Original Article Knowledge of and Attitudes Regarding Postoperative Pain among the Pediatric Cardiac Nursing Staff: An Indian Experience Ashish R. Dongara, MD,* Shail N. Shah,* Somashekhar M. Nimbalkar, MD,*,† Ajay G. Phatak, MPH,† and Archana S. Nimbalkar, MSc, DCH‡ ---
From the *Department of Pediatrics, Pramukhswami Medical College, Karamsad, Gujarat, Anand, India; † Central Research Services, H.M. Patel Academic Center, Charutar Arogya Mandal, Karamsad, Gujarat, Anand, India; ‡Department of Physiology, Pramukhswami Medical College, Gujarat, Anand, India. Address correspondence to Somashekhar M. Nimbalkar, MD, Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat 388325, India. E-mail: somu_somu@yahoo. com Received April 10, 2014; Revised August 8, 2014; Accepted August 8, 2014. No funding was obtained for this study. AD designed the study, collected the data, and wrote the paper. SS designed the study, collected the data, and provided inputs to the paper. SM conceived the study, designed the study, and gave critical inputs to the paper. AN conceived the study, analyzed the data, and provided critical inputs to the paper. AP analyzed and interpreted the data and wrote the paper. All authors approved the final version of this manuscript. SM is the guarantor for the paper. The authors declare they have no conflict of interest to disclose. 1524-9042/$36.00 Ó 2015 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2014.08.009
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ABSTRACT:
Pain following cardiac intervention in children is a common, but complex phenomenon. Identifying and reporting pain is the responsibility of the nursing staff, who are the primary caregivers and spend the most time with the patients. Inadequately managed pain in children may lead to multiple short- and long-term adverse effects. The aim of this cross-sectional study was to assess the knowledge and attitudes regarding postoperative pain in children among the nursing staff at B.M. Patel Cardiac Center, Karamsad, Anand, Gujarat, India. The study included 42 of the 45 nurses employed in the cardiac center. The nurses participating in the study were responsible for the care of the pediatric patients. A modified Knowledge and Attitudes Survey Regarding Pain and a sociodemographic questionnaire were administered after obtaining written informed consent. The study was approved by the institutional Human Research Ethics Committee. Mean (SD) experience in years of the nursing staff was 2.32 (1.69) years (range 1 month to 5 years). Of the nurses, 67% were posted in the cardiac surgical intensive care unit (ICU). The mean (SD) score for true/false questions was 11.48 (2.95; range 7,19). The average correct response rate of the true/false questions was 45.9%. Knowledge about pain was only affected by the ward in which the nurse was posted. In first (asymptomatic) and second (symptomatic) case scenarios, 78.6% and 59.5% underestimated pain, respectively. Knowledge and attitudes regarding pain and its management is poor among nurses. Targeted training sessions and repeated reinforcement sessions are essential for holistic patient care. Ó 2015 by the American Society for Pain Management Nursing
Pain Management Nursing, Vol 16, No 3 (June), 2015: pp 314-320
Nurses’ Knowledge and Attitudes about Pain
Postoperative patient care requires a team effort that includes surgeons, anesthetists, intensivists, nutritionists, physiotherapists, and nurses. The nursing staff plays a very vital role, as they are the primary responders and caregivers who spend the most time with the patient. They are responsible for identifying and reporting the patients’ needs to the treating clinicians in an effort to achieve the best possible management of care. In postoperative patients, pain is the most common feature and demands attention. It is an extremely complex sensation, which is partly related to actual or potential tissue damage (IASP Subcommittee on Taxonomy, 1979). Patient’s perception of pain depends on psychological, social, and cultural factors, as well as on previous pain experiences (Goldman, 1993; Price, 2000). The subjective nature of pain makes it difficult to assess. The challenge of assessing pain becomes even greater with pediatric patients. The factors contributing to difficulty in pain assessment in children include a wide range of mental and physical development, limited communication skills, and varying coping mechanisms (Goldman, 1993). Younger children cannot verbalize pain and thus it becomes the caregiver’s responsibility to identify and manage it. The caregiver’s perception of a child’s pain is also a subjective entity that varies with education, age, sex, marital status, own children, previous experience with his or her own hospitalization, and previous experience with his or her own pain (Goldman, 1993; Johnston, 1989; Nimbalkar, Dongara, Ganjiwale, & Nimbalkar, 2013; O’Rourke, 2004). A growing body of scientific evidence now suggests that inadequately managed pain in children may have multiple adverse effects, such as delays in recovery, prolonged hospitalization, psychological stress, increased sleeplessness, altered perception of the sensory system, abnormal responses to stress and pain in the future, and other developmental abnormalities (Van Hulle Vincent, 2005). The younger the child, the harder it is to assess pain and the more pronounced the adverse effects (Anand, 1998; Broome, Richtsmeier, Maikler, & Alexander, 1996). Belief that young children, and particularly infants, do not perceive as much pain as adults because of their immature nervous system has not been shown. It has been demonstrated that infants and children experience pain to a similar degree or even higher compared with adults (Anand, 1998; Young, 2005). The American Academy of Pediatrics (2010) recommends ongoing assessment of the presence and severity of pain and the child’s response to treatment so that pain can be managed adequately. Efficient pain management can help reduce morbidity and
315
mortality. However, a necessary precursor to efficient pain management is the identification of pain, which is a challenging task and also may require validated age-appropriate pain assessment tools. Previous studies indicated that the knowledge regarding pain in children is insufficient, the day-today practices followed by the hospital staff are far from ideal, and attitudes are casual (Nimbalkar et al., 2013). The objective of the present study was to assess nurses’ knowledge and attitudes regarding postoperative pain in children in the B.M. Patel Cardiac Center, Gujarat and to determine the factors associated with their knowledge and attitudes.
MATERIALS AND METHODS The cross-sectional survey was conducted at B.M. Patel Cardiac Center and Shree Krishna Hospital, Karamsad, Anand, Gujarat during September and October 2013. The cardiac center has been functional since October 2008 and has performed more than 850 operations to date. All cardiac surgeries are performed at the study center except cardiac transplantation. The nurses employed were carefully selected from a pool of nurses working at Shree Krishna Hospital and underwent relevant training. There was no standardized written protocol for pain management at the time of this survey. The study was approved by the institutional Human Research Ethics Committee. Written informed consent was obtained from the participating nurses. Sample All 45 nurses employed in the cardiac center (cardiac care unit and cardiac surgical ICU) were included in the study. Instrument A modified Knowledge and Attitudes Survey Regarding Pain questionnaire (Ferrell, & McCaffery, 2008) and a sociodemographic questionnaire were used to collect the data. The Knowledge and Attitudes Survey Regarding Pain questionnaire was developed in 1987 and updated in 2008. The content of the tool was derived from current standards of pain management as recommended by the American Pain Society and the World Health Organization. Construct validity, test–retest reliability, and internal consistency of the tool have been well established (Ferrell, & McCaffery, 2008). The following modifications were made to the questionnaire: 1. Questions related to medications that are not routinely used at the study center were deleted.
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2. Questions related to chronic and cancer-related pain were deleted. 3. Questions were modified to suit the study center’s present practice protocols. 4. Some questions were added to suit the study objectives.
The modified tool contained 25 true/false questions, 8 multiple-choice questions, and 2 case scenarios. It was consensually validated by the authors, who have extensive experience in pain research in children. The questionnaire was pre-tested on 10 randomly selected nurses (excluded from the study). A group discussion was organized by the authors to determine if the nurses appropriately understood the questions and the responses accurately reflected their views. One point was awarded for each correct answer, whereas no point was awarded for wrong answers. Thus, a higher score implied more knowledge. The sociodemographic questionnaire contained variables that may influence knowledge level, such as age, location where the nurses work, experience, marital status, and being a parent. Locations where the nurses work were categorized as ‘‘cardiac surgical ICU,’’ ‘‘cardiac medical ICU,’’ and ‘‘cardiac operation theater.’’ Method The questionnaire was distributed following written informed consent. There was no time limit and the nurses returned the completed questionnaire at their convenience. An interactive session was organized to empower nurses regarding the finer nuances of pain management in children. Queries raised by the nurses were deliberated and elaborately addressed. Knowledge level was estimated in terms of total score derived from true/false and multiple-choice questions. Case scenarios were analyzed separately. Descriptive statistics (mean [SD], frequencies [%]) were used to depict the baseline characteristics and knowledge level of the nurses. Independent sample t test was used to determine the association between knowledge level and various sociodemographic variables at the univariate level. Multiple regression was used to determine overall contribution of these variables. The analysis was performed using SPSS 14.0 (SPSS Inc, Chicago, Illinois, USA).
cardiac surgical ICU (66.7%). The mean (SD) experience in years of the nursing staff was 2.32 (1.69) years, with the minimum experience being 1 month and the maximum being 5 years. The mean (SD) score for true/false questions was 11.48 (2.95), with a minimum score of 7 and a maximum score of 19, out of the maximum possible score of 25. The mean (SD) score for multiple-choice questions was 5.26 (1.50), with a minimum score of 3 and maximum score of 7, out of a maximum possible score of 8. The mean (SD) total score was 16.74 (2.34) with a minimum score of 12 and a maximum score of 23, out of the maximum possible score of 33 (Fig. 1). The average correct response rate of the nurses for the true/false statements was 45.9%. The statements that received the most frequent incorrect responses were: 1. Patients may sleep despite severe pain. 2. Combining analgesics that work by different mechanisms may result in better pain control with fewer side effects than using a single analgesic. 3. Patients should be encouraged to endure as much pain as possible before administering an opioid. 4. A patient should experience discomfort before giving the next dose of pain medication. 5. Because their nervous system is underdeveloped, children under 2 years of age have decreased pain sensitivity and limited memory of painful experiences.
The statements that received the most frequent correct responses were: 1. Giving opioids on a regular basis is preferred over a PRN (as-needed) schedule for continuous pain. 2. If a patient reports pain relief and euphoria, he or she should be given a lower dose of the analgesic.
RESULTS An excellent response rate was observed, with questionnaires completed by 42 (93.3%) of the 45 eligible nurses. Twenty-four of the nurses (57.1%) were aged 20 to 25 years; 30 were unmarried (71.4%); 32 were not parents (76.2%); and 28 and were posted in the
FIGURE 1. - Box plots showing distribution of scores. MCQ ¼ multiple-choice question.
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Nurses’ Knowledge and Attitudes about Pain
TABLE 1. Response of the Nursing Staff to True/False Statements Statement Vital sign are always reliable indicators of the intensity of a patients pain. Because their nervous system is underdeveloped, children under 2 years of age have decreased pain sensitivity and limited memory of painful experiences. Patients who can be distracted from pain usually do not have severe pain. Patient may sleep despite severe pain. Combining analgesics that work by different mechanisms may result in better pain control with fewer side effects than using a single analgesic. The usual duration of analgesia of 1 to 2 mg fentanyl IV is 4 to 5 hours. Opioids should not be used in patients with a history of substance abuse. Patients should be encouraged to endure as much pain as possible before using an opioid. Children younger than 11 years old cannot reliably report pain so clinicians should rely solely on the parents’ assessment of the child’s pain intensity. Patients’ spiritual beliefs may lead them to think pain and suffering are necessary. After an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with individual patient’s response. Lack of pain expression does not necessarily mean absence of pain. Patients should be maintained in a pain-free state If a patient reports pain relief and euphoria, he or she should be given a lower dose of the analgesic. Patients can tolerate high doses of opioids without sedation or respiratory depression. Estimated pain by an MD or RN is a more valid measure of pain than the patient self-report. Patients may be hesitant to ask for pain medications due to their fears about use of opioids. Patients have the right to expect total pain relief as the goal of treatment. Continuous assessment of pain and medication effectiveness is necessary for good pain management. Giving opioids on a regular basis is preferred over a PRN schedule for continuous pain. A patient should experience discomfort before giving the next dose of pain medication. Comparable stimuli in different people produce the same intensity of pain. Non-drug interventions (heat, music, imagery, etc.) are very effective for mild to moderate pain control but rarely helpful for more severe pain. Beyond a certain dosage of morphine, increases in dose will not increase pain relief. In order to be effective, heat and cold should only be applied to the painful areas.
3. After an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with individual patient’s response. 4. Patients have the right to expect total pain relief as the goal of treatment. 5. Continuous assessment of pain and medication effectiveness is necessary for good pain management (Table 1).
All of the nurses correctly indicated that the intravenous route is the recommended route for administration of opioid analgesics in patients with postoperative pain. Twenty-eight (66.7%) nurses correctly said that morphine/fentanyl is the drug of choice for treatment of prolonged moderate to severe pain. Thirty-eight (90.5%) nurses correctly indicated that an around-theclock fixed schedule should be followed initially for postoperative pain. Thirty-three (78.6%) nurses correctly responded that the most likely reason for a patient with pain to demand increased doses of pain
Correct Answer (%)
Incorrect Answer
20 (47.6) 12 (28.6)
22 30
14 (33.3) 1 (2.4) 8 (19)
26 41 34
16 (38.1) 24 (57.1) 9 (21.4) 23 (54.8)
26 18 33 19
20 (47.6) 28 (66.7)
22 14
15 (35.7) 25 (59.5) 28 (66.7)
27 17 14
18 (42.9) 16 (38.1) 14 (33.3) 27 (64.3) 27 (64.3)
24 26 28 15 15
34 (81) 10 (23.8) 25 (59.5) 23 (54.8)
8 32 17 19
21 (50) 24 (57.1)
21 18
medication is because of increased pain. Thirty-one (73.8%) nurses felt that the most accurate judge of the patient’s pain was the patient him or herself. Twenty-seven (64.3%) nurses incorrectly answered the question regarding the addiction potential of opioid analgesics. Thirty-three (78.6%) nurses correctly knew the time for peak effect of intravenous fentanyl. Forty-one (97.6%) nurses did not know the time for the peak effect of oral paracetamol. Univariate analysis using independent sample t test revealed that marital status (p ¼ .20), age group (p ¼ .24), and being a parent (p ¼ .12) were not statistically significantly associated with the total score, but ward posted (p ¼ .04) was significantly associated with total score. The backward stepwise multiple regression analysis showed that the ward posted (p ¼ .04) was the only significantly associated variable with the total score, albeit the predictive value of the model was poor (r2 ¼ 10%).
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Two case scenarios were given to assess the ability of the nurses to identify pain in postoperative patients and to make decisions regarding its management. In the first (asymptomatic) case, 33 (78.6%) of the nurses underestimated pain in the patient and 36 (85.7%) chose not to treat the patient’s pain. In the second (symptomatic) case, 25 (59.5%) nurses underestimated pain and 26 (61.9%) chose not to treat the patient’s pain. In both case scenarios, the patients had rated their pain as 8 on a visual analog scale. In general, the nurses were not only insufficiently empowered in identification of pain, but they also were hesitant to aggressively and proactively manage pain.
DISCUSSION Considering the small number of eligible nurses, coupled with the fact that this was not a multicenter study, it was possible to achieve an excellent response rate (93.3%) compared with other studies with response rates of 61.4% and 71% (Lui, So, & Fong, 2008; P€ olkki et al., 2010). The authors met in person with all of the eligible nurses to administer the questionnaires and to actively encourage them to complete the questionnaires without any fear of possible consequences of wrong answers. The nurses did not report directly to any of the authors in any way related to employment and the authors had no way of influencing the careers of the nurses. This exclusively research-based relationship increased the reliability of the survey. The majority of the nurses were less than 25 years of age, with only 16.7% older than 30 years. More than 70% of theses nurses were single. The age group in the present study is younger than other studies, which ranged from 30 to 38.1 years (Lui et al., 2008; P€ olkki et al., 2010). The mean experience of the nursing staff was also less than other studies, which ranged from 5 to 9 years (Lui et al., 2008; P€ olkki et al., 2010). The knowledge level and attitudes in terms of scores of true/false and multiple-choice questions and the total score was far below the satisfactory level. Similar results have been reported in other studies (Broome et al., 1996; Hamilton, & Edgar, 1992; Lui et al., 2008; P€ olkki et al., 2010; Qadire, & Khalaileh, 2014; Vortherms, Ryan, & Ward, 1992). Schultz et al. have documented that, like the nursing staff, young doctors also display poor knowledge and attitudes about appropriate pain management (Schultz, Loughran-Fowlds, & Spence, 2010). No statistically significant association was noted between sociodemographic factors and the knowledge and attitudes of the nurses regarding pain. Similar results were reported in studies conducted in
different parts of the world and in different settings (Nimbalkar et al., 2013; Nimbalkar, Dongara, Phatak, & Nimbalkar, 2014; Schultz et al., 2010). These findings demonstrate that although the problem is well documented and recognized, it is not addressed sufficiently. Nurses working in the cardiac surgical ICU have statistically significantly higher total scores compared with the nurses in the cardiac medical care unit, despite similar educational backgrounds. It is likely that more exposure to postoperative patients in cardiac care ICU and interactions with treating clinicians resulted in the acquired knowledge. It is reassuring that the nursing staff felt the need to stay updated and thereby made efforts to improve their knowledge. The questions that were answered incorrectly most often suggested that the nurses did not have sufficient knowledge of the mechanism of pain nor of the causation and behavioral parameters of a patient in pain. Similar results reported by other studies showed that nurses had limited awareness about these domains of pain (Hamilton & Edgar, 1992; Lui et al., 2008; Schultz et al., 2010; Van Hulle Vincent, 2005). The majority of nurses correctly answered those questions related to certain aspects of patient care such as routine postoperative practices and patient monitoring. The current scenario in India is that pain and its management constitute a miniscule part of the routine educational curriculum. No workshops or clinical sessions are a part of the routine nursing curriculum. Also, no periodic workshops or refresher courses are held. These factors may have a cumulative effect, resulting in nurses having a lack of knowledge about pain. The nurses correctly answered the questions that were part of the routine patient care protocol, which indicates that they can be empowered regarding appropriate pain management. There has been evidence demonstrating that nurses’ attitudes and knowledge of patient pain can be improved by targeted workshops (Huth, Gregg, & Lin, 2010). In case vignettes, the nurses rated pain intensity higher for patients who displayed more signs of discomfort. When a patient showed fewer signs, but rated pain as significant, the nurses discounted the patients’ self-reports, and thus these patients often went untreated. On the contrary, a majority of the nurses (70%) felt that the patient was the most accurate judge of his or her own pain. This discrepancy in their knowledge and attitude is concerning. Despite being aware that self-report was considered to be accurate, the nurses showed a tendency to discount patient’s self-reported pain. This discrepancy between knowledge and practice also was found in other studies
Nurses’ Knowledge and Attitudes about Pain
(P€ olkki et al., 2010; Subhashini, Vatsa, & Lodha, 2009). A possible and simple solution to this problem would be the introduction of a standard pain identification protocol or checklist. Patients encountered by the cardiac nursing staff have undergone complicated surgeries and many times have serious complications such as sepsis, meningitis, or hypoxic neurologic injury, which makes identification of pain all the more difficult and hence it becomes incumbent on the nursing staff to assess pain accurately. This insufficient knowledge and inappropriate attitude pertaining to pain also have been found in clinicians and doctors (Schultz et al., 2010; Vortherms, Ryan, & Ward, 1992). Most of the studies conducted to determine the barriers for optimal pain management reported ‘ failure to prescribe analgesics’’ by the treating clinician as the root cause. Other causes included myths believed by health care providers, such as the inability of neonates to feel pain, short-duration procedures not necessitating analgesia, and absence of long-term effects of pain (Subhashini et al., 2009; Van Hulle Vincent, 2005, 2007; Young, 2005). Various abnormalities in the patient’s health status also have been identified as factors
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influencing the caregiver’s perception of a patient’s pain (Breau et al., 2004).
CONCLUSION The knowledge and attitudes of the cardiac nursing staff caring for the pediatric patient population is nonoptimal. There is an urgent need for education and sensitization of all health care providers regarding accurate pain assessment and appropriate pain management (Wysong, 2014). An artful combination of empowerment, reinforcement, and monitoring can ensure optimal pain management, which is necessary for holistic care, especially among patients who are postoperative, expecting a prolonged hospital stay, and cannot verbalize their pain. Acknowledgments The authors acknowledge Rajendra Desai for helping with the analysis of the data and Nisha Fahey for editing the manuscript. They also acknowledge the help and cooperation provided by the nursing staff of B.M. Patel Cardiac Center, Gujarat.
REFERENCES American Academy of Pediatrics (2010). Policy statement: Prevention and management of pain in the neonate: An update. Pediatrics, 2006; 118(5), 2231–2241. Anand, K. J. (1998). Clinical importance of pain and stress in preterm neonates. Biology of the Neonate, 73(1), 1–9. Breau, L. M., McGrath, P. J., Stevens, B., Beyene, J., Camfield, C. S., Finley, G. A., Franck, L., Howlett, A., O’Brien, K., & Ohlsson, A. (2004). Healthcare professionals’ perceptions of pain in infants at risk for neurological impairment. BMC Pediatrics, 4(1), 23. Broome, M. E., Richtsmeier, A., Maikler, V., & Alexander, M. (1996). Pediatric pain practices: A national survey of health professionals. Journal of Pain and Symptom Management, 11(5), 312–320. Ferrell, B. & McCaffery, M. (2008). Knowledge and Attitudes Survey Regarding Pain (revised 2008). City of Hope Pain and Palliative Care Resource Center. Retrieved January 21, 2014, from http://prc.coh.org/res_inst.asp. Goldman, A. (1993). Pain management. Archives of Disease in Childhood, 68(3), 423–425. Hamilton, J., & Edgar, L. (1992). A survey examining nurses’ knowledge of pain control. Journal of Pain and Symptom Management, 7(1), 18–26. Huth, M. M., Gregg, T. L., & Lin, L. (2010). Education changes Mexican nurses’ knowledge and attitudes regarding pediatric pain. Pain Management Nursing, 11(4), 201–208. International Association for the Study of Pain (IASP), Subcommittee on Taxonomy. (1979). Pain terms: A list with definitions and notes on usage. Recommended by the IASP subcommittee on taxonomy. Pain, 6(3), 249. Johnston, C. C. (1989). Pain assessment and management in infants. Pediatrician, 16(1-2), 16–23.
Lui, L. Y., So, W. K., & Fong, D. Y. (2008). Knowledge and attitudes regarding pain management among nurses in Hong Kong medical units. Journal of Clinical Nursing, 17(15), 2014–2021. Nimbalkar, A., Dongara, A., Ganjiwale, J., & Nimbalkar, S. (2013). Pain in children: Knowledge and perceptions of the nursing staff at a rural tertiary care teaching hospital in India. Indian Journal of Pediatrics, 80(6), 470–475. Nimbalkar, A., Dongara, A., Phatak, A., & Nimbalkar, S. (2014). Knowledge and attitudes regarding neonatal pain among nursing staff of pediatric department: An Indian experience. Pain Management Nursing, 15(1), 69–75. O’Rourke, D. (2004). The measurement of pain in infants, children, and adolescents: From policy to practice. Physical Therapy, 84(6), 560–570. P€ olkki, T., Korhonen, A., Laukkala, H., Saarela, T., Vehvil€ainen-Julkunen, K., & Pietil€a, A. M. (2010). Nurses’ attitudes and perceptions of pain assessment in neonatal intensive care. Scandinavian Journal of Caring Sciences, 24(1), 49–55. Price, D. (2000). Psychological and neural mechanisms of the affective dimension of pain. Science, 288(5472), 1769–1772. Qadire, M. A., & Khalaileh, M. A. (2014). Jordanian nurses knowledge and attitude regarding pain management. Pain Management Nursing, 15(1), 220–228. Schultz, M., Loughran-Fowlds, A., & Spence, K. (2010). Neonatal pain: A comparison of the beliefs and practices of junior doctors and current best evidence. Journal of Paediatrics and Child Health, 46(1-2), 23–28. 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.
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Van Hulle Vincent, C. (2005). Nurses’ knowledge, attitudes, and practices: Regarding children’s pain. MCN The American Journal of Maternal/Child Nursing, 30(3), 177–183. Van Hulle Vincent, C. (2007). Nurses’ perceptions of children’s pain: A pilot study of cognitive representations. Journal of Pain and Symptom Management, 33(3), 290–301. Vortherms, R., Ryan, P., & Ward, S. (1992). Knowledge of, attitudes toward, and barriers to pharmacologic
management of cancer pain in a statewide random sample of nurses. Research in Nursing and Health, 15(6), 459–466. Wysong, P. R. (2014). Nurses’ beliefs and self-reported practices related to pain assessment in nonverbal patients. Pain Management Nursing, 15(1), 176–185. Young, K. (2005). Pediatric procedural pain. Annals of Emergency Medicine, 45(2), 160–171.
From the *Department of Pediatrics, Pramukhswami Medical College, Karamsad, Gujarat, Anand, India; † Central Research Services, H.M. Patel Academic Center, Charutar Arogya Mandal, Karamsad, Gujarat, Anand, India; ‡Department of Physiology, Pramukhswami Medical College, Gujarat, Anand, India. Address correspondence to Somashekhar M. Nimbalkar, MD, Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat 388325, India. E-mail: somu_somu@yahoo. com Received April 10, 2014; Revised August 8, 2014; Accepted August 8, 2014. No funding was obtained for this study. AD designed the study, collected the data, and wrote the paper. SS designed the study, collected the data, and provided inputs to the paper. SM conceived the study, designed the study, and gave critical inputs to the paper. AN conceived the study, analyzed the data, and provided critical inputs to the paper. AP analyzed and interpreted the data and wrote the paper. All authors approved the final version of this manuscript. SM is the guarantor for the paper. The authors declare they have no conflict of interest to disclose. 1524-9042/$36.00 Ó 2015 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2014.08.009
-
ABSTRACT:
Pain following cardiac intervention in children is a common, but complex phenomenon. Identifying and reporting pain is the responsibility of the nursing staff, who are the primary caregivers and spend the most time with the patients. Inadequately managed pain in children may lead to multiple short- and long-term adverse effects. The aim of this cross-sectional study was to assess the knowledge and attitudes regarding postoperative pain in children among the nursing staff at B.M. Patel Cardiac Center, Karamsad, Anand, Gujarat, India. The study included 42 of the 45 nurses employed in the cardiac center. The nurses participating in the study were responsible for the care of the pediatric patients. A modified Knowledge and Attitudes Survey Regarding Pain and a sociodemographic questionnaire were administered after obtaining written informed consent. The study was approved by the institutional Human Research Ethics Committee. Mean (SD) experience in years of the nursing staff was 2.32 (1.69) years (range 1 month to 5 years). Of the nurses, 67% were posted in the cardiac surgical intensive care unit (ICU). The mean (SD) score for true/false questions was 11.48 (2.95; range 7,19). The average correct response rate of the true/false questions was 45.9%. Knowledge about pain was only affected by the ward in which the nurse was posted. In first (asymptomatic) and second (symptomatic) case scenarios, 78.6% and 59.5% underestimated pain, respectively. Knowledge and attitudes regarding pain and its management is poor among nurses. Targeted training sessions and repeated reinforcement sessions are essential for holistic patient care. Ó 2015 by the American Society for Pain Management Nursing
Pain Management Nursing, Vol 16, No 3 (June), 2015: pp 314-320
Nurses’ Knowledge and Attitudes about Pain
Postoperative patient care requires a team effort that includes surgeons, anesthetists, intensivists, nutritionists, physiotherapists, and nurses. The nursing staff plays a very vital role, as they are the primary responders and caregivers who spend the most time with the patient. They are responsible for identifying and reporting the patients’ needs to the treating clinicians in an effort to achieve the best possible management of care. In postoperative patients, pain is the most common feature and demands attention. It is an extremely complex sensation, which is partly related to actual or potential tissue damage (IASP Subcommittee on Taxonomy, 1979). Patient’s perception of pain depends on psychological, social, and cultural factors, as well as on previous pain experiences (Goldman, 1993; Price, 2000). The subjective nature of pain makes it difficult to assess. The challenge of assessing pain becomes even greater with pediatric patients. The factors contributing to difficulty in pain assessment in children include a wide range of mental and physical development, limited communication skills, and varying coping mechanisms (Goldman, 1993). Younger children cannot verbalize pain and thus it becomes the caregiver’s responsibility to identify and manage it. The caregiver’s perception of a child’s pain is also a subjective entity that varies with education, age, sex, marital status, own children, previous experience with his or her own hospitalization, and previous experience with his or her own pain (Goldman, 1993; Johnston, 1989; Nimbalkar, Dongara, Ganjiwale, & Nimbalkar, 2013; O’Rourke, 2004). A growing body of scientific evidence now suggests that inadequately managed pain in children may have multiple adverse effects, such as delays in recovery, prolonged hospitalization, psychological stress, increased sleeplessness, altered perception of the sensory system, abnormal responses to stress and pain in the future, and other developmental abnormalities (Van Hulle Vincent, 2005). The younger the child, the harder it is to assess pain and the more pronounced the adverse effects (Anand, 1998; Broome, Richtsmeier, Maikler, & Alexander, 1996). Belief that young children, and particularly infants, do not perceive as much pain as adults because of their immature nervous system has not been shown. It has been demonstrated that infants and children experience pain to a similar degree or even higher compared with adults (Anand, 1998; Young, 2005). The American Academy of Pediatrics (2010) recommends ongoing assessment of the presence and severity of pain and the child’s response to treatment so that pain can be managed adequately. Efficient pain management can help reduce morbidity and
315
mortality. However, a necessary precursor to efficient pain management is the identification of pain, which is a challenging task and also may require validated age-appropriate pain assessment tools. Previous studies indicated that the knowledge regarding pain in children is insufficient, the day-today practices followed by the hospital staff are far from ideal, and attitudes are casual (Nimbalkar et al., 2013). The objective of the present study was to assess nurses’ knowledge and attitudes regarding postoperative pain in children in the B.M. Patel Cardiac Center, Gujarat and to determine the factors associated with their knowledge and attitudes.
MATERIALS AND METHODS The cross-sectional survey was conducted at B.M. Patel Cardiac Center and Shree Krishna Hospital, Karamsad, Anand, Gujarat during September and October 2013. The cardiac center has been functional since October 2008 and has performed more than 850 operations to date. All cardiac surgeries are performed at the study center except cardiac transplantation. The nurses employed were carefully selected from a pool of nurses working at Shree Krishna Hospital and underwent relevant training. There was no standardized written protocol for pain management at the time of this survey. The study was approved by the institutional Human Research Ethics Committee. Written informed consent was obtained from the participating nurses. Sample All 45 nurses employed in the cardiac center (cardiac care unit and cardiac surgical ICU) were included in the study. Instrument A modified Knowledge and Attitudes Survey Regarding Pain questionnaire (Ferrell, & McCaffery, 2008) and a sociodemographic questionnaire were used to collect the data. The Knowledge and Attitudes Survey Regarding Pain questionnaire was developed in 1987 and updated in 2008. The content of the tool was derived from current standards of pain management as recommended by the American Pain Society and the World Health Organization. Construct validity, test–retest reliability, and internal consistency of the tool have been well established (Ferrell, & McCaffery, 2008). The following modifications were made to the questionnaire: 1. Questions related to medications that are not routinely used at the study center were deleted.
316
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2. Questions related to chronic and cancer-related pain were deleted. 3. Questions were modified to suit the study center’s present practice protocols. 4. Some questions were added to suit the study objectives.
The modified tool contained 25 true/false questions, 8 multiple-choice questions, and 2 case scenarios. It was consensually validated by the authors, who have extensive experience in pain research in children. The questionnaire was pre-tested on 10 randomly selected nurses (excluded from the study). A group discussion was organized by the authors to determine if the nurses appropriately understood the questions and the responses accurately reflected their views. One point was awarded for each correct answer, whereas no point was awarded for wrong answers. Thus, a higher score implied more knowledge. The sociodemographic questionnaire contained variables that may influence knowledge level, such as age, location where the nurses work, experience, marital status, and being a parent. Locations where the nurses work were categorized as ‘‘cardiac surgical ICU,’’ ‘‘cardiac medical ICU,’’ and ‘‘cardiac operation theater.’’ Method The questionnaire was distributed following written informed consent. There was no time limit and the nurses returned the completed questionnaire at their convenience. An interactive session was organized to empower nurses regarding the finer nuances of pain management in children. Queries raised by the nurses were deliberated and elaborately addressed. Knowledge level was estimated in terms of total score derived from true/false and multiple-choice questions. Case scenarios were analyzed separately. Descriptive statistics (mean [SD], frequencies [%]) were used to depict the baseline characteristics and knowledge level of the nurses. Independent sample t test was used to determine the association between knowledge level and various sociodemographic variables at the univariate level. Multiple regression was used to determine overall contribution of these variables. The analysis was performed using SPSS 14.0 (SPSS Inc, Chicago, Illinois, USA).
cardiac surgical ICU (66.7%). The mean (SD) experience in years of the nursing staff was 2.32 (1.69) years, with the minimum experience being 1 month and the maximum being 5 years. The mean (SD) score for true/false questions was 11.48 (2.95), with a minimum score of 7 and a maximum score of 19, out of the maximum possible score of 25. The mean (SD) score for multiple-choice questions was 5.26 (1.50), with a minimum score of 3 and maximum score of 7, out of a maximum possible score of 8. The mean (SD) total score was 16.74 (2.34) with a minimum score of 12 and a maximum score of 23, out of the maximum possible score of 33 (Fig. 1). The average correct response rate of the nurses for the true/false statements was 45.9%. The statements that received the most frequent incorrect responses were: 1. Patients may sleep despite severe pain. 2. Combining analgesics that work by different mechanisms may result in better pain control with fewer side effects than using a single analgesic. 3. Patients should be encouraged to endure as much pain as possible before administering an opioid. 4. A patient should experience discomfort before giving the next dose of pain medication. 5. Because their nervous system is underdeveloped, children under 2 years of age have decreased pain sensitivity and limited memory of painful experiences.
The statements that received the most frequent correct responses were: 1. Giving opioids on a regular basis is preferred over a PRN (as-needed) schedule for continuous pain. 2. If a patient reports pain relief and euphoria, he or she should be given a lower dose of the analgesic.
RESULTS An excellent response rate was observed, with questionnaires completed by 42 (93.3%) of the 45 eligible nurses. Twenty-four of the nurses (57.1%) were aged 20 to 25 years; 30 were unmarried (71.4%); 32 were not parents (76.2%); and 28 and were posted in the
FIGURE 1. - Box plots showing distribution of scores. MCQ ¼ multiple-choice question.
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TABLE 1. Response of the Nursing Staff to True/False Statements Statement Vital sign are always reliable indicators of the intensity of a patients pain. Because their nervous system is underdeveloped, children under 2 years of age have decreased pain sensitivity and limited memory of painful experiences. Patients who can be distracted from pain usually do not have severe pain. Patient may sleep despite severe pain. Combining analgesics that work by different mechanisms may result in better pain control with fewer side effects than using a single analgesic. The usual duration of analgesia of 1 to 2 mg fentanyl IV is 4 to 5 hours. Opioids should not be used in patients with a history of substance abuse. Patients should be encouraged to endure as much pain as possible before using an opioid. Children younger than 11 years old cannot reliably report pain so clinicians should rely solely on the parents’ assessment of the child’s pain intensity. Patients’ spiritual beliefs may lead them to think pain and suffering are necessary. After an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with individual patient’s response. Lack of pain expression does not necessarily mean absence of pain. Patients should be maintained in a pain-free state If a patient reports pain relief and euphoria, he or she should be given a lower dose of the analgesic. Patients can tolerate high doses of opioids without sedation or respiratory depression. Estimated pain by an MD or RN is a more valid measure of pain than the patient self-report. Patients may be hesitant to ask for pain medications due to their fears about use of opioids. Patients have the right to expect total pain relief as the goal of treatment. Continuous assessment of pain and medication effectiveness is necessary for good pain management. Giving opioids on a regular basis is preferred over a PRN schedule for continuous pain. A patient should experience discomfort before giving the next dose of pain medication. Comparable stimuli in different people produce the same intensity of pain. Non-drug interventions (heat, music, imagery, etc.) are very effective for mild to moderate pain control but rarely helpful for more severe pain. Beyond a certain dosage of morphine, increases in dose will not increase pain relief. In order to be effective, heat and cold should only be applied to the painful areas.
3. After an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with individual patient’s response. 4. Patients have the right to expect total pain relief as the goal of treatment. 5. Continuous assessment of pain and medication effectiveness is necessary for good pain management (Table 1).
All of the nurses correctly indicated that the intravenous route is the recommended route for administration of opioid analgesics in patients with postoperative pain. Twenty-eight (66.7%) nurses correctly said that morphine/fentanyl is the drug of choice for treatment of prolonged moderate to severe pain. Thirty-eight (90.5%) nurses correctly indicated that an around-theclock fixed schedule should be followed initially for postoperative pain. Thirty-three (78.6%) nurses correctly responded that the most likely reason for a patient with pain to demand increased doses of pain
Correct Answer (%)
Incorrect Answer
20 (47.6) 12 (28.6)
22 30
14 (33.3) 1 (2.4) 8 (19)
26 41 34
16 (38.1) 24 (57.1) 9 (21.4) 23 (54.8)
26 18 33 19
20 (47.6) 28 (66.7)
22 14
15 (35.7) 25 (59.5) 28 (66.7)
27 17 14
18 (42.9) 16 (38.1) 14 (33.3) 27 (64.3) 27 (64.3)
24 26 28 15 15
34 (81) 10 (23.8) 25 (59.5) 23 (54.8)
8 32 17 19
21 (50) 24 (57.1)
21 18
medication is because of increased pain. Thirty-one (73.8%) nurses felt that the most accurate judge of the patient’s pain was the patient him or herself. Twenty-seven (64.3%) nurses incorrectly answered the question regarding the addiction potential of opioid analgesics. Thirty-three (78.6%) nurses correctly knew the time for peak effect of intravenous fentanyl. Forty-one (97.6%) nurses did not know the time for the peak effect of oral paracetamol. Univariate analysis using independent sample t test revealed that marital status (p ¼ .20), age group (p ¼ .24), and being a parent (p ¼ .12) were not statistically significantly associated with the total score, but ward posted (p ¼ .04) was significantly associated with total score. The backward stepwise multiple regression analysis showed that the ward posted (p ¼ .04) was the only significantly associated variable with the total score, albeit the predictive value of the model was poor (r2 ¼ 10%).
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Two case scenarios were given to assess the ability of the nurses to identify pain in postoperative patients and to make decisions regarding its management. In the first (asymptomatic) case, 33 (78.6%) of the nurses underestimated pain in the patient and 36 (85.7%) chose not to treat the patient’s pain. In the second (symptomatic) case, 25 (59.5%) nurses underestimated pain and 26 (61.9%) chose not to treat the patient’s pain. In both case scenarios, the patients had rated their pain as 8 on a visual analog scale. In general, the nurses were not only insufficiently empowered in identification of pain, but they also were hesitant to aggressively and proactively manage pain.
DISCUSSION Considering the small number of eligible nurses, coupled with the fact that this was not a multicenter study, it was possible to achieve an excellent response rate (93.3%) compared with other studies with response rates of 61.4% and 71% (Lui, So, & Fong, 2008; P€ olkki et al., 2010). The authors met in person with all of the eligible nurses to administer the questionnaires and to actively encourage them to complete the questionnaires without any fear of possible consequences of wrong answers. The nurses did not report directly to any of the authors in any way related to employment and the authors had no way of influencing the careers of the nurses. This exclusively research-based relationship increased the reliability of the survey. The majority of the nurses were less than 25 years of age, with only 16.7% older than 30 years. More than 70% of theses nurses were single. The age group in the present study is younger than other studies, which ranged from 30 to 38.1 years (Lui et al., 2008; P€ olkki et al., 2010). The mean experience of the nursing staff was also less than other studies, which ranged from 5 to 9 years (Lui et al., 2008; P€ olkki et al., 2010). The knowledge level and attitudes in terms of scores of true/false and multiple-choice questions and the total score was far below the satisfactory level. Similar results have been reported in other studies (Broome et al., 1996; Hamilton, & Edgar, 1992; Lui et al., 2008; P€ olkki et al., 2010; Qadire, & Khalaileh, 2014; Vortherms, Ryan, & Ward, 1992). Schultz et al. have documented that, like the nursing staff, young doctors also display poor knowledge and attitudes about appropriate pain management (Schultz, Loughran-Fowlds, & Spence, 2010). No statistically significant association was noted between sociodemographic factors and the knowledge and attitudes of the nurses regarding pain. Similar results were reported in studies conducted in
different parts of the world and in different settings (Nimbalkar et al., 2013; Nimbalkar, Dongara, Phatak, & Nimbalkar, 2014; Schultz et al., 2010). These findings demonstrate that although the problem is well documented and recognized, it is not addressed sufficiently. Nurses working in the cardiac surgical ICU have statistically significantly higher total scores compared with the nurses in the cardiac medical care unit, despite similar educational backgrounds. It is likely that more exposure to postoperative patients in cardiac care ICU and interactions with treating clinicians resulted in the acquired knowledge. It is reassuring that the nursing staff felt the need to stay updated and thereby made efforts to improve their knowledge. The questions that were answered incorrectly most often suggested that the nurses did not have sufficient knowledge of the mechanism of pain nor of the causation and behavioral parameters of a patient in pain. Similar results reported by other studies showed that nurses had limited awareness about these domains of pain (Hamilton & Edgar, 1992; Lui et al., 2008; Schultz et al., 2010; Van Hulle Vincent, 2005). The majority of nurses correctly answered those questions related to certain aspects of patient care such as routine postoperative practices and patient monitoring. The current scenario in India is that pain and its management constitute a miniscule part of the routine educational curriculum. No workshops or clinical sessions are a part of the routine nursing curriculum. Also, no periodic workshops or refresher courses are held. These factors may have a cumulative effect, resulting in nurses having a lack of knowledge about pain. The nurses correctly answered the questions that were part of the routine patient care protocol, which indicates that they can be empowered regarding appropriate pain management. There has been evidence demonstrating that nurses’ attitudes and knowledge of patient pain can be improved by targeted workshops (Huth, Gregg, & Lin, 2010). In case vignettes, the nurses rated pain intensity higher for patients who displayed more signs of discomfort. When a patient showed fewer signs, but rated pain as significant, the nurses discounted the patients’ self-reports, and thus these patients often went untreated. On the contrary, a majority of the nurses (70%) felt that the patient was the most accurate judge of his or her own pain. This discrepancy in their knowledge and attitude is concerning. Despite being aware that self-report was considered to be accurate, the nurses showed a tendency to discount patient’s self-reported pain. This discrepancy between knowledge and practice also was found in other studies
Nurses’ Knowledge and Attitudes about Pain
(P€ olkki et al., 2010; Subhashini, Vatsa, & Lodha, 2009). A possible and simple solution to this problem would be the introduction of a standard pain identification protocol or checklist. Patients encountered by the cardiac nursing staff have undergone complicated surgeries and many times have serious complications such as sepsis, meningitis, or hypoxic neurologic injury, which makes identification of pain all the more difficult and hence it becomes incumbent on the nursing staff to assess pain accurately. This insufficient knowledge and inappropriate attitude pertaining to pain also have been found in clinicians and doctors (Schultz et al., 2010; Vortherms, Ryan, & Ward, 1992). Most of the studies conducted to determine the barriers for optimal pain management reported ‘ failure to prescribe analgesics’’ by the treating clinician as the root cause. Other causes included myths believed by health care providers, such as the inability of neonates to feel pain, short-duration procedures not necessitating analgesia, and absence of long-term effects of pain (Subhashini et al., 2009; Van Hulle Vincent, 2005, 2007; Young, 2005). Various abnormalities in the patient’s health status also have been identified as factors
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influencing the caregiver’s perception of a patient’s pain (Breau et al., 2004).
CONCLUSION The knowledge and attitudes of the cardiac nursing staff caring for the pediatric patient population is nonoptimal. There is an urgent need for education and sensitization of all health care providers regarding accurate pain assessment and appropriate pain management (Wysong, 2014). An artful combination of empowerment, reinforcement, and monitoring can ensure optimal pain management, which is necessary for holistic care, especially among patients who are postoperative, expecting a prolonged hospital stay, and cannot verbalize their pain. Acknowledgments The authors acknowledge Rajendra Desai for helping with the analysis of the data and Nisha Fahey for editing the manuscript. They also acknowledge the help and cooperation provided by the nursing staff of B.M. Patel Cardiac Center, Gujarat.
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