Original Article Knowledge and Attitudes Regarding Pediatric Pain in Mongolian Nurses ---
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From the Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, Texas. Address correspondence to Dr. Lisa Lunsford, DNP, RN, CPNP, Department of Pediatrics, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229. E-mail: LunsfordL3@ uthscsa.edu Received August 4, 2014; Revised August 19, 2014; Accepted August 19, 2014. 1524-9042/$36.00 Ó 2015 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2014.08.007
Lisa Lunsford, DNP, RN, CPNP
ABSTRACT:
The World Health Organization and the International Association for Study of Pain cite the significance of pediatric pain as a significant global health issue. Developing countries may have increased needs compared with developed countries because of limited resources and lack of training. In Mongolia a paucity of data exist regarding nursing knowledge of pediatric pain management. The purpose of this project was to assess the current knowledge of pediatric pain and to assess the effectiveness of educational intervention on improving knowledge and attitudes of pediatric nurses working at a major children’s hospital in Mongolia. Knowledge and attitudes of Mongolian nurses were evaluated before and after a 2-hour educational intervention. The translated Modified Mongolian Pediatric Nurses’ Knowledge and Attitudes Survey Regarding Pain—Shriner’s Revision survey was used as a pre- and postintervention assessment instrument with local nurses at a pediatric hospital in Ulaanbaatar, Mongolia. One hundred sixtyseven nurses attended the conference, with 155 nurses completing the pre- and postsurveys. The mean score on the presurvey was 12.7 out of 35 (26.4% correct), whereas the mean score on the postsurvey score was 16.7 out of 35 (47.8% correct). A paired t test showed a significant statistical difference between scores (p < .0001). Pediatric nurses in Mongolia demonstrate insufficient knowledge of pediatric pain management. The educational intervention was effective in improving pediatric pain knowledge and attitudes in Mongolian nurses. It is recommended to establish similar educational endeavors with nurses around the world to improve pain knowledge and attitudes. Ó 2015 by the American Society for Pain Management Nursing Pediatric pain has long been recognized as a significant global health issue by the World Health Organization (WHO) and the International Association for the Study of Pain (IASP) (Kumar, 2007). Since Dr. Eland and Anderson’s hallmark study 1977, which revealed significant mismanagement of children in the United States of America experiencing pain after surgeries (Eland & Anderson, 1977), much attention has turned to this previously neglected area of study (Hamers, Huijer Abu-Saad, van den Hout, & Halfens, 1998). Understandably, pediatric pain is a complex phenomenon requiring knowledge, understanding, and Pain Management Nursing, Vol 16, No 3 (June), 2015: pp 346-353
Pediatric Pain Knowledge and Attitudes in Mongolian Nurses
appreciation of its nature. In the past decade, nursing has concentrated its efforts to increase awareness and education on pediatric pain. Because of these efforts, nurses are understanding and assessing pediatric pain more appropriately (Griffen, Polit, & Byrne, 2008). In developed countries, many validated pediatric pain tools such as the FACES pain scale by Wong and Baker have been created to assist the nurse in the assessment of pain (Hicks, von Baeyer, Spafford, van Korlarr, & Goodenough, 2001; Standford, Chambers, Craig, McGrath, & Cassidy, 2005). Various educational approaches such as one-on-one coaching and pain educational conferences have been used to increase nursing knowledge with measured success (Griffen et al., 2008; Johnston et al., 2007). Research in countries such as China and Hong Kong demonstrate that significant education gaps exist among their nurses. However, with the introduction of educational programs on pediatric pain, increased knowledge has been demonstrated (Chiang, Chen, & Huang, 2006; Tse & Chan, 2004; Zhang et al., 2008). Although the awareness and treatment of pediatric pain has improved in developed countries, there is a significant concern by WHO and the IASP for developing countries experiencing additional economic hardships (Finley, McGrath, & Chambers, 2006). A developing country is defined, per the World Bank, as one ‘‘in which most people have a lower standard of living with access to fewer goods and services than do most people in high-income countries’’ (Finley et al., 2006, p. 177). Mongolia is classified as a developing country (Sovd, Purev, Byambajav, Sereenen, & Gankhuyag, 2008). Mongolia is situated between the Russian Federation and the People’s Republic of China with an estimated population of 2.9 million people, with youth (children through adolescents) accounting for nearly 29% (Sovd et al., 2008). It ranks 152nd out of 226 countries in gross domestic product (GDP), which reflects the per-capita welfare state of a country (Central Intelligence Agency, 2014). From its transition in 1990 from communism, Mongolia has struggled as a country, with 29% of the population living below the poverty line (Central Intelligence Agency, 2014). Among developing countries such as Mongolia, a wide spectrum of varying economic, culture, and political stability exists (Size, Soyannwo, & Justins, 2007). It is difficult to assess current pediatric pain practices in developing countries because of the lack of research pertaining to pediatric pain management and assessment. Most understanding comes from reports from personal observations by visiting healthcare providers (Bosenberg, 2007). Suggested barriers to pediatric pain
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management include limited access to pediatric appropriate analgesia, lack of physician and nursing knowledge of pediatric pain assessment and management, lack of validated pediatric pain tools translated appropriately, and general lack of government resources (Bosenberg, 2006). This is concerning because pediatric nurses hold a paramount role in the appropriate assessment and management of children in pain and remain the largest group of healthcare providers responsible for the direct care of hospitalized children (Huth, Gregg, & Lin, 2010; Manworren, 2000). One study assessing working conditions in three main hospitals in Mongolia found that all hospitals had electrical power, oxygen sources, running water, and a laboratory, and most had access to radiology. Issues identified by staff include access to medical equipment, access to disposable care items, and education and advanced training for physicians and nurses (Dunser et al., 2009). Dunser, Baelani, and Ganbold (2006) report the lack of appropriate pediatric analgesia in several hospitals in cities, including Ulaanbaatar Mongolia, despite the WHO Essential Medicine List recommendations. Challenging working conditions, including high patient-to-nurse ratios, are also cited as a source of frustration for nurses and physicians and a barrier to quality patient care (Bagaajav, Myagmarjav, Nanjid, Otgon, & Chae, 2011). When healthcare systems are distracted with economic and political challenges, it becomes difficult to prioritize appropriate pediatric pain management. In the WHO normative guidelines on pain management from the Delphi study, appropriate pediatric pain relief is a significant issue for developing countries (Kumar, 2007). In the report, healthcare providers were concerned about the lack of pediatric pain knowledge and management. The report calls for research to focus on education for providers (Kumar, 2007). Size et al. (2007) also identified pain education as one of the most significant barriers for pain management in developing countries. This is consistent with surveys of healthcare providers working in Thailand, Nigeria, and sub-Saharan Africa, demonstrating that healthcare professionals are acutely aware of their knowledge deficits (Bond, 2011; Size et al., 2007). As the awareness of the importance of appropriate pediatric pain management has increased in developed countries, several developing countries assessed their pediatric nurses’ knowledge and management of pediatric pain (Huth et al., 2010; Matthew, Matthew, & Singhi, 2011). Several nursing knowledge and attitudes assessments conducted in India, Jordan, and Mexico emphasize the significant need for nursing education on pain knowledge and assessment (Abdalrahim, Majali, Stromberg, &
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Bergbom, 2011; Huth et al., 2010; Matthew et al., 2011; Subhashini, Vatsa, & Lodha, 2009). Unfortunately, education for healthcare providers on appropriate pediatric pain practices is often nonexistent in developing countries (Bond, 2011). Few pediatric pain assessment tools have been validated and translated for nurses to use with children in developing countries (Bosenberg, 2007). Specific to Mongolia, education on pain physiology, management, or assessment is not included in the Mongolian nursing curriculum. Before this study, no pediatric pain assessment tools were translated into Khalka Mongol. To date, there are no published records describing Mongolian nursing knowledge related to pediatric pain management. The WHO has stated that pain relief is a right of children worldwide and has established pediatric pain guidelines and essential pediatric appropriate medication lists to assist healthcare organizations (Olmstead, Scott, & Austin, 2010). Assessing and advocating for pediatric pain requires education. Pain education for healthcare providers working in developing countries has been cited as a strategy for increasing knowledge (Size et al., 2007). Physicians and nurses in developing countries including Mongolia have asked for education related to pain and pain management (Dunser et al., 2009). Therefore, this study begins to identify the educational needs of Mongolian pediatric nurses regarding pediatric pain management.
METHODS Aim This study was performed to assess current knowledge of and attitudes regarding pediatric pain of Mongolian pediatric nurses working at the National Center for Maternal and Child Health (MCH) in Ulaanbaatar, Mongolia, and to evaluate the change in knowledge after a pediatric pain conference conducted at MCH. Needs Assessment Before the study, a needs assessment was conducted with the director of nursing and the deputy director of MCH on what pain education nurses at MCH have had. Interviews with nursing instructors from the schools of nursing at Ulaanbaatar University and the University of Mongolia Health Science Center intimated that Mongolian nurses lack knowledge about pediatric pain assessment and lack awareness of pediatric pain assessment tools because of educational time constraints in nursing curricula.
Project Design The survey collection and educational program took place at the MCH Hospital, which employs 506 nurses. Two half-day conferences were held to maximize opportunities for the estimated 250 pediatric nurses to attend. The conferences were translated into Khalkha Mongol by a Mongolian physician proficient in English and Khalkha Mongol. The design of this project was presurvey–postsurvey design. The Modified Mongolian Pediatric Nurses’ Knowledge and Attitudes Survey Regarding Pain— Shriner’s Revision (MMPNKAS-S) was used. Nursing demographics and characteristics were collected with the presurvey, including gender, age, years of experience as a pediatric nurse, type of nursing education, and whether the nurse had a personal experience with pain. On completion of the MMPNKAS-S, a 2.5-hour presentation on pediatric pain knowledge, assessment, and management based on current IASP guidelines was offered (Table 1). The guidelines for the presentation included an introduction to pain knowledge, terms, tools, pain assessment, a review of pharmacology, and a review of nonpharmacologic methods to relieve pain. A pediatric palliative care nurse practitioner assisted in content development for pain pathways, pain assessment, and pharmacology. A child life specialist experienced with Mongolia culture assisted in the development of the cognitive-behavioral method content. The FACES pain assessment tool created by Wong and Baker was translated into Mongolian with Connie Baker’s permission and was introduced as pediatric pain tool. The conference used PowerPoint slides for graphics. Immediately after the conference, the MMPNKAS-S was readministered.
Procedure Institutional Review Board (IRB) approval was obtained from Vanderbilt University before the implementation of this study. At MCH, the deputy director and the director of nursing must grant researchers permission for any study conducted at their hospital. After reviewing the purpose of the project, the design, and the educational content with the directors, the researcher for this study expressed the importance of ensuring confidentiality and anonymity to nursing participants. The deputy director of MCH and the director of nursing at MCH granted permission with the request that subanalyses between demographic variables and survey results not be performed, concerned that nurses might not participate in the project should the score be potentially linked to the individual nurse. Participation in the surveys and conference was
Pediatric Pain Knowledge and Attitudes in Mongolian Nurses
TABLE 1. Topical Outline for Education on Pediatric Pain 1. Introduction to the significance of pediatric pain WHO position statement on pain IASP (2005) position statement on pain 2. Brief physiology of pain—10 minutes Types of pain children may experience When differing types of pain may occur Pain terminology 3. Pain assessment Location, intensity, quality, pattern Behavioral assessment Developmental considerations in pain assessment Introduction to FACES pain tool Introduction to self-report of pain 4. Pharmacology Brief review of analgesia available in Mongolia Route and dosing considerations and duration considerations Side effects 5. Cognitive-behavioral therapies Distractional play Massage Change of environment Music 6. Reassessment Remembering what helped Total instructional time: 1 hour 30 minutes IASP ¼ International Association for Study of Pain. Outline structured by End of Life Nursing Education Consortium (ELNEC). Pediatric palliative care. Washington, D.C. Revised January 2012.
voluntary. Nurses had the option to not complete the surveys and only attend the conference and an option to refuse the project entirely at the beginning of the conference. No personal identifiers were present on the survey. Instrument In 2000, Dr. Rene Manworren developed the Pediatric Nursing Knowledge and Attitudes Survey (PNKAS) as a tool to measure pediatric nursing knowledge related to pediatric pain management (Manworren, 2001). The PNKAS is comprised of content expectations from the WHO, the Agency for Healthcare Policy and Research and Quality (AHCPR), and the American Pain Society (APS) guidelines and is formatted with multiple choice and true/false questions. Twelve nurses and child life specialists from the United States of America established the test-retest reliability. Results demonstrated r ¼ .67. Cronbach’s alpha was .72, demonstrating acceptable internal consistency (Manworren, 2001). In 2002 the PNKAS was modified to accommodate the assessment of nurses not working in oncology settings (Rieman, Gordon, & Marvin, 2007). With collaboration and permission from Dr.
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Manworren, the MMPNKAS-S was used for this study because it excludes questions regarding pediatric cancer—MCH does not have a oncology program—and questions relating to medications not available in Mongolia. Additionally, questions assessing the nurses’ ability to select an amount of pain medication based on a range ordered by the physician or pro re nada (PRN) assessments were removed because nurses do not use the PRN system in Mongolia. The MMPNKAS-S is a 35-item questionnaire with a score range of 0-35 and has been translated into the Khalkha Mongol language. Data Analysis The presurvey and postsurvey were collected and reviewed for completeness. Surveys partially completed or missing data were excluded. Surveys were scored for total number of correct answers. An unpaired t test was conducted to analyze differences between the scores before and after the educational conference. To ensure that there was no difference between the morning and afternoon presurvey and postsurvey scores, a one-way ANOVA was performed. Nursing characteristics such as highest level of nursing education, years working in pediatric nursing, and personal experience with pain were obtained to understand demographics of pediatric nurses working at MCH. Statistical analysis was conducted using PASW Statistics Version 18 (SPSS Inc., Chicago, IL).
RESULTS Sample A convenience sample of 162 nurses or 32% of the total nurses from MCH attended the pediatric pain conference. Ninety-seven nurses attended the morning conference and 67 nurses attended the afternoon conference. Attending the morning or afternoon was solely based on the nurse’s preference. Nurses volunteered their demographic data of gender, age, highest educational degree, years in nursing, and personal experience with pain (Table 2). A total of 150 nurses completed demographics. From the total sample, nurses were predominantly women and had personal experiences with pain. Nurses older than age 40 comprised the largest group, with nurses between the ages of 25 and 30 comprising the second largest group. Nearly half the nurses had a degree and slightly more than half held a diploma degree in nursing. The largest group of nurses had less than 5 years of experience in nursing. The second largest group had experienced more than 15 years in nursing.
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TABLE 2. Nursing Characteristics
Gender (n ¼ 150) Male Female Age (n ¼ 148) 40 years Nursing degree (n ¼ 140) Assistant nurse Diploma nurse Bachelor’s in nursing Years in nursing (n ¼ 140) 0-5 6-10 11-15 >15 Personal experience with pain (n ¼ 148) Yes No
Total, N (%)
Morning, N (%)
Afternoon, N (%)
11 (7.3) 139 (92.7)
6 (6.5) 86 (93.5)
5 (8.6) 53 (91.3)
22 (14.9) 37 (25) 19 (12.8) 22 (14.9) 48 (32.4)
14 (15.3) 26 (28.6) 11 (12.1) 13 (14.3) 27 (29.7)
8 (14) 11 (19.3) 8 (14.1) 9 (15.8) 21 (36.8)
2 (1.4) 73 (52.1) 65 (46.4)
0 43 (51.8) 40 (48.2)
2 (3.5) 30 (52.6) 25 (43.9)
62 (44.3) 20 (14.3) 14 (10) 44 (31.4)
40 (48.2) 12 (14.5) 6 (7.2) 25 (30.1)
22 (38.6) 8 (14) 8 (14) 19 (33.3)
134 (89.9) 15 (10.1)
80 (88.9) 10 (11.1)
54 (91.5) 5 (8.5)
Survey Results A total of 155 nurses completed the pre- and postsurvey. From the morning and afternoon sessions 97 and 58 surveys were completed, respectively. The range of possible scores was 0-35. The mean raw score of the morning group presurvey was 12.96 2.5. The mean raw score of the presurvey for the afternoon group was 12.36 2.92. The mean presurvey raw score for the combined morning and afternoon groups was 12.74 2.67. Scores from the morning and afternoon presurvey ranged from 6 to 22. The mean presurvey percent for the combined morning and afternoon groups was 36.38% 7.63%. The percentage for combined presurvey ranged from 17% to 65% (Fig. 1). The mean morning postsurvey raw score was 16.88 3.74. The mean afternoon postsurvey score was 16.5 4.15. The mean postsurvey raw score for the combined morning and afternoon groups was 16.74 3.89. Scores from the morning and afternoon postsurvey ranged from 10 to 30. The mean postsurvey percentage score for the combined morning and afternoon groups was 47.81% 11.13%. Percentages for combined postsurvey ranged from 24% to 84% (Fig. 2). The difference in scores between the precombined and postcombined was statistically significant (p < .0001; 95% CI 4.74 to 3.23) (Fig. 3). An ANOVA was performed to verify the different mean results between the morning pre- and postsurvey and afternoon pre- and postsurvey (F [3, 306] ¼ 37.55; p < .0001).
DISCUSSION Demographics Before the study, information describing current characteristics of pediatric nurses at MCH was absent. Remaining consistent with nurses from Hong Kong, Mexico, and the United States of America, the majority of nurses at MCH are women (Huth et al., 2010; Rieman & Gordon, 2007; Tse & Chan, 2004). Nearly half of the pediatric nurses in Mongolia are bachelor’s of science in nursing (BSN) prepared. This finding is similar to Canada, Hong Kong, Jordan, and the United States of America (Abdalrahim et al., 2011; Johnston et al., 2007; Rieman & Gordon, 2007; Tse & Chan, 2004). The majority of participants had been working as a pediatric nurse for less than 5 years. The second largest group (31%) had been in pediatric nursing for more than 15 years. These results may occur if nursing was chosen as a profession later in life or as a second career. This bimodal distribution is different than Hong Kong or Mexico, where the majority of nurses have less than 5 years of nursing experience (Huth et al., 2010; Tse & Chan, 2004). Survey Scores The presurvey scores demonstrate that Mongolian nurses have insufficient knowledge of pediatric pain as evidenced by a mean nursing score of 12.7, or
Pediatric Pain Knowledge and Attitudes in Mongolian Nurses
FIGURE 1.
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Presurvey percent combined scores.
36.4%. Studies in Mexico and Turkey using a modified version of the PNKAS reveal similar findings. Mean presurvey scores in Mexico and Turkey were 13 out of 30, or 43%, and 15 out of 40, or 38% (Ekim & Ocakci, 2013; Huth et al., 2010). Other studies assessing nursing knowledge of pediatric pain used different survey instruments, making it challenging to infer comparisons. However, similar results are demonstrated in studies performed in Hong Kong and Jordan (Abdalrahim et al., 2011; Tse & Chan, 2004). Studies using the PNKAS in the United States and Canada demonstrate higher mean prescores of greater than 27, or 66% (Johnston et al., 2007; Le May et al., 2009; Manworren, 2000). Because nurses comprise the largest group of providers caring for patients, a baseline assessment of nursing knowledge and attitudes of pain management
FIGURE 2.
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Postsurvey percent combined scores.
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is critical for every country caring for children (Huth et al., 2010). This study sheds light on the paucity of nursing knowledge of pediatric pain management in Mongolia as consistent with findings in Mexico and Turkey. Results from aforementioned surveys demonstrate that variations of scores exist between developing countries and developed countries. Several factors may contribute to the findings of nurses’ baseline assessment and management of pediatric pain in Mongolia. First, information on pain assessment and management is not included in the curricula of Mongolian nursing programs. Second, before this project no validated pediatric pain tools had been translated into Mongolian. It is unreasonable to expect competency in pediatric pain knowledge and assessment if nurses have lacked exposure to pediatric pain concepts, management strategies, or tools. Invariably the responsibility for providing education and awareness on pediatric pain is charged to individuals who do have an understanding of pediatric pain practices and pharmacology. Overall project scores significantly increased after the educational offering. This is consistent with other studies demonstrating the positive effects of education concentrated on pediatric pain knowledge and management (Huth et al., 2010; Johnston et al., 2007; Rieman & Gordon, 2007). Before this study, no data assessed the impact of didactic educational sessions on knowledge in Mongolia. This finding is encouraging for future projects wishing to collaborate with Mongolian nurses on potential educational opportunities. It is important to recognize that the increase in overall scores does not insinuate knowledge translation at the bedside. Rather, increase in scores reflects knowledge gained from the educational offering. The art of transforming knowledge of pediatric pain into improved pediatric pain practices by nursing is a multifaceted concept requiring continual reinforcement of pain knowledge and management strategies by nursing educators and mentors. Furthermore the hospital’s nursing leadership and nursing culture experienced in each nursing unit must embrace the importance of pediatric pain management.
FIGURE 3.
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Pre- and postsurvey percentage results.
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Strengths Strengths of this study include obtaining demographics of pediatric nurses in Mongolia. By using the MMPNKAS-S survey a baseline analysis of pediatric pain knowledge and attitudes of nurses working at MCH is now available. From the results of this analysis, future research and education can be tailored to the specific needs of Mongolian nurses. Before this study, educational conferences have been offered to nurses in Mongolia. However, the long-term effect of such offerings had not been assessed. This study ascertains that pain knowledge increased after an educational offering. Last, Mongolian nurses have a translated FACES pain tool for use in pain assessments. Limitations Limitations of this study include offering the study and educational offering on 1 day. Because of this, nurses working the night or weekend shift or nurses on holiday did not have an opportunity to participate. A large amount of new information was presented during the educational conference. It is possible that the majority of nurses were not able to absorb some components of the lecture such as information on side effects of pain medications. Another drawback was administering the postsurvey immediately after the educational conference. The assurance of true knowledge retention would have been established if a longer period passed before administering the postsurvey. Significance for Nursing The IASP and WHO agree that pediatric pain management is a global health priority. Developing countries have identified key needs as resources, training, and funding (Kumar, 2004). With such a dichotomy of educational resources available in developing countries it becomes an ethical mandate for those who have access to resources to share with those who
may not. Because nurses are held to an ethical code to treat children with compassion and competent care, the compulsory actions of sharing how this can be achieved with nurses in countries without resources is essential (Olmstead et al., 2010). The importance of collaborative relationships with nursing leaders in developing countries cannot be stressed enough. Nurses with particular interest in global health should initiate partnerships with nursing leadership in countries visited during medical mission endeavors or projects. The aim of such partnerships is to encourage dialogue on identified problems encountered by either party as to participate in any medical project is to be a teacher as well as a student. Portraying that developed countries are more skilled at caring for children will certainly extinguish any hopes of a lasting relationship. Therefore nurses should be supported and encouraged to engage in collaborative projects with nursing staff in developing countries.
CONCLUSIONS This study identifies that although pediatric pain knowledge in Mongolian nurses working at MCH is insufficient, educational sessions may be an effective way to improve overall knowledge as evidenced by the significant results demonstrated in the postsurvey analysis. This suggests the importance of including pain management content in both undergraduate curriculum and continuing education opportunities. Future partnerships with nursing leadership at MCH should continue to focus on reinforcing this new knowledge and translating it into bedside practice. By empowering nurses to appropriately manage children in pain, mandates offered by the WHO and IASP are satisfied and children are appropriately allowed the relief of unnecessary suffering.
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From the Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, Texas. Address correspondence to Dr. Lisa Lunsford, DNP, RN, CPNP, Department of Pediatrics, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229. E-mail: LunsfordL3@ uthscsa.edu Received August 4, 2014; Revised August 19, 2014; Accepted August 19, 2014. 1524-9042/$36.00 Ó 2015 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2014.08.007
Lisa Lunsford, DNP, RN, CPNP
ABSTRACT:
The World Health Organization and the International Association for Study of Pain cite the significance of pediatric pain as a significant global health issue. Developing countries may have increased needs compared with developed countries because of limited resources and lack of training. In Mongolia a paucity of data exist regarding nursing knowledge of pediatric pain management. The purpose of this project was to assess the current knowledge of pediatric pain and to assess the effectiveness of educational intervention on improving knowledge and attitudes of pediatric nurses working at a major children’s hospital in Mongolia. Knowledge and attitudes of Mongolian nurses were evaluated before and after a 2-hour educational intervention. The translated Modified Mongolian Pediatric Nurses’ Knowledge and Attitudes Survey Regarding Pain—Shriner’s Revision survey was used as a pre- and postintervention assessment instrument with local nurses at a pediatric hospital in Ulaanbaatar, Mongolia. One hundred sixtyseven nurses attended the conference, with 155 nurses completing the pre- and postsurveys. The mean score on the presurvey was 12.7 out of 35 (26.4% correct), whereas the mean score on the postsurvey score was 16.7 out of 35 (47.8% correct). A paired t test showed a significant statistical difference between scores (p < .0001). Pediatric nurses in Mongolia demonstrate insufficient knowledge of pediatric pain management. The educational intervention was effective in improving pediatric pain knowledge and attitudes in Mongolian nurses. It is recommended to establish similar educational endeavors with nurses around the world to improve pain knowledge and attitudes. Ó 2015 by the American Society for Pain Management Nursing Pediatric pain has long been recognized as a significant global health issue by the World Health Organization (WHO) and the International Association for the Study of Pain (IASP) (Kumar, 2007). Since Dr. Eland and Anderson’s hallmark study 1977, which revealed significant mismanagement of children in the United States of America experiencing pain after surgeries (Eland & Anderson, 1977), much attention has turned to this previously neglected area of study (Hamers, Huijer Abu-Saad, van den Hout, & Halfens, 1998). Understandably, pediatric pain is a complex phenomenon requiring knowledge, understanding, and Pain Management Nursing, Vol 16, No 3 (June), 2015: pp 346-353
Pediatric Pain Knowledge and Attitudes in Mongolian Nurses
appreciation of its nature. In the past decade, nursing has concentrated its efforts to increase awareness and education on pediatric pain. Because of these efforts, nurses are understanding and assessing pediatric pain more appropriately (Griffen, Polit, & Byrne, 2008). In developed countries, many validated pediatric pain tools such as the FACES pain scale by Wong and Baker have been created to assist the nurse in the assessment of pain (Hicks, von Baeyer, Spafford, van Korlarr, & Goodenough, 2001; Standford, Chambers, Craig, McGrath, & Cassidy, 2005). Various educational approaches such as one-on-one coaching and pain educational conferences have been used to increase nursing knowledge with measured success (Griffen et al., 2008; Johnston et al., 2007). Research in countries such as China and Hong Kong demonstrate that significant education gaps exist among their nurses. However, with the introduction of educational programs on pediatric pain, increased knowledge has been demonstrated (Chiang, Chen, & Huang, 2006; Tse & Chan, 2004; Zhang et al., 2008). Although the awareness and treatment of pediatric pain has improved in developed countries, there is a significant concern by WHO and the IASP for developing countries experiencing additional economic hardships (Finley, McGrath, & Chambers, 2006). A developing country is defined, per the World Bank, as one ‘‘in which most people have a lower standard of living with access to fewer goods and services than do most people in high-income countries’’ (Finley et al., 2006, p. 177). Mongolia is classified as a developing country (Sovd, Purev, Byambajav, Sereenen, & Gankhuyag, 2008). Mongolia is situated between the Russian Federation and the People’s Republic of China with an estimated population of 2.9 million people, with youth (children through adolescents) accounting for nearly 29% (Sovd et al., 2008). It ranks 152nd out of 226 countries in gross domestic product (GDP), which reflects the per-capita welfare state of a country (Central Intelligence Agency, 2014). From its transition in 1990 from communism, Mongolia has struggled as a country, with 29% of the population living below the poverty line (Central Intelligence Agency, 2014). Among developing countries such as Mongolia, a wide spectrum of varying economic, culture, and political stability exists (Size, Soyannwo, & Justins, 2007). It is difficult to assess current pediatric pain practices in developing countries because of the lack of research pertaining to pediatric pain management and assessment. Most understanding comes from reports from personal observations by visiting healthcare providers (Bosenberg, 2007). Suggested barriers to pediatric pain
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management include limited access to pediatric appropriate analgesia, lack of physician and nursing knowledge of pediatric pain assessment and management, lack of validated pediatric pain tools translated appropriately, and general lack of government resources (Bosenberg, 2006). This is concerning because pediatric nurses hold a paramount role in the appropriate assessment and management of children in pain and remain the largest group of healthcare providers responsible for the direct care of hospitalized children (Huth, Gregg, & Lin, 2010; Manworren, 2000). One study assessing working conditions in three main hospitals in Mongolia found that all hospitals had electrical power, oxygen sources, running water, and a laboratory, and most had access to radiology. Issues identified by staff include access to medical equipment, access to disposable care items, and education and advanced training for physicians and nurses (Dunser et al., 2009). Dunser, Baelani, and Ganbold (2006) report the lack of appropriate pediatric analgesia in several hospitals in cities, including Ulaanbaatar Mongolia, despite the WHO Essential Medicine List recommendations. Challenging working conditions, including high patient-to-nurse ratios, are also cited as a source of frustration for nurses and physicians and a barrier to quality patient care (Bagaajav, Myagmarjav, Nanjid, Otgon, & Chae, 2011). When healthcare systems are distracted with economic and political challenges, it becomes difficult to prioritize appropriate pediatric pain management. In the WHO normative guidelines on pain management from the Delphi study, appropriate pediatric pain relief is a significant issue for developing countries (Kumar, 2007). In the report, healthcare providers were concerned about the lack of pediatric pain knowledge and management. The report calls for research to focus on education for providers (Kumar, 2007). Size et al. (2007) also identified pain education as one of the most significant barriers for pain management in developing countries. This is consistent with surveys of healthcare providers working in Thailand, Nigeria, and sub-Saharan Africa, demonstrating that healthcare professionals are acutely aware of their knowledge deficits (Bond, 2011; Size et al., 2007). As the awareness of the importance of appropriate pediatric pain management has increased in developed countries, several developing countries assessed their pediatric nurses’ knowledge and management of pediatric pain (Huth et al., 2010; Matthew, Matthew, & Singhi, 2011). Several nursing knowledge and attitudes assessments conducted in India, Jordan, and Mexico emphasize the significant need for nursing education on pain knowledge and assessment (Abdalrahim, Majali, Stromberg, &
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Bergbom, 2011; Huth et al., 2010; Matthew et al., 2011; Subhashini, Vatsa, & Lodha, 2009). Unfortunately, education for healthcare providers on appropriate pediatric pain practices is often nonexistent in developing countries (Bond, 2011). Few pediatric pain assessment tools have been validated and translated for nurses to use with children in developing countries (Bosenberg, 2007). Specific to Mongolia, education on pain physiology, management, or assessment is not included in the Mongolian nursing curriculum. Before this study, no pediatric pain assessment tools were translated into Khalka Mongol. To date, there are no published records describing Mongolian nursing knowledge related to pediatric pain management. The WHO has stated that pain relief is a right of children worldwide and has established pediatric pain guidelines and essential pediatric appropriate medication lists to assist healthcare organizations (Olmstead, Scott, & Austin, 2010). Assessing and advocating for pediatric pain requires education. Pain education for healthcare providers working in developing countries has been cited as a strategy for increasing knowledge (Size et al., 2007). Physicians and nurses in developing countries including Mongolia have asked for education related to pain and pain management (Dunser et al., 2009). Therefore, this study begins to identify the educational needs of Mongolian pediatric nurses regarding pediatric pain management.
METHODS Aim This study was performed to assess current knowledge of and attitudes regarding pediatric pain of Mongolian pediatric nurses working at the National Center for Maternal and Child Health (MCH) in Ulaanbaatar, Mongolia, and to evaluate the change in knowledge after a pediatric pain conference conducted at MCH. Needs Assessment Before the study, a needs assessment was conducted with the director of nursing and the deputy director of MCH on what pain education nurses at MCH have had. Interviews with nursing instructors from the schools of nursing at Ulaanbaatar University and the University of Mongolia Health Science Center intimated that Mongolian nurses lack knowledge about pediatric pain assessment and lack awareness of pediatric pain assessment tools because of educational time constraints in nursing curricula.
Project Design The survey collection and educational program took place at the MCH Hospital, which employs 506 nurses. Two half-day conferences were held to maximize opportunities for the estimated 250 pediatric nurses to attend. The conferences were translated into Khalkha Mongol by a Mongolian physician proficient in English and Khalkha Mongol. The design of this project was presurvey–postsurvey design. The Modified Mongolian Pediatric Nurses’ Knowledge and Attitudes Survey Regarding Pain— Shriner’s Revision (MMPNKAS-S) was used. Nursing demographics and characteristics were collected with the presurvey, including gender, age, years of experience as a pediatric nurse, type of nursing education, and whether the nurse had a personal experience with pain. On completion of the MMPNKAS-S, a 2.5-hour presentation on pediatric pain knowledge, assessment, and management based on current IASP guidelines was offered (Table 1). The guidelines for the presentation included an introduction to pain knowledge, terms, tools, pain assessment, a review of pharmacology, and a review of nonpharmacologic methods to relieve pain. A pediatric palliative care nurse practitioner assisted in content development for pain pathways, pain assessment, and pharmacology. A child life specialist experienced with Mongolia culture assisted in the development of the cognitive-behavioral method content. The FACES pain assessment tool created by Wong and Baker was translated into Mongolian with Connie Baker’s permission and was introduced as pediatric pain tool. The conference used PowerPoint slides for graphics. Immediately after the conference, the MMPNKAS-S was readministered.
Procedure Institutional Review Board (IRB) approval was obtained from Vanderbilt University before the implementation of this study. At MCH, the deputy director and the director of nursing must grant researchers permission for any study conducted at their hospital. After reviewing the purpose of the project, the design, and the educational content with the directors, the researcher for this study expressed the importance of ensuring confidentiality and anonymity to nursing participants. The deputy director of MCH and the director of nursing at MCH granted permission with the request that subanalyses between demographic variables and survey results not be performed, concerned that nurses might not participate in the project should the score be potentially linked to the individual nurse. Participation in the surveys and conference was
Pediatric Pain Knowledge and Attitudes in Mongolian Nurses
TABLE 1. Topical Outline for Education on Pediatric Pain 1. Introduction to the significance of pediatric pain WHO position statement on pain IASP (2005) position statement on pain 2. Brief physiology of pain—10 minutes Types of pain children may experience When differing types of pain may occur Pain terminology 3. Pain assessment Location, intensity, quality, pattern Behavioral assessment Developmental considerations in pain assessment Introduction to FACES pain tool Introduction to self-report of pain 4. Pharmacology Brief review of analgesia available in Mongolia Route and dosing considerations and duration considerations Side effects 5. Cognitive-behavioral therapies Distractional play Massage Change of environment Music 6. Reassessment Remembering what helped Total instructional time: 1 hour 30 minutes IASP ¼ International Association for Study of Pain. Outline structured by End of Life Nursing Education Consortium (ELNEC). Pediatric palliative care. Washington, D.C. Revised January 2012.
voluntary. Nurses had the option to not complete the surveys and only attend the conference and an option to refuse the project entirely at the beginning of the conference. No personal identifiers were present on the survey. Instrument In 2000, Dr. Rene Manworren developed the Pediatric Nursing Knowledge and Attitudes Survey (PNKAS) as a tool to measure pediatric nursing knowledge related to pediatric pain management (Manworren, 2001). The PNKAS is comprised of content expectations from the WHO, the Agency for Healthcare Policy and Research and Quality (AHCPR), and the American Pain Society (APS) guidelines and is formatted with multiple choice and true/false questions. Twelve nurses and child life specialists from the United States of America established the test-retest reliability. Results demonstrated r ¼ .67. Cronbach’s alpha was .72, demonstrating acceptable internal consistency (Manworren, 2001). In 2002 the PNKAS was modified to accommodate the assessment of nurses not working in oncology settings (Rieman, Gordon, & Marvin, 2007). With collaboration and permission from Dr.
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Manworren, the MMPNKAS-S was used for this study because it excludes questions regarding pediatric cancer—MCH does not have a oncology program—and questions relating to medications not available in Mongolia. Additionally, questions assessing the nurses’ ability to select an amount of pain medication based on a range ordered by the physician or pro re nada (PRN) assessments were removed because nurses do not use the PRN system in Mongolia. The MMPNKAS-S is a 35-item questionnaire with a score range of 0-35 and has been translated into the Khalkha Mongol language. Data Analysis The presurvey and postsurvey were collected and reviewed for completeness. Surveys partially completed or missing data were excluded. Surveys were scored for total number of correct answers. An unpaired t test was conducted to analyze differences between the scores before and after the educational conference. To ensure that there was no difference between the morning and afternoon presurvey and postsurvey scores, a one-way ANOVA was performed. Nursing characteristics such as highest level of nursing education, years working in pediatric nursing, and personal experience with pain were obtained to understand demographics of pediatric nurses working at MCH. Statistical analysis was conducted using PASW Statistics Version 18 (SPSS Inc., Chicago, IL).
RESULTS Sample A convenience sample of 162 nurses or 32% of the total nurses from MCH attended the pediatric pain conference. Ninety-seven nurses attended the morning conference and 67 nurses attended the afternoon conference. Attending the morning or afternoon was solely based on the nurse’s preference. Nurses volunteered their demographic data of gender, age, highest educational degree, years in nursing, and personal experience with pain (Table 2). A total of 150 nurses completed demographics. From the total sample, nurses were predominantly women and had personal experiences with pain. Nurses older than age 40 comprised the largest group, with nurses between the ages of 25 and 30 comprising the second largest group. Nearly half the nurses had a degree and slightly more than half held a diploma degree in nursing. The largest group of nurses had less than 5 years of experience in nursing. The second largest group had experienced more than 15 years in nursing.
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TABLE 2. Nursing Characteristics
Gender (n ¼ 150) Male Female Age (n ¼ 148) 40 years Nursing degree (n ¼ 140) Assistant nurse Diploma nurse Bachelor’s in nursing Years in nursing (n ¼ 140) 0-5 6-10 11-15 >15 Personal experience with pain (n ¼ 148) Yes No
Total, N (%)
Morning, N (%)
Afternoon, N (%)
11 (7.3) 139 (92.7)
6 (6.5) 86 (93.5)
5 (8.6) 53 (91.3)
22 (14.9) 37 (25) 19 (12.8) 22 (14.9) 48 (32.4)
14 (15.3) 26 (28.6) 11 (12.1) 13 (14.3) 27 (29.7)
8 (14) 11 (19.3) 8 (14.1) 9 (15.8) 21 (36.8)
2 (1.4) 73 (52.1) 65 (46.4)
0 43 (51.8) 40 (48.2)
2 (3.5) 30 (52.6) 25 (43.9)
62 (44.3) 20 (14.3) 14 (10) 44 (31.4)
40 (48.2) 12 (14.5) 6 (7.2) 25 (30.1)
22 (38.6) 8 (14) 8 (14) 19 (33.3)
134 (89.9) 15 (10.1)
80 (88.9) 10 (11.1)
54 (91.5) 5 (8.5)
Survey Results A total of 155 nurses completed the pre- and postsurvey. From the morning and afternoon sessions 97 and 58 surveys were completed, respectively. The range of possible scores was 0-35. The mean raw score of the morning group presurvey was 12.96 2.5. The mean raw score of the presurvey for the afternoon group was 12.36 2.92. The mean presurvey raw score for the combined morning and afternoon groups was 12.74 2.67. Scores from the morning and afternoon presurvey ranged from 6 to 22. The mean presurvey percent for the combined morning and afternoon groups was 36.38% 7.63%. The percentage for combined presurvey ranged from 17% to 65% (Fig. 1). The mean morning postsurvey raw score was 16.88 3.74. The mean afternoon postsurvey score was 16.5 4.15. The mean postsurvey raw score for the combined morning and afternoon groups was 16.74 3.89. Scores from the morning and afternoon postsurvey ranged from 10 to 30. The mean postsurvey percentage score for the combined morning and afternoon groups was 47.81% 11.13%. Percentages for combined postsurvey ranged from 24% to 84% (Fig. 2). The difference in scores between the precombined and postcombined was statistically significant (p < .0001; 95% CI 4.74 to 3.23) (Fig. 3). An ANOVA was performed to verify the different mean results between the morning pre- and postsurvey and afternoon pre- and postsurvey (F [3, 306] ¼ 37.55; p < .0001).
DISCUSSION Demographics Before the study, information describing current characteristics of pediatric nurses at MCH was absent. Remaining consistent with nurses from Hong Kong, Mexico, and the United States of America, the majority of nurses at MCH are women (Huth et al., 2010; Rieman & Gordon, 2007; Tse & Chan, 2004). Nearly half of the pediatric nurses in Mongolia are bachelor’s of science in nursing (BSN) prepared. This finding is similar to Canada, Hong Kong, Jordan, and the United States of America (Abdalrahim et al., 2011; Johnston et al., 2007; Rieman & Gordon, 2007; Tse & Chan, 2004). The majority of participants had been working as a pediatric nurse for less than 5 years. The second largest group (31%) had been in pediatric nursing for more than 15 years. These results may occur if nursing was chosen as a profession later in life or as a second career. This bimodal distribution is different than Hong Kong or Mexico, where the majority of nurses have less than 5 years of nursing experience (Huth et al., 2010; Tse & Chan, 2004). Survey Scores The presurvey scores demonstrate that Mongolian nurses have insufficient knowledge of pediatric pain as evidenced by a mean nursing score of 12.7, or
Pediatric Pain Knowledge and Attitudes in Mongolian Nurses
FIGURE 1.
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Presurvey percent combined scores.
36.4%. Studies in Mexico and Turkey using a modified version of the PNKAS reveal similar findings. Mean presurvey scores in Mexico and Turkey were 13 out of 30, or 43%, and 15 out of 40, or 38% (Ekim & Ocakci, 2013; Huth et al., 2010). Other studies assessing nursing knowledge of pediatric pain used different survey instruments, making it challenging to infer comparisons. However, similar results are demonstrated in studies performed in Hong Kong and Jordan (Abdalrahim et al., 2011; Tse & Chan, 2004). Studies using the PNKAS in the United States and Canada demonstrate higher mean prescores of greater than 27, or 66% (Johnston et al., 2007; Le May et al., 2009; Manworren, 2000). Because nurses comprise the largest group of providers caring for patients, a baseline assessment of nursing knowledge and attitudes of pain management
FIGURE 2.
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Postsurvey percent combined scores.
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is critical for every country caring for children (Huth et al., 2010). This study sheds light on the paucity of nursing knowledge of pediatric pain management in Mongolia as consistent with findings in Mexico and Turkey. Results from aforementioned surveys demonstrate that variations of scores exist between developing countries and developed countries. Several factors may contribute to the findings of nurses’ baseline assessment and management of pediatric pain in Mongolia. First, information on pain assessment and management is not included in the curricula of Mongolian nursing programs. Second, before this project no validated pediatric pain tools had been translated into Mongolian. It is unreasonable to expect competency in pediatric pain knowledge and assessment if nurses have lacked exposure to pediatric pain concepts, management strategies, or tools. Invariably the responsibility for providing education and awareness on pediatric pain is charged to individuals who do have an understanding of pediatric pain practices and pharmacology. Overall project scores significantly increased after the educational offering. This is consistent with other studies demonstrating the positive effects of education concentrated on pediatric pain knowledge and management (Huth et al., 2010; Johnston et al., 2007; Rieman & Gordon, 2007). Before this study, no data assessed the impact of didactic educational sessions on knowledge in Mongolia. This finding is encouraging for future projects wishing to collaborate with Mongolian nurses on potential educational opportunities. It is important to recognize that the increase in overall scores does not insinuate knowledge translation at the bedside. Rather, increase in scores reflects knowledge gained from the educational offering. The art of transforming knowledge of pediatric pain into improved pediatric pain practices by nursing is a multifaceted concept requiring continual reinforcement of pain knowledge and management strategies by nursing educators and mentors. Furthermore the hospital’s nursing leadership and nursing culture experienced in each nursing unit must embrace the importance of pediatric pain management.
FIGURE 3.
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Pre- and postsurvey percentage results.
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Strengths Strengths of this study include obtaining demographics of pediatric nurses in Mongolia. By using the MMPNKAS-S survey a baseline analysis of pediatric pain knowledge and attitudes of nurses working at MCH is now available. From the results of this analysis, future research and education can be tailored to the specific needs of Mongolian nurses. Before this study, educational conferences have been offered to nurses in Mongolia. However, the long-term effect of such offerings had not been assessed. This study ascertains that pain knowledge increased after an educational offering. Last, Mongolian nurses have a translated FACES pain tool for use in pain assessments. Limitations Limitations of this study include offering the study and educational offering on 1 day. Because of this, nurses working the night or weekend shift or nurses on holiday did not have an opportunity to participate. A large amount of new information was presented during the educational conference. It is possible that the majority of nurses were not able to absorb some components of the lecture such as information on side effects of pain medications. Another drawback was administering the postsurvey immediately after the educational conference. The assurance of true knowledge retention would have been established if a longer period passed before administering the postsurvey. Significance for Nursing The IASP and WHO agree that pediatric pain management is a global health priority. Developing countries have identified key needs as resources, training, and funding (Kumar, 2004). With such a dichotomy of educational resources available in developing countries it becomes an ethical mandate for those who have access to resources to share with those who
may not. Because nurses are held to an ethical code to treat children with compassion and competent care, the compulsory actions of sharing how this can be achieved with nurses in countries without resources is essential (Olmstead et al., 2010). The importance of collaborative relationships with nursing leaders in developing countries cannot be stressed enough. Nurses with particular interest in global health should initiate partnerships with nursing leadership in countries visited during medical mission endeavors or projects. The aim of such partnerships is to encourage dialogue on identified problems encountered by either party as to participate in any medical project is to be a teacher as well as a student. Portraying that developed countries are more skilled at caring for children will certainly extinguish any hopes of a lasting relationship. Therefore nurses should be supported and encouraged to engage in collaborative projects with nursing staff in developing countries.
CONCLUSIONS This study identifies that although pediatric pain knowledge in Mongolian nurses working at MCH is insufficient, educational sessions may be an effective way to improve overall knowledge as evidenced by the significant results demonstrated in the postsurvey analysis. This suggests the importance of including pain management content in both undergraduate curriculum and continuing education opportunities. Future partnerships with nursing leadership at MCH should continue to focus on reinforcing this new knowledge and translating it into bedside practice. By empowering nurses to appropriately manage children in pain, mandates offered by the WHO and IASP are satisfied and children are appropriately allowed the relief of unnecessary suffering.
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