Original Article Knowledge and Attitudes Regarding Pain Management of Pediatric Nurses in Turkey ---
-
Ayfer Ekim, MSc, RN, and Ayse Ferda Ocakcı, PhD
ABSTRACT:
Nurses play an important role in managing children’s pain. The nurse’s accurate assessment, appropriate intervention, and evaluation of pain relief measures are necessary for positive patient outcomes. The aim of this study was to determine the level of knowledge and attitudes of pediatric nurses regarding the child’s pain. The Pediatric Nurses’ Knowledge and Attitude Survey (PNKAS) was used to evaluate the nurses’ knowledge and attitudes. The PNKAS consists of 40 questions. In this study, 29.9% of nurses had a diploma and 40.6% associate’s, 25.0% bachelor’s, and 4.5% master’s degree, and respondents had an everage 6.1 years pediatric nursing experience. The total mean score on the PNKAS scale was 38.2%. The highest score was 65%, and the lowest score 15%. The findings of the survey show that pediatric nurses in Turkey have insufficient knowledge regarding pain management and could benefit from additional education on that issue. Ó 2013 by the American Society for Pain Management Nursing
From the Department of Pediatric Nursing, Faculty of Health Sciences, Marmara University, Istanbul, Turkey. Address correspondence to Ayfer Ekim, MSc, RN, Marmara University, Department of Pediatric Nursing, 34688 Istanbul, Turkey. E-mail: [email protected] Received October 8, 2010; Revised February 18, 2012; Accepted February 19, 2012. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2012.02.004
Pain is defined by the International Association for the Study of Pain (IASP) as ‘‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’’ (IASP Task Force on Taxonomy, 1994). What makes assessment of pain so complicated is that it is both a sensory and emotional personal experience (Cohen, Lemanek, Blount, Dahlquist, Lim, Palermo,... Weiss, 2008). Pain may be associated with a lifethreatening event as well as emotional and psychologic consequences affecting the child’s quality of life and scholastic performance (Crandall & Sevedra, 2005). Pain management is an extremely important area in the health care of children (Reiman, Gordon, & Marvin, 2007; Twycross & Dowden, 2009). The basic principles of pain management recommend that pain should be assessed regularly, using appropriate methods and tools, acknowledging that the person experiencing pain is the best person to report his/her pain, even if that person is a child (Smart, 2005). An important responsibility of health care professionals who care for children is eliminating pain and suffering when possible (Subhashini, Vatsa, & Lodha, 2009). Nurses play a crucial role in the assessment and management of a child’s pain, because they provide care all 24 hours of the day and are the health care professional spending the most direct time with the child (P€ olkki, Laukkala, Vehvilainen-Julkunen & Pietila, 2003; Zhang, Hsu, Zou, Li, Pain Management Nursing, Vol 14, No 4 (December), 2013: pp e262-e267
Pediatric Nurses’ Knowledge and Attitudes in Turkey
Wang, & Huang, 2008). Knowledge and attitudes affect the nursing decisions about patient care (Rieman & Gordon, 2007). Pain management is now considered an important patient outcome when evaluating the effectiveness of nursing care (Edwards, Nash, Yates, Walsh, Fentiman, McDowel,... Najman, 2001; Plaisance & Logan, 2006). Nurses need to understand pain and be able to assess and manage pain to improve the experiences (Smart, 2005). The American Academy of Pediatrics (AAP) and the American Pain Society (APS) attribute the lack of effective pain management to myths, insufficient knowledge, and inadequate application of knowledge of health care professionals. Experts on pain suggest that inadequate pain relief may also stem from nurses’ acknowledgment that studies on the subject was part of their nursing program (Plaisance & Logan, 2006). The quality of pain treatment depends on the knowledge, attitudes, and skills of those who provide the treatment (Dihle, Bjølseth & Helseth, 2006; Rond, de Wit, van Dam, van Campen, den Hartog, & Klievink, 2000). A lack of knowledge about pain assessment may mean that nurses are unable to assess pain accurately and therefore unable to apply their knowledge in practice (Twycross & Dowden, 2009). The aim of the present study was to determine the level of knowledge and attitudes regarding pain management of nurses working at pediatric units in Turkey.
METHODS In this study, two measures were used: 1) the Participant Demographic form which consisted of 14 questions about the nurses’ age, sex, years of experience, educational background, membership in a professional organization, and publications followed related to their profession; and 2) the Pediatric Nurses’ Knowledge and Attitudes Survey Regarding Pain (PNKAS) Manworren (2001) developed this tool from an adaptation of the Nurses’ Knowledge and Attitudes Survey Regarding Pain (NKAS), first developed by McCaffery and Ferrell (1997). Content of the PNKAS reflects the standards for pediatric pain management. The questionnaire, including multiple-choice and true/false questions, aims to measure the knowledge and attitudes of pediatric nurses on pain assessment, pain management, and pharmacologic and nonpharmacologic interventions. Permission was obtained from Manworren. The questionnaire was translated into Turkish by two English linguists and checked for suitability of content against the English text. Necessary permissions were obtained from the institutions to collect data. The surveys were completed during face-to-face interviews with the nurses.
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Interviews were performed by the researchers. Completion of surveys was voluntary and responses were anonymous. Beforehand, the nurses were informed about the objectives and content of the study. Each of the interviews lasted 15-20 minutes. Data Analysis The data were analyzed with SPSS 16 for Windows software. Cronbach alpha test was used to assess the reliability of the questionnaire. The scale’s alpha value reported by Manworren was 0.72. The alpha value in the present study was 0.64. When the 39th and 40th questions, which had a low response rate (85% of participants did not answer questions 39 and 40), were removed, the new alpha value was 0.72. PNKAS consists of 40 questions. PNKAS scores were expressed as a percentage of correct answers. Data were analyzed by using descriptive statistics, t test, Kruskal-Wallis analysis, and Pearson correlation test. p values of 50%. The number of questions answered correctly ranged from 6 to 26. The ten questions that were most answered correctly are presented in Table 2,
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TABLE 1. Demographic Characteristics of Sample (n ¼ 224) n Age (y) 20-25 29 26-32 106 33-39 65 40-46 24 Sex Female 201 Male 23 Education level Diploma 67 Associate 91 Bachelor 56 Master 10 Years of nursing experience 1-5 65 6-10 47 11-15 61 16-20 25 $20 26 Years of pediatric nursing experience 1-5 135 6-10 46 11-15 25 16-20 13 $20 5 Membership in a nursing organization Yes 37 No 187
% 12.9 47.4 29.0 10.7 89.7 10.3 29.9 40.6 25.0 4.5 29.9 21.0 27.2 11.2 11.6 60.3 20.5 11.2 5.8 2.2 16.5 83.5
and the ten questions that were least answered incorrectly are presented in Table 3. The mean score of 40.8% for the Bachelors of Science in Nursing group was highest; however, it was not significantly different from the Masters of Science in Nursing group (39.0%). Bachelors of Science in Nursing and Masters of Science in Nursing groups’ PNKAS results scored statistically significantly higher than associate’s degree (36.4%) and diploma (38.2%) groups (F ¼ 2.99; p ¼ .03). Associate’s degree and diploma groups’ mean scores were not found to be statistically different. More experience had the lowest scores (34.1%). Those with experience of 1-5 years scored significantly higher than the nurses who had $10 years of experience (F ¼ 3.42; p ¼ .01). Even though PNKAS scores decreased significantly as the years of nursing experience, increased pediatric nursing experience was not significantly correlated with PNKAS scores (r ¼ 0.022; p > .05). When the PNKAS scores were compared on the basis of age groups, the group aged 20-25 years scored significantly higher than the three other groups (F ¼ 4.47; p ¼ .03). The PNKAS scores of the nurses in the age 33-39 and 40-46 years groups were not statistically
TABLE 2. Questions Most Frequently Answered Correctly (n ¼ 224) Question
n
% Correct
Children who require repeated painful procedures (e.g., daily blood draws), receive maximum treatment for the pain and anxiety of the first procedure to minimize the development of anticipatory anxiety before subsequent procedures (True) After the initial recommended dose of opioid analgesic, subsequent doses should be adjusted in accordance with the individual patient’s response (True) Analgesia for chronic cancer pain should be given (around the clock on a fixed schedule) The recommended route of administration of opioid analgesics to children with brief, severe pain of sudden onset, e.g., trauma or postoperative pain, is (IV) Ibuprofen and other nonsteroidal antiinflammatory agents are not effective analgesics for bone pain caused by metastases (False) The child/adolescent with pain should be encouraged to endure as much pain as possible before resorting to a pain relief measure (False) Because of an underdeveloped neurologic system, children under 2 years of age have decreased pain sensitivity and limited memory of painful experiences (False) Parents should not be present during painful procedures (False) If the infant/child/adolescent can be distracted from his pain this usually means that he is not experiencing a high level of pain (False) Respiratory depression rarely occurs in children/adolescents who have been receiving opioids over a period of months (True)
193
86.2
186
83.0
147
65.6
139
62.1
130
58.0
126
56.2
120
53.5
119
53.1
119
53.1
116
52.0
different (p > .05). Figure 1 shows the pediatric nurses’ knowledge and attitude survey scores according to age groups. Intensive care nurses’ PNKAS mean scores (43.1%) were higher than those of medical pediatric unit nurses and pediatric surgery unit nurses, and the result was statistically significant (F ¼ 13.6; p ¼ .00).
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Pediatric Nurses’ Knowledge and Attitudes in Turkey
TABLE 3. Questions Most Frequently Answered Incorrectly (n ¼ 224) Question What do you think is the percentage of patients who overreport the amount of pain they have? (0 or 10%) Which of the following IV doses of morphine administered would be equivalent to 15 mg oral morphine? (morphine 5 mg IV) A child with chronic cancer pain has been receiving daily opioid analgesics for 2 months. The doses increased during this time period. Yesterday the child was receiving morphine 20 mg/h intravenously. Today he has been receiving 25 mg/h intravenously for 3 hours. The likelihood of the child developing clinically significant respiratory depression is (less than 1%) The recommended route of administration of opioid analgesics to children with prolonged cancer-related pain is (oral) Adolescents with a history of substance abuse should not be given opioids for pain because they are at high risk for repeated addiction (False) Research shows that promethazine (Phenergan) is a reliable potentiator of opioid analgesics (False) Young infants, less than 6 months of age, cannot tolerate opioids for pain relief (False) The usual duration of analgesia of morphine IV is 4-5 hours (False) The most accurate judge of the intensity of the child’s/ adolescent’s pain is (the child/ adolescent) To be effective, heat and cold should be applied directly to the painful area (False)
n 207
% Incorrect 92.4
100 80 60
43.9
39.3
36.1
33.6
40 20
191
85.3
188
83.9
0
20-26
27-33
34-39
40-46
FIGURE 1. - Differences in Pediatric Nurses’ Knowledge and Attitude Survey scores (% correct) according to age groups (years).
DISCUSSION
182
81.2
176
78.6
172
76.8
170
75.8
167
74.6
167
74.6
162
72.3
Effective pain management for children requires adequate knowledge, appropriate attitudes, and assessment skills (Yildirim, Cicek, & Uyar, 2008). Nurses are responsible for assessing pain, treating pain with pharmacologic and nonpharmacologic interventions, and reassessing the patient to evaluate the effectiveness of these interventions (Manworren, 2007). In the present study, pediatric nurses in Turkey completed the PNKAS, and the individual PNKAS scores ranged from 15% to 65%, with a mean score of 38.2%. Rieman and Gordon (2007) found PNKAS scores to range from 37% to 100%, with a mean score of 74%. In Manworren’s (2001) survey, individual scores ranged from 37% to 98%, with a mean score of 66%. In Tiernan’s (2008) survey of Irish nurses, the mean score was 62%. Compared with these
100 80 60
43.3
38.6
37.1
40 20
Medical pediatric unit nurses (38.1%) and pediatric surgery unit nurses (37.1%) scores did not significantly differ (p > .05) (Figure 2). In Pearson correlation analysis, no significant correlations were found between the average PNKAS scores and sex, pediatric nursing experience, having had pain education, and membership in a nurse organization.
0 Intensive care units
Medical units
Surgery units
FIGURE 2. - Differences in Pediatric Nurses’ Knowledge and Attitude Survey scores (% correct) according to pediatric units.
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Ekim and Ocakcı
surveys, it is obvious that the scores from our survey are quite low. The top ten correct results documented by Manworren (2000) states that only five of the top ten questions, which means the questions answered correctly, only one answered correctly by more than half of the participants. According to results taken from the survey, education level of the nurses positively affects their knowledge and attitude about pain management. These results have some similarities with the results taken from other research (Ellis et al., 2007; Reiman & Gordon, 2007; Manworren, 2000). Studies have found that as experience increases, knowledge and attitudes about pain management improve as well (Lui, So, & Fong, 2008; Reiman & Gordon, 2007). Manworren (2000) did not report a significantly correlation between experience and PNKAS scores. In our survey, it was noted that as the nursing experience increased the PNKAS scores decreased significantly. In Turkey, bachelor-degree nursing education programs have become widespread since 1996. Such a result therefore can be explained that in Turkey the nursing education is raised to bachelor’s degree, and the less experienced nurses have bachelor’s and master’s degrees. Most of the nurses answered the questions about pharmacology and addiction incorrectly. For example, the question ‘‘Which of the following IV doses of morphine administered would be equivalent to 15 mg of oral morphine?’’ was answered incorrectly by 85.3% of nurses; the question ‘‘The usual duration of analgesia of morphine IV is 4-5 hours’’ was answered incorrectly by 74.6% of the nurses; and ‘‘Adolescents with a history of substance abuse should not be given opioids for pain, because they are at high risk for repeated addiction’’ was answered incorrectly by 78.6%. The majority of surveys show that nurses have insufficient knowledge about pharmacologic interventions in pain management. For example, Vincent (2005) found that in the assessment of children’s pain, nurses have
knowledge deficits about analgesic drugs. Ellis et al. (2007) stated that nurses have limited knowledge about analgesic drugs. And Tiernan (2008) stated that Irish nurses have pharmacologic knowledge deficits.
CONCLUSION This study finds that the pediatric nurses in Turkey need more education about pain management. To accomplish this, pain assessment and management must be integrated into the nursing curriculum. Academic nursing programs should focus not only on theoretic knowledge, but pain management should also be given more importance in clinical practice training. Teaching methods that aim to improve the knowledge should be applied. For example, the clinical discussion of individual patients and their care and problem-based learning educational strategies should be considered. Education programs for pediatric pain management should include the assessment of pain according to the child’s developmental level, using appropriate assessment tools and pharmacologic and nonpharmacologic interventions in pain treatment, and approaching the child and the family when the child is in pain. Education programs should continue after graduation of the nurses and they should be informed about the latest developments on pain management. Because it can be more difficult to change attitudes than to change knowledge, education programs should consistently be updated and improved (Edwards et al., 2001). In the present study, pain management knowledge deficiencies were identified, although in a limited sample group. These results will guide the preparation of nursing curriculum and training programs for pediatric nursing staff. Also, based on these results, pain management guidelines can be developed for the nurses in pediatric practice areas. And nurses should be informed about the importance of using these guidelines.
REFERENCES Cohen, L. L., Lemanek, K., Blount, R. L., Dahlquist, L. M., Lim, C. S., Palermo, T. M., McKenna, K. D., & Weiss, K. E. (2008). Evidence based assessment of pediatric pain. Journal of Pediatric Psychology, 33(9), 939–955. Crandall, M., & Savedra, M. (2005). Multidimensional assessment using the adolescent pediatric pain tool: A case report. Journal for Specialists in Pediatric Nursing, 10(3), 115–123. Edwards, H. E., Nash, R. E., Yates, P. M., Walsh, A. M., Fentiman, B. J., McDowel, J. K., Skerman, H. M., & Najman, J. M. (2001). Improving pain management by nurses: A pilot peer intervention program. Nursing and Health Sciences, 3(1), 35–45.
Ellis, J. A., McCleary, L., Blouin, B., Dube, K., Rowley, B., MacNeil, M., & Cooke, C. (2007). Implementing best practice pain management in a pediatric hospital. Journal for Specialists in Pediatric Nursing, 12(4), 264–277. IASP Task Force on Taxonomy (1994). Part III: Pain terms, a current list with definitions and notes on usage. In H. Merskey, & N. Bogduk (Eds.), Classification of chronic pain, (2nd ed.) (pp. 209–214) Seattle, WA: IASP Press. Lui, L. Y. Y., So, W. K. W., & Fong, D. Y. T. (2008). Knowledge and attitudes regarding pain management among nurses in Hong Kong medical units. Journal of Clinical Nursing, 17(15), 2014–2021.
Pediatric Nurses’ Knowledge and Attitudes in Turkey
McCaffery, M., & Ferrell, B. R. (1997). Nurses’ knowledge of pain assessment and management: How much progress have we made? Journal of Pain and Symptom Management, 14(3), 175–188. Manworren, R. C. (2000). Pediatric nurses’ knowledge and attitudes survey regarding pain. Pediatric Nursing, 26(6), 610–614. Manworren, R. C. (2001). Development and testing of the pediatric nurses’ knowledge and attitudes survey regarding pain. Pediatric Nursing, 27(2), 151–158. Manworren, R. C. (2007). It’s time to relieve children’s pain. Journal for Specialists in Pediatric Nursing, 12(3), 196–198. Plaisance, L., & Logan, C. (2006). Nursing students’ knowledge and attitudes regarding pain. Pain Management Nursing, 7(4), 167–175. P€ olkki, T., Laukkala, L., Vehvilainen-Julkunen, K., & Pietila, A. M. (2003). Factors influencing nurses’ use of nonpharmacological pain alleviation methods in pediatric patients. Scandinavian Journal of Caring Sciences, 17(4), 373–383. Rieman, M. T., & Gordon, M. (2007). Pain management competency evidenced by a survey of pediatric nurses’ knowledge and attitudes. Pediatric Nursing, 33(4), 307–312. Rieman, M. T., Gordon, M., & Marvin, J. M. (2007). Pediatric nurses’ knowledge and attitudes survey regarding pain: A competency tool modification. Pediatric Nursing, 33(4), 303–314. Rond, M. E., de Wit, R., van Dam, F. S., van Campen, B. T., den Hartog, Y. M., & Klievink, R. M. (2000). A pain
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monitoring program for nurses: Effects on nurses’ pain knowledge and attitude. Journal of Pain and Symptom Management, 19(6), 457–467. Smart, S. (2005). Post-operative pain management knowledge and attitudes of pediatric nurses: A New Zealand regional view. Unpublished master’s thesis, Victoria University of Wellington, New Zealand. Subhashini, L., Vatsa, M., & Lodha, R. (2009). Knowledge, attitude and practices among health care professionals regarding pain. Indian Journal of Pediatrics, 76(9), 913–916. Tiernan, E. P. (2008). A survey of registered nurses’ knowledge and attitudes regarding pediatric pain assessment and management: An Irish perspective. Archives of Disease in Childhood, 93(Suppl. 2), 18. Twycross, A., & Dowden, S. J. (2009). Status of pediatric nurses’ knowledge about pain. Pediatric Pain Letter, 11(3), 17–21. Vincent, C. V. H. (2005). Nurses’ perceptions of children’s pain: A pilot study of cognitive representations. Journal of Pain and Symptom Management, 33(3), 290–301. Yildirim, K. Y., Cicek, F., & Uyar, M. (2008). Knowledge and attitudes of Turkish oncology nurses about cancer pain management. Pain Management Nursing, 9(1), 17–25. Zhang, C. H., Hsu, L., Zou, B. R., Li, J. F., Wang, Y. H., & Huang, J. (2008). Effects of a pain education program on nurses’ pain knowledge, attitudes and pain assessment practices in China. Journal of Pain and Symptom Management, 36(6), 616–627.
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Ayfer Ekim, MSc, RN, and Ayse Ferda Ocakcı, PhD
ABSTRACT:
Nurses play an important role in managing children’s pain. The nurse’s accurate assessment, appropriate intervention, and evaluation of pain relief measures are necessary for positive patient outcomes. The aim of this study was to determine the level of knowledge and attitudes of pediatric nurses regarding the child’s pain. The Pediatric Nurses’ Knowledge and Attitude Survey (PNKAS) was used to evaluate the nurses’ knowledge and attitudes. The PNKAS consists of 40 questions. In this study, 29.9% of nurses had a diploma and 40.6% associate’s, 25.0% bachelor’s, and 4.5% master’s degree, and respondents had an everage 6.1 years pediatric nursing experience. The total mean score on the PNKAS scale was 38.2%. The highest score was 65%, and the lowest score 15%. The findings of the survey show that pediatric nurses in Turkey have insufficient knowledge regarding pain management and could benefit from additional education on that issue. Ó 2013 by the American Society for Pain Management Nursing
From the Department of Pediatric Nursing, Faculty of Health Sciences, Marmara University, Istanbul, Turkey. Address correspondence to Ayfer Ekim, MSc, RN, Marmara University, Department of Pediatric Nursing, 34688 Istanbul, Turkey. E-mail: [email protected] Received October 8, 2010; Revised February 18, 2012; Accepted February 19, 2012. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2012.02.004
Pain is defined by the International Association for the Study of Pain (IASP) as ‘‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’’ (IASP Task Force on Taxonomy, 1994). What makes assessment of pain so complicated is that it is both a sensory and emotional personal experience (Cohen, Lemanek, Blount, Dahlquist, Lim, Palermo,... Weiss, 2008). Pain may be associated with a lifethreatening event as well as emotional and psychologic consequences affecting the child’s quality of life and scholastic performance (Crandall & Sevedra, 2005). Pain management is an extremely important area in the health care of children (Reiman, Gordon, & Marvin, 2007; Twycross & Dowden, 2009). The basic principles of pain management recommend that pain should be assessed regularly, using appropriate methods and tools, acknowledging that the person experiencing pain is the best person to report his/her pain, even if that person is a child (Smart, 2005). An important responsibility of health care professionals who care for children is eliminating pain and suffering when possible (Subhashini, Vatsa, & Lodha, 2009). Nurses play a crucial role in the assessment and management of a child’s pain, because they provide care all 24 hours of the day and are the health care professional spending the most direct time with the child (P€ olkki, Laukkala, Vehvilainen-Julkunen & Pietila, 2003; Zhang, Hsu, Zou, Li, Pain Management Nursing, Vol 14, No 4 (December), 2013: pp e262-e267
Pediatric Nurses’ Knowledge and Attitudes in Turkey
Wang, & Huang, 2008). Knowledge and attitudes affect the nursing decisions about patient care (Rieman & Gordon, 2007). Pain management is now considered an important patient outcome when evaluating the effectiveness of nursing care (Edwards, Nash, Yates, Walsh, Fentiman, McDowel,... Najman, 2001; Plaisance & Logan, 2006). Nurses need to understand pain and be able to assess and manage pain to improve the experiences (Smart, 2005). The American Academy of Pediatrics (AAP) and the American Pain Society (APS) attribute the lack of effective pain management to myths, insufficient knowledge, and inadequate application of knowledge of health care professionals. Experts on pain suggest that inadequate pain relief may also stem from nurses’ acknowledgment that studies on the subject was part of their nursing program (Plaisance & Logan, 2006). The quality of pain treatment depends on the knowledge, attitudes, and skills of those who provide the treatment (Dihle, Bjølseth & Helseth, 2006; Rond, de Wit, van Dam, van Campen, den Hartog, & Klievink, 2000). A lack of knowledge about pain assessment may mean that nurses are unable to assess pain accurately and therefore unable to apply their knowledge in practice (Twycross & Dowden, 2009). The aim of the present study was to determine the level of knowledge and attitudes regarding pain management of nurses working at pediatric units in Turkey.
METHODS In this study, two measures were used: 1) the Participant Demographic form which consisted of 14 questions about the nurses’ age, sex, years of experience, educational background, membership in a professional organization, and publications followed related to their profession; and 2) the Pediatric Nurses’ Knowledge and Attitudes Survey Regarding Pain (PNKAS) Manworren (2001) developed this tool from an adaptation of the Nurses’ Knowledge and Attitudes Survey Regarding Pain (NKAS), first developed by McCaffery and Ferrell (1997). Content of the PNKAS reflects the standards for pediatric pain management. The questionnaire, including multiple-choice and true/false questions, aims to measure the knowledge and attitudes of pediatric nurses on pain assessment, pain management, and pharmacologic and nonpharmacologic interventions. Permission was obtained from Manworren. The questionnaire was translated into Turkish by two English linguists and checked for suitability of content against the English text. Necessary permissions were obtained from the institutions to collect data. The surveys were completed during face-to-face interviews with the nurses.
e263
Interviews were performed by the researchers. Completion of surveys was voluntary and responses were anonymous. Beforehand, the nurses were informed about the objectives and content of the study. Each of the interviews lasted 15-20 minutes. Data Analysis The data were analyzed with SPSS 16 for Windows software. Cronbach alpha test was used to assess the reliability of the questionnaire. The scale’s alpha value reported by Manworren was 0.72. The alpha value in the present study was 0.64. When the 39th and 40th questions, which had a low response rate (85% of participants did not answer questions 39 and 40), were removed, the new alpha value was 0.72. PNKAS consists of 40 questions. PNKAS scores were expressed as a percentage of correct answers. Data were analyzed by using descriptive statistics, t test, Kruskal-Wallis analysis, and Pearson correlation test. p values of 50%. The number of questions answered correctly ranged from 6 to 26. The ten questions that were most answered correctly are presented in Table 2,
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Ekim and Ocakcı
TABLE 1. Demographic Characteristics of Sample (n ¼ 224) n Age (y) 20-25 29 26-32 106 33-39 65 40-46 24 Sex Female 201 Male 23 Education level Diploma 67 Associate 91 Bachelor 56 Master 10 Years of nursing experience 1-5 65 6-10 47 11-15 61 16-20 25 $20 26 Years of pediatric nursing experience 1-5 135 6-10 46 11-15 25 16-20 13 $20 5 Membership in a nursing organization Yes 37 No 187
% 12.9 47.4 29.0 10.7 89.7 10.3 29.9 40.6 25.0 4.5 29.9 21.0 27.2 11.2 11.6 60.3 20.5 11.2 5.8 2.2 16.5 83.5
and the ten questions that were least answered incorrectly are presented in Table 3. The mean score of 40.8% for the Bachelors of Science in Nursing group was highest; however, it was not significantly different from the Masters of Science in Nursing group (39.0%). Bachelors of Science in Nursing and Masters of Science in Nursing groups’ PNKAS results scored statistically significantly higher than associate’s degree (36.4%) and diploma (38.2%) groups (F ¼ 2.99; p ¼ .03). Associate’s degree and diploma groups’ mean scores were not found to be statistically different. More experience had the lowest scores (34.1%). Those with experience of 1-5 years scored significantly higher than the nurses who had $10 years of experience (F ¼ 3.42; p ¼ .01). Even though PNKAS scores decreased significantly as the years of nursing experience, increased pediatric nursing experience was not significantly correlated with PNKAS scores (r ¼ 0.022; p > .05). When the PNKAS scores were compared on the basis of age groups, the group aged 20-25 years scored significantly higher than the three other groups (F ¼ 4.47; p ¼ .03). The PNKAS scores of the nurses in the age 33-39 and 40-46 years groups were not statistically
TABLE 2. Questions Most Frequently Answered Correctly (n ¼ 224) Question
n
% Correct
Children who require repeated painful procedures (e.g., daily blood draws), receive maximum treatment for the pain and anxiety of the first procedure to minimize the development of anticipatory anxiety before subsequent procedures (True) After the initial recommended dose of opioid analgesic, subsequent doses should be adjusted in accordance with the individual patient’s response (True) Analgesia for chronic cancer pain should be given (around the clock on a fixed schedule) The recommended route of administration of opioid analgesics to children with brief, severe pain of sudden onset, e.g., trauma or postoperative pain, is (IV) Ibuprofen and other nonsteroidal antiinflammatory agents are not effective analgesics for bone pain caused by metastases (False) The child/adolescent with pain should be encouraged to endure as much pain as possible before resorting to a pain relief measure (False) Because of an underdeveloped neurologic system, children under 2 years of age have decreased pain sensitivity and limited memory of painful experiences (False) Parents should not be present during painful procedures (False) If the infant/child/adolescent can be distracted from his pain this usually means that he is not experiencing a high level of pain (False) Respiratory depression rarely occurs in children/adolescents who have been receiving opioids over a period of months (True)
193
86.2
186
83.0
147
65.6
139
62.1
130
58.0
126
56.2
120
53.5
119
53.1
119
53.1
116
52.0
different (p > .05). Figure 1 shows the pediatric nurses’ knowledge and attitude survey scores according to age groups. Intensive care nurses’ PNKAS mean scores (43.1%) were higher than those of medical pediatric unit nurses and pediatric surgery unit nurses, and the result was statistically significant (F ¼ 13.6; p ¼ .00).
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Pediatric Nurses’ Knowledge and Attitudes in Turkey
TABLE 3. Questions Most Frequently Answered Incorrectly (n ¼ 224) Question What do you think is the percentage of patients who overreport the amount of pain they have? (0 or 10%) Which of the following IV doses of morphine administered would be equivalent to 15 mg oral morphine? (morphine 5 mg IV) A child with chronic cancer pain has been receiving daily opioid analgesics for 2 months. The doses increased during this time period. Yesterday the child was receiving morphine 20 mg/h intravenously. Today he has been receiving 25 mg/h intravenously for 3 hours. The likelihood of the child developing clinically significant respiratory depression is (less than 1%) The recommended route of administration of opioid analgesics to children with prolonged cancer-related pain is (oral) Adolescents with a history of substance abuse should not be given opioids for pain because they are at high risk for repeated addiction (False) Research shows that promethazine (Phenergan) is a reliable potentiator of opioid analgesics (False) Young infants, less than 6 months of age, cannot tolerate opioids for pain relief (False) The usual duration of analgesia of morphine IV is 4-5 hours (False) The most accurate judge of the intensity of the child’s/ adolescent’s pain is (the child/ adolescent) To be effective, heat and cold should be applied directly to the painful area (False)
n 207
% Incorrect 92.4
100 80 60
43.9
39.3
36.1
33.6
40 20
191
85.3
188
83.9
0
20-26
27-33
34-39
40-46
FIGURE 1. - Differences in Pediatric Nurses’ Knowledge and Attitude Survey scores (% correct) according to age groups (years).
DISCUSSION
182
81.2
176
78.6
172
76.8
170
75.8
167
74.6
167
74.6
162
72.3
Effective pain management for children requires adequate knowledge, appropriate attitudes, and assessment skills (Yildirim, Cicek, & Uyar, 2008). Nurses are responsible for assessing pain, treating pain with pharmacologic and nonpharmacologic interventions, and reassessing the patient to evaluate the effectiveness of these interventions (Manworren, 2007). In the present study, pediatric nurses in Turkey completed the PNKAS, and the individual PNKAS scores ranged from 15% to 65%, with a mean score of 38.2%. Rieman and Gordon (2007) found PNKAS scores to range from 37% to 100%, with a mean score of 74%. In Manworren’s (2001) survey, individual scores ranged from 37% to 98%, with a mean score of 66%. In Tiernan’s (2008) survey of Irish nurses, the mean score was 62%. Compared with these
100 80 60
43.3
38.6
37.1
40 20
Medical pediatric unit nurses (38.1%) and pediatric surgery unit nurses (37.1%) scores did not significantly differ (p > .05) (Figure 2). In Pearson correlation analysis, no significant correlations were found between the average PNKAS scores and sex, pediatric nursing experience, having had pain education, and membership in a nurse organization.
0 Intensive care units
Medical units
Surgery units
FIGURE 2. - Differences in Pediatric Nurses’ Knowledge and Attitude Survey scores (% correct) according to pediatric units.
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surveys, it is obvious that the scores from our survey are quite low. The top ten correct results documented by Manworren (2000) states that only five of the top ten questions, which means the questions answered correctly, only one answered correctly by more than half of the participants. According to results taken from the survey, education level of the nurses positively affects their knowledge and attitude about pain management. These results have some similarities with the results taken from other research (Ellis et al., 2007; Reiman & Gordon, 2007; Manworren, 2000). Studies have found that as experience increases, knowledge and attitudes about pain management improve as well (Lui, So, & Fong, 2008; Reiman & Gordon, 2007). Manworren (2000) did not report a significantly correlation between experience and PNKAS scores. In our survey, it was noted that as the nursing experience increased the PNKAS scores decreased significantly. In Turkey, bachelor-degree nursing education programs have become widespread since 1996. Such a result therefore can be explained that in Turkey the nursing education is raised to bachelor’s degree, and the less experienced nurses have bachelor’s and master’s degrees. Most of the nurses answered the questions about pharmacology and addiction incorrectly. For example, the question ‘‘Which of the following IV doses of morphine administered would be equivalent to 15 mg of oral morphine?’’ was answered incorrectly by 85.3% of nurses; the question ‘‘The usual duration of analgesia of morphine IV is 4-5 hours’’ was answered incorrectly by 74.6% of the nurses; and ‘‘Adolescents with a history of substance abuse should not be given opioids for pain, because they are at high risk for repeated addiction’’ was answered incorrectly by 78.6%. The majority of surveys show that nurses have insufficient knowledge about pharmacologic interventions in pain management. For example, Vincent (2005) found that in the assessment of children’s pain, nurses have
knowledge deficits about analgesic drugs. Ellis et al. (2007) stated that nurses have limited knowledge about analgesic drugs. And Tiernan (2008) stated that Irish nurses have pharmacologic knowledge deficits.
CONCLUSION This study finds that the pediatric nurses in Turkey need more education about pain management. To accomplish this, pain assessment and management must be integrated into the nursing curriculum. Academic nursing programs should focus not only on theoretic knowledge, but pain management should also be given more importance in clinical practice training. Teaching methods that aim to improve the knowledge should be applied. For example, the clinical discussion of individual patients and their care and problem-based learning educational strategies should be considered. Education programs for pediatric pain management should include the assessment of pain according to the child’s developmental level, using appropriate assessment tools and pharmacologic and nonpharmacologic interventions in pain treatment, and approaching the child and the family when the child is in pain. Education programs should continue after graduation of the nurses and they should be informed about the latest developments on pain management. Because it can be more difficult to change attitudes than to change knowledge, education programs should consistently be updated and improved (Edwards et al., 2001). In the present study, pain management knowledge deficiencies were identified, although in a limited sample group. These results will guide the preparation of nursing curriculum and training programs for pediatric nursing staff. Also, based on these results, pain management guidelines can be developed for the nurses in pediatric practice areas. And nurses should be informed about the importance of using these guidelines.
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