics, unpaired t test, and Spearman correlation test. The results indicate that 51.7% of participants were male and the average age was 27.2 (SD 4.7) years. In addition, most nurses had a bachelor’s degree (90.5%) and worked in medical and surgical wards. Furthermore, 52% of nurses reported no previous pain education in the last five years. The average of correct answers was 19.3 out of 40 (SD 4.7) and the rate of correct answers ranged from 10% (item 38) to 72% (item 22). It was found that there were no significant differences between nurses’ gender and educational level and the total knowledge and attitude score, except for exposure to previous pain education (t ¼ L3.64; df ¼ 195; p < .001). Nurses with previous pain education got higher mean scores on the questionnaire. Jordanian nurses expressed a lower level of pain knowledge than that reported worldwide. Continuous education and reforming undergraduate curricula to address pain management are recommended. Ó 2014 by the American Society for Pain Management Nursing Pain is one of the most common symptoms experienced by patients (Everdingen Rijke, Kessels, Schouten, Kleef, & Atijn, 2007). In addition, pain is a universal human experience, and the World Health Organization (WHO) declared some time ago that pain is a worldwide problem, the solution to which necessitates more collaborative work to reach the optimal level of control (Stjernsward & Teoh, 1990). Pain control is a vitally important goal, because neglected pain can cause patients to lose hope, impede their response to treatment, and negatively affect their quality of life (Al-Atiyyat, 2008; Sykes, Fallon, & Patt, 2003). Although guidelines and pharmacologic interventions exist to manage pain, poor assessment and undermedication is well documented in the United Kingdom, United States, Canada, France, and throughout Asia (Breivik, Cherny, Collett, de Conno, Filbet, Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 220-228
Knowledge of Pain in Jordan
& Foubert, 2009). In addition, the barriers to pain management are abundant and can be related to patients, family caregivers, and health care providers. In particular, health care professionals have been found to lack appropriate knowledge to assess and manage pain and may hold negative attitudes toward pain management (Bernardi, Catania, Lambert, Tridello, & Luzzani, 2007; David, Deborah, & Porterfield, 2003; Eftekhar, Mohagheghi, Yarandi, Eghtesadi-Araghi, Moosavi-Jarahi, & Gilani, 2007; Finley, Forgeron, & Arnaout, 2008; Johnson, Kassner, Houser, & Kutner, 2005). A considerable number of studies have been conducted to examine health care professionals’ knowledge in managing patients’ pain. For example, a study was conducted in Hong Kong to examine the attitudes regarding pain of nurses working on medical floors and to assess their knowledge level (Lui, So, & Fong, 2008). One hundred forty-seven nurses completed the Nurses’ Knowledge and Attitudes questionnaire (NKA). It was found that nurses lacked the knowledge required to manage pain optimally; in addition, negative attitudes toward pain were prominent. However, nurses with longer working experience seemed to have better knowledge of pain management (Lui et al., 2008). Another study of 287 nurses in Italy, who were surveyed with the NKA, confirmed that nurses have a low level of knowledge regarding cancer pain management (Bernardi et al., 2007). That study, wherein the sample of nurses was selected to represent all nurses in Italy, found that nurses got a mean average score of 21.4 out of 39 on the NKA, indicating a low level of knowledge. In addition, there was a significant difference between the mean NKA scores between nurses who received pain education and those who did not (mean scores 22 and 20, respectively; p ¼ .02) (Bernardi et al., 2007). Furthermore, a study to evaluate nurses’ knowledge of pain among 72 nurses who were either hospice or district nurses in the U.K. found that nurses had a low level of pain knowledge, with relatively special nurses having better knowledge in managing pain (Wilson, 2007). Knowledge deficit is prevalent among health care professionals. It is estimated that 50% of health care providers lack sufficient knowledge of pain assessment and pain management, including the effects and side effects of medications. However, extensive research has focused on health care workers’ knowledge and attitudes regarding cancer pain management in particular (Bernardi et al., 2007; Eftekhar et al., 2007; Gallagher, Hawley, & Yeomans, 2004; Xue, Schulman-Green, Czaplinski, Harris, & McCorkle, 2007). Health care workers not only lack knowledge and training about managing cancer pain, but they also held myths and misconceptions about pain treatment to the extent
that they left pain uncontrolled. Education may help to reach the ultimate goal of good pain management (Zhang, Hsu, Zou, Li, Wang, & Huang, 2008). Bernardi et al. (2007) reported that nurses tend to disregard or undervalue pain when it is reported by cancer patients in particular. Another study that explored the knowledge and attitudes of 350 nurses regarding pain management found that nurses abstained from giving patients opioid treatments because of a fear of addiction. In addition, they found that nurses held negative attitudes toward using analgesic during the early course of diseases that are combined with pain (Klopper, Andersson, Minkkinen, Ohlsson, & Sj€ ostr€ om, 2006). In Jordan, a study was conducted to evaluate the effects of educational course on postoperative pain management nurses’ knowledge and attitudes. A quasiexperimental design was used. The results of the preeducation phase indicated that the percentage of correct answers on the knowledge questionnaire items was only 45.7%. Furthermore, nurses tend to disregard patients’ self-reporting of pain if this was not combined with a physical cause, such as trauma or tissue injury (Abdalrahim, Majali, Stomberg, & Bergbom, 2011). That study included only 65 nurses and was conducted in a single setting, which may limit the generalization of its conclusions and implications. Overall, the available evidence indicates that health care providers hold negative attitudes and misconceptions and lack the adequate knowledge and training regarding pain management. Searching the related literature revealed that there is paucity of literature about nurses’ knowledge regarding pain management within the Arab world, including Jordan. Therefore, the present study aimed to evaluate nurses’ knowledge and attitudes regarding pain treatment in Jordan.
METHODS Aim This study was conducted to explore Jordanian nurses’ knowledge and attitudes regarding pain management. Design and Sample A quantitative research method and a descriptive crosssectional survey design were used. Data were collected from 4 settings (hospitals) that represent the health care sector in Jordan. One of them is located in the northern part of the country (King Abdullah University Hospital) and the other three in the capital city, Amman (Prince Hamzah Hospital, King Hussein Cancer Center, and the Islamic Hospital; Table 1). The target population was nurses working in the oncology, medical, surgical, and intermediate and
Al Qadire and Al Khalaileh
TABLE 1. Study Settings Hospital
No. of Participants
King Abdullah University Hospital Prince Hamzah Hospital Islamic Hospital King Hussein Cancer Center
North Central Central Central
University Governmental Private Charity
504 300 276 170
General General General Cancer treatment
69 50 52 40
intensive care units. Because it was difficult to approach all nurses in all hospitals, the abovementioned hospitals were selected to represent all divisions of the health care sector in Jordan. Therefore, 400 questionnaires were sent to these hospitals. A total of 211 convenient nurses with undergraduate (bachelor’s) degrees completed the study questionnaire, a response rate of 52%. Procedure The researchers obtained ethical approval from the Al Al-Bayat University (the researchers’ workplace), and then approval was obtained from other Ethics Committees in the hospital settings. One hundred empty questionnaires were sent to each setting, targeting nurses working in oncology, medical, surgical, and intermediate care floors within the selected hospitals. An information sheet that explained the study aims, procedures, and participants’ role was sent with the questionnaire. Nurses who agreed to participate signed the consent form and completed the questionnaire, after which the completed questionnaires were gathered in the offices of the head nurses and subsequently collected by the research team. The research team visited the hospital 3 times to remind nurses to fill in the questioners and to answer their questions or concerns about the study. Ethical Considerations The research team believed that maintaining the confidentiality and anonymity of the participants was crucial to this study. In Jordan, the researcher is required to gain hospital Ethics Committee approval before commencing any study. Thus, ethical approval for the study was obtained from the Al Al-Bayait University and then from the Ethics Committees of each hospital. The researchers explained the study aims, procedures, and participants’ role in the study to all prospective participants before they started. In addition, participation in the study was voluntary, and the participants had the permission to withdraw at any stage of the research. Furthermore, the identities of the participants were not disclosed, and only aggregate data were reported.
Instruments Demographics Data Sheet (DDS). The DDS includes questions designed to elicit information about the participants’ (i.e., nurses’) demographic characteristics, such as gender, age, educational level, previous postregistration pain education, area and duration of clinical experience. Knowledge and Attitudes Survey Regarding Pain (KAS). The KAS is a 40-item questionnaire developed by Ferrell, McGuire, and Donovan (1993) to assess nurses’ knowledge and attitudes toward pain management. It consists of 22 true/false questions and 18 multiple-choice ones. Howell acknowledged that the KAS is the only available instrument to measure nurses’ knowledge and attitudes about pain management (Howell, 2000). The content validity of KAS was established by a panel of pain experts. The KAS content was based on the pain management guidelines of the American Pain Society, WHO, and the Agency for Health Care Policy and Research. The KAS Cronbach alpha is 0.70 and test-retest reliability >0.80 (Howell, 2000; Vallerand, Riley-Doucet, Hasenau, & Templin, 2004). However, the names of the drugs mentioned in the questionnaire were checked for their availability and use in hospitals, because this tool was first developed and used in the U.S. and Europe. It was found that all medications are available and used in Jordan under the same names, except for the drug Vicodin (5 mg hydrocodone þ 500 mg acetaminophen). This drug is known as Revacod, and acetaminophen is known as paracetamol. Therefore, these names were changed wherever they were mentioned in the original questionnaire. The questionnaire was administered in English, because Jordanian nurses are able to understand and answer questions in the original language of the KAS (all nursing education, curricula, and examination in Jordanian nursing institutions are conducted in English). Data Analysis All returned questionnaires were checked for missing data. Questionnaires that were left blank or half-filled were excluded. Data were entered and analyzed with
Knowledge of Pain in Jordan
the Statistical Package for the Social Sciences software (version 17; SPSS). Statistical tests used in this study included descriptive, inferential, and correlation. Descriptive statistics such as percentages and frequencies were used to describe the sample characteristics and nurses’ responses to the questionnaire items. Unpaired t test was used to examine the differences between different categories of participants.
RESULTS Sample Characteristics A total of 211 nurses completed and returned the study questionnaire. As shown in Table 2, 51.7% of the participants were male, and the average age was 27.2 (SD 4.7) years. In addition, most nurses had a bachelor’s degree (90.5%) and were working in medical and surgical wards. Furthermore, 52% of nurses reported no previous pain education in the past 5 years. Nurses’ Knowledge and Attitudes Regarding Pain Management The percentages of the correctly answered items in the questionnaire are presented in Table 3. The mean of the total correct answers was 19.3 (SD 4.7) out of 40 (total score if all items answered correctly), and the rate of correct answers ranged from 10% (item 38) to 72% (item 22). The results show that many items were incorrectly answered, mainly those related to: 1) the recommended morphine dose; 2) the recommended and preferred route of opioid administration; and 3) the ability to differentiate between addiction, tolerance, and physical dependency. However, it seems that nurses recognized that pain may be present despite normal vital signs (and indicators such as relaxed facial expressions) among patients with pain. Interestingly, most nurses agreed that the patient is the only reliable source for pain reporting (66.8%). Overall, it was found that nurses were deficient in their knowledge of required pharmacologic interventions to treat their patients’ pain and of pain reporting–related issues generally. Although the authors of the questionnaire recommended that researchers use the total questionnaire score rather than categorizing its items into knowledge and attitudes, some items indicate the questioned nurses’ beliefs and others their practice. The comparison of some questions revealed a discrepancy between the nurses’ beliefs and practices. For example, despite 66.8% of nurses agreeing that the patient is the most reliable source for pain report (item 31), 50% of nurses would still encourage patients to tolerate more pain
TABLE 2. Demographic and Professional Characteristics of Nurses Characteristic
Age (y) Nursing experience (y) Gender Male Female Education level Bachelor Master Working area Medical and surgical Oncology Intermediate and intensive care Gynecology Others Previous pain education Yes No
27.2 (4.7) 4.6 (4)
109 (51.7) 88 (41.7) 191(90.5) 10 (4.7) 116 (55) 36 (17) 14 (6.6) 3 (1.4) 24 (11.4) 87 (41.2) 110 (52.1)
*The total numbers differ from the total sample number (211) owing to missing data.
before administering any pain medications, and another 47% would like to use placebo rather than actual pain medication. Although one-half of the nurses believed that vital signs may not reflect the presence of pain, presuming that patient is the source of pain report, most (63.3%) failed to assign the right pain score in scenario A (item 37, where the patient shows normal vital signs and a relaxed face and is smiling). The nurses tended to assign a high score and administer a higher medication dose when treating the patient with a grimacing face, crying, shouting, or unstable vital signs. When the total score of the questionnaire was compared regarding nurses’ gender, educational level, and exposure to previous pain education, no significant differences were identified between those characteristics and the total knowledge and attitude score, except for the exposure to previous pain education, as shown in the results of the unpaired t test (Table 4). The p value was