European Journal of Oncology Nursing 19 (2015) 44e49
Contents lists available at ScienceDirect
European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon
Quantitative study of oncology nurses' knowledge and attitudes towards pain management in Saudi Arabian hospitals Mohammed Alqahtani*, Linda Katherine Jones School of Health Science, RMIT University, PO Box 71, Bundoora Victoria, 3083 Melbourne, Victoria, Australia
a b s t r a c t Keywords: Attitudes Knowledge Oncology Pain Nursing education Saudi Arabia
Pain is an unpleasant human experience, often associated with underlying medical conditions, and a key reason for individuals experiencing pain to seek medical advice. However, the pain experience is unique and subjective, and affects people's quality of life, as well as impacting on their concerned family members. Optimal pain management requires adequate knowledge, a positive attitude, and competent pain assessment measures. It has been reported that oncology nurses in the Kingdom of Saudi Arabia (KSA) have inadequate knowledge, assessment skills and management of pain. Objective: This paper aims to examine nurses' knowledge and attitudes regarding pain management in Saudi Arabian hospitals (SA). Method: A cross-sectional survey was administered to 320 nurses exhibiting considerable racial, cultural, religious and professional diversity, working in oncology units at five hospitals in the KSA. Selfcompleted survey questionnaires were distributed using the ‘Knowledge and Attitudes Survey Regarding Pain’ (KASRP) tool. Results: The nurses exhibited a relatively poor overall knowledge of pain management (mean score ¼ 45.1%; 95% CI ¼ 43.9%, 46.2%). The mean KASRP scores varied significantly at a ¼ 0.05 with respect to the nurses' nationality, whether they had attended pain-related courses, and whether they had participated in research. Conclusion: The results indicate the urgency needed to reform pain management education for oncology nurses in the KSA. © 2014 Elsevier Ltd. All rights reserved.
Introduction Although it is the moral and ethical responsibility of all nurses to ensure the fundamental right of patients to live free of pain (Brennan et al., 2007), over 20 years of research has indicated that in general, nurses have insufficient knowledge and ability to evaluate and manage pain (McCaffery and Ferrell, 1997; Polomano et al., 2008). In particular, the mismanagement and undertreatment of cancer pain remains a widespread problem (Cohen et al., 2008; Espinosa et al., 2008; Rustøen et al., 2009; Rustøen et al., 2013). Significant deficiencies among oncology nurses in Europe and Asia have been revealed by the relatively low mean scores (percentage of correct answers) that they achieved on the ‘Knowledge and Attitudes Survey Regarding Pain’ (KASRP) tool (Ferrell and McCaffery, -Herna ndez et al., 2012)dfor example, 48.6% in Spain (Salvado
* Corresponding author. E-mail addresses: [email protected] (M. Alqahtani), [email protected]. au (L.K. Jones). http://dx.doi.org/10.1016/j.ejon.2014.07.013 1462-3889/© 2014 Elsevier Ltd. All rights reserved.
2009); 55.0% in Italy (Bernardi et al., 2007); 50.5% in Taiwan (Lai et al., 2003); and 35.4% in Turkey (Yildirim et al., 2008). The KASRP has not previously been administered in the Kingdom of Saudi Arabia (KSA), and there is no previous research on the knowledge and attitudes of oncology nurses towards pain management in Saudi Arabian hospitals. The only previous study of nurses' knowledge concerning pharmacological measures of acute pain management, conducted among 300 nurses in Jeddah in 2007, suggested that ‘Nurses’ knowledge of acute pain management is deficient in many aspects' (Kaki et al., 2009). In the light of this, the overall aim of the current mixed methods study was to explore the knowledge and attitudes of oncology nurses towards the management of pain in the KSA healthcare sector. This paper presents the findings from the quantitative phase. Oncology nurses were selected because relieving pain in the presence of identified and diagnosed concerns is one of the central goals of many oncology nursing interventions (Espinosa et al., 2008). However, it is argued that many of the frameworks, intervention protocols and assessment tools have not been used
M. Alqahtani, L.K. Jones / European Journal of Oncology Nursing 19 (2015) 44e49
effectively by oncology nurses to improve the care of patients experiencing pain (Cohen et al., 2008). The main objectives were (a) to measure the nurses' knowledge and attitudes towards pain management in oncology units at five KSA hospitals using the KASRP; and (b) to determine the extent to which the KASRP scores varied with respect to the nurses' demographic characteristics (gender, age, religion and nationality) and contextual characteristics (education, years of experience, participation in research, conference attendance and attendance at pain management courses). The latter objective was important because the nurse population in the KSA is a multinational assemblage, exhibiting considerable racial, cultural, religious and professional diversity (Van Rooyen et al., 2010). This situation has arisen because the KSA is faced with a chronic shortage of Saudi nurses, accompanied by high rates of turnover. Consequently, expatriate nurses currently form a large proportion of the nursing workforce in Saudi healthcare facilities (Almalki et al., 2011). The final objective of this study was to apply the findings to provide managerial and practical recommendations for health-service providers in the KSA that may help to promote improvements in the nursing healthcare of cancer patients.
Methods The inclusion criteria for the sample were registered nurses aged 21e60 years with at least three months' work experience in adult oncology units at Five large (>500 bed) hospitals in the KSA. Nurses working in paediatric oncology units were excluded because children have unique and special needs. Directors of nursing services, associate degree nurses and patient care assistants were also excluded because their knowledge would not be equivalent to nurses who cared for adult patients in oncology units. Recruiting began after ethical approval was obtained from the Human Research Ethics Committee at RMIT University (BSEHAPP 37e11 ALQAHTANI). The researcher contacted the director of nursing of each hospital to seek permission to access the oncology unit managers. The researcher then met with the oncology unit managers of each hospital and explained the purpose of the study, the data collection tool, and the time required for nurses to complete the questionnaire. Subsequently, the oncology unit managers facilitated the recruitment of nurses within their unit. The nurses were then screened for their eligibility to participate. Nurses who met the inclusion criteria were provided with a package through the unit manager including a cover letter and copy of the questionnaire. Participants were asked to return the questionnaire to the researcher through a box in the office of the unit manager. A total of 400 packages were distributed, of which 340 were returned, but 20 were incomplete. Three hundred and twenty nurses provided valid responses with no missing values, representing a response rate of 80%. The KASRP was modified by the use of Arabic names in the case studies. A KASRP score for each participant was computed, with the proportion of correct answers being expressed as a percentage. Internal consistency reliability was estimated using the KudereRichardson (KR-20) coefficient, which is equivalent to Cronbach's alpha for tests with dichotomous (correct or incorrect) responses. Pearson's r coefficients were computed to determine whether there were any correlations between the KASRP scores and the age (years), work experience (years) and hospital experience (months) of the nurses. Multifactorial analysis of variance (ANOVA) was conducted to compare the mean KASRP scores between groups of nurses, classified by their demographic and
45
contextual characteristics, assuming homogeneity of variance, confirmed by Levene's test. Results The demographic characteristics of the 320 participants are summarised in Table 1. The sample was dominated by females. Their ages ranged from 24 to 65 years (M ¼ 34.2 years, SD ¼ 8.6). The majority of the nurses were between the ages of 24 and 39 years. Approximately three-quarters were expatriates, mainly Filipino and Indian, and most were Christian. Less than 25% were Muslims from Saudi Arabia or other Middle Eastern nations. The contextual characteristics of the participants are summarised in Table 2. Less than half of the nurses had previously worked in the KSA. Their experience in nursing ranged widely, from 1 to 38 years (M ¼ 10.8, SD ¼ 7.5). Approximately three-quarters had more than two years hospital experience. Most had attended specialist courses for nurses; however, relatively few had participated in research or attended conferences concerned with pain management. Virtually all the nurses had used a pain-assessment scale and/or a pain-grading tool. The frequency distribution of the percentage scores for the KASRP was approximately normal, indicated by a bell-shaped histogram (Fig. 1). On average, the mean scores indicated that the nurses exhibited a relatively poor overall knowledge of pain management (M ¼ 45.1%; 95% CI ¼ 43.9%, 46.2%). Only 26% of the nurses scored >50%. Four nurses (1.2%) with a KASRP score >85% represented extreme outliers. The frequencies of the participants who obtained correct answers for more than 50% of the 37 items are presented in Table 3. The majority of the nurses (>70%) were able to answer questions requiring factual answers about the administration of analgesics and addiction, specifically (in order from highest percentage correct): Item 14, the adjustment of the dose in accordance with the individual patient's response; Item 20, the definition of narcotic/ opioid addiction; Item 23, when analgesic medication is considered
Table 1 Nurses' demographic characteristics. Characteristic
Group
Frequency
Per cent
Gender
Female Male 21e29 30e39 40e49 50e59 60þ Christian Islam Hindu Other religions Philippines India KSA Middle East Other nationality South Africa Pacific Islander Asian Arabic Caucasian American Indian African Single Married Separated Divorced Widowed
284 36 124 123 46 19 8 236 70 7 7 176 90 23 16 9 6 176 96 39 4 3 2 102 201 11 1 5
88.8% 11.2% 38.8% 38.4% 14.4% 5.9% 2.5% 73.8% 21.9% 2.2% 2.2% 55.0% 28.1% 7.2% 5.0% 2.8% 1.9% 55.0% 30.0% 12.2% 1.2% 0.9% 0.6% 31.9% 66.2% 3.4% 0.3% 1.6%
Age (years)
Religion
Nationality
Race
Marital status
46
M. Alqahtani, L.K. Jones / European Journal of Oncology Nursing 19 (2015) 44e49
Table 2 Nurses' contextual characteristics.
Table 3 KASRP items answered correctly by >50% of the nurses.
Characteristic
Group
Frequency
Per cent
Item
Per cent correct
Previously worked in KSA?
Yes No 1e4 months 4e8 months 8e12 months 12e24 months >24 months 25 Diploma BSc MSc Yes No Pain management Chemotherapy Patient safety Multiple courses None Yes No Yes No Yes No
132 188 18 20 22 22 238 45 157 57 26 15 20 110 206 4 48 272 38 57 36 120 69 104 216 314 6 303 17
41.2% 58.8% 5.6% 6.2% 6.9% 6.9% 74.4% 14.1% 49.1% 17.8% 8.1% 4.7% 6.3% 34.4% 64.4% 1.2% 15.0% 85.0% 11.9% 17.8% 11.2% 37.5% 21.6% 32.5% 67.5% 98.1% 1.9% 94.7% 5.3%
14. After an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with the individual patient's response. 20. Narcotic/opioid addiction is defined as a chronic neurobiologic disease, characterised by behaviours that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. 23. Analgesic medication is considered the drug of choice for the treatment of prolonged moderate to severe pain for cancer patients. 25. Analgesics for post-operative pain should initially be given …. 31. The time to peak effect for morphine given IV is …. 6. Combining analgesics that work by different mechanisms (e.g., combining an opioid with an NSAIDa) may result in better pain control with fewer side effects than using a single analgesic agent. 22. The recommended route administration of opioid analgesics for patients with brief, severe pain of sudden onset such as trauma or post-operative pain. 29. The most accurate judge of the intensity of the patient's pain is …. 5. Respiratory depression rarely occurs in patients who have been receiving stable doses of opioids over a period of months. 11. Elderly patients cannot tolerate opioids for pain relief. 27. The most likely reason a patient with pain would request increased doses of pain medication is …. 13. Patients' spiritual beliefs may lead them to think pain and suffering are necessary. 19. Benzodiazepines are not effective pain relievers unless the pain is due to muscle spasm. 12. Patients should be encouraged to endure as much pain as possible before using an opioid.
83.1%
Hospital experience (months)
Work experience (years)
Education
Participated in research? Attended pain-related courses?
Attended conferences? Used pain-assessment scale? Used pain-grading tool?
the drug of choice; Item 25, when analgesics for post-operative pain should initially be given; Item 31, the time to peak effect for morphine; Item 6, combining analgesics that work by different mechanisms; and Item 22, the recommended route administration of opioid analgesics for patients with brief, severe pain. Between 50% and 70% of the participating nurses were able to answer further questions concerning their knowledge and beliefs about the administration of analgesics, including: Item 5, respiratory depression; Item 11, elderly patients' tolerance of opioids for pain relief; Item 27, the most likely reason a patient with pain would request increased doses of medication; Item 13, patients' spiritual beliefs; Item 19, the effectiveness of Benzodiazepines; Item 12, how much pain patients should be encouraged to endure before using an opioid. The frequencies of the participants who obtained correct answers for 50% or less of the 37 items are presented in Table 4. Very
Fig. 1. Frequency distribution of the percentage of correct answers for the KASRP obtained by oncology nurses (N ¼ 320) at Five KSA hospitals.
a
80.9%
79.7%
79.4% 76.3% 74.7%
71.6%
71.3% 66.9%
63.4% 62.2% 61.3% 59.4% 55.9%
Non-steroidal anti-inflammatory drug.
few (less than 25%) of the participants could answer correctly those questions that involved making value judgements rather than providing factual answers concerning analgesic administration, including: Item 24, which doses of morphine administered over a four-hour period would be equivalent to 30 mg of oral morphine given in 24 h?; Item 1, whether vital signs are always reliable indicators of the intensity of patients' pain; Item 34, circling a number that represents an assessment of Mohammad's pain; Item 37, checking an action that they would take; Item 3, whether patients may sleep in spite of severe pain; Item 17, opioids should not be used during the pain evaluation period; Item 33, manifestation of physical dependence on opioids; Item 26, the likelihood of the patient developing clinically significant respiratory depression in the absence of new comorbidity; Items 35 and 36, checking an action that they would take; and Item 21, the recommended route of administration of opioid analgesics for patients with persistent cancer-related pain. No significant Pearson's r correlations were found at a ¼ 0.05 between the KASRP scores and the age, work experience or hospital experience of the nurses. The results of multifactorial ANOVA are summarised in Table 5. The non-significant (p > 0.05) effects of gender, religion, race, education and conference attendance were excluded from the ANOVA model. The significant effects (p < 0.05) on the mean KASRP scores with respect to the nurses' nationality, attendance at pain-related courses and participation in research are illustrated in Fig. 2. Nurses from South Africa and other countries achieved the highest mean KASRP score (49.6%), followed by nurses from the KSA and Middle East (46.8%), the Philippines (45.9%) and India (41.9%). The mean KASRP score of the
M. Alqahtani, L.K. Jones / European Journal of Oncology Nursing 19 (2015) 44e49 Table 4 KASRP items answered correctly by 50% of the nurses. Item
Per cent correct
30. How likely is it that patients who develop pain already have an alcohol and/or drug abuse problem? 18. Anticonvulsant drugs such as gabapentin (Neurontin) produce optimal pain relief after a single dose. 15. Giving patients sterile water by injection (placebo) is a useful test to determine if the pain is real. 4. Aspirin and other non-steroidal anti-inflammatory agents are NOT effective analgesics for painful bone metastasis. 16. Vicodin (hydrocodone 5 mg þ acetaminophen 500 mg) PO is approximately equal to 5e10 mg of morphine PO. 2. Patients who can be distracted from pain usually do not have severe pain. 28. Which of the following is useful for treatment of cancer pain?.. 10. Morphine has a dose ceiling (i.e., a dose above which no greater pain relief can be obtained). 8. Research shows that promethazine (Phenergan) and hydroxyzine (Vistaril) are reliable potentiators of opioid analgesics. 32. The time to peak effect for morphine given IV orally …. 36. Circle the number that represents your assessment of Ahmad's pain. 7. The usual duration of analgesia of 1e2 mg morphine IV is 4e5 h. 9. Opioids should not be used in patients with a history of substance abuse. 24. Which of the following IV doses of morphine administered over a four-hour period would be equivalent to 30 mg of oral morphine given over 4 h?
50.0% 47.2% 46.6% 45.9% 44.7% 44.4% 40.9% 39.4% 38.4%
34.7% 34.4% 33.1% 29.4% 24.7%
nurses who had attended pain-related courses (45.9%) was 3.8% higher than the nurses who had not attended such courses. The mean KASRP score of the nurses who had participated in research (50.9%) was 7.2% higher than the nurses who had not participated in research. There were no significant interactions, implying that the mean KASRP scores for all nationalities increased in parallel with respect to attendance at pain-related courses and participation in research. Discussion The mean KASRP score among the sample of 320 nurses was 45.1%, which was low in comparison to international standards. Although all of the participants were experienced registered nurses, their mean KASRP score was found to be little more than that achieved by student nurses in Iran (Rahimi-Madesh et al., 2010) and Jordan (Al-Khawaldeh et al., 2013). These results supported a previous suggestion (Kaki et al., 2009) that the knowledge of pain management among nurses in the KSA is generally deficient. Further, the results of this study were not consistent with other studies in which the KASRP scores were found to be significantly higher among nurses with longer working experience (Lui et al., 2008; Tafas et al., 2002; Tse and Chan, 2004; Wang and Tsai, 2010; Yildirim et al., 2008) and nurses with the highest qualifications (Duke et al., 2013; Plaisance and Logan, 2006). However, the results were consistent with the conclusion that nurses who Table 5 Multifactorial ANOVA to compare the mean KASRP scores with respect to the effects of nationality, participation in research and attendance at pain-related courses of the oncology nurses (N ¼ 320) at five KSA hospitals. Effect
F
p
Nationality Attend pain-related courses Participation in research
4.63 5.10 19.05
0.003a 0.025a
Contents lists available at ScienceDirect
European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon
Quantitative study of oncology nurses' knowledge and attitudes towards pain management in Saudi Arabian hospitals Mohammed Alqahtani*, Linda Katherine Jones School of Health Science, RMIT University, PO Box 71, Bundoora Victoria, 3083 Melbourne, Victoria, Australia
a b s t r a c t Keywords: Attitudes Knowledge Oncology Pain Nursing education Saudi Arabia
Pain is an unpleasant human experience, often associated with underlying medical conditions, and a key reason for individuals experiencing pain to seek medical advice. However, the pain experience is unique and subjective, and affects people's quality of life, as well as impacting on their concerned family members. Optimal pain management requires adequate knowledge, a positive attitude, and competent pain assessment measures. It has been reported that oncology nurses in the Kingdom of Saudi Arabia (KSA) have inadequate knowledge, assessment skills and management of pain. Objective: This paper aims to examine nurses' knowledge and attitudes regarding pain management in Saudi Arabian hospitals (SA). Method: A cross-sectional survey was administered to 320 nurses exhibiting considerable racial, cultural, religious and professional diversity, working in oncology units at five hospitals in the KSA. Selfcompleted survey questionnaires were distributed using the ‘Knowledge and Attitudes Survey Regarding Pain’ (KASRP) tool. Results: The nurses exhibited a relatively poor overall knowledge of pain management (mean score ¼ 45.1%; 95% CI ¼ 43.9%, 46.2%). The mean KASRP scores varied significantly at a ¼ 0.05 with respect to the nurses' nationality, whether they had attended pain-related courses, and whether they had participated in research. Conclusion: The results indicate the urgency needed to reform pain management education for oncology nurses in the KSA. © 2014 Elsevier Ltd. All rights reserved.
Introduction Although it is the moral and ethical responsibility of all nurses to ensure the fundamental right of patients to live free of pain (Brennan et al., 2007), over 20 years of research has indicated that in general, nurses have insufficient knowledge and ability to evaluate and manage pain (McCaffery and Ferrell, 1997; Polomano et al., 2008). In particular, the mismanagement and undertreatment of cancer pain remains a widespread problem (Cohen et al., 2008; Espinosa et al., 2008; Rustøen et al., 2009; Rustøen et al., 2013). Significant deficiencies among oncology nurses in Europe and Asia have been revealed by the relatively low mean scores (percentage of correct answers) that they achieved on the ‘Knowledge and Attitudes Survey Regarding Pain’ (KASRP) tool (Ferrell and McCaffery, -Herna ndez et al., 2012)dfor example, 48.6% in Spain (Salvado
* Corresponding author. E-mail addresses: [email protected] (M. Alqahtani), [email protected]. au (L.K. Jones). http://dx.doi.org/10.1016/j.ejon.2014.07.013 1462-3889/© 2014 Elsevier Ltd. All rights reserved.
2009); 55.0% in Italy (Bernardi et al., 2007); 50.5% in Taiwan (Lai et al., 2003); and 35.4% in Turkey (Yildirim et al., 2008). The KASRP has not previously been administered in the Kingdom of Saudi Arabia (KSA), and there is no previous research on the knowledge and attitudes of oncology nurses towards pain management in Saudi Arabian hospitals. The only previous study of nurses' knowledge concerning pharmacological measures of acute pain management, conducted among 300 nurses in Jeddah in 2007, suggested that ‘Nurses’ knowledge of acute pain management is deficient in many aspects' (Kaki et al., 2009). In the light of this, the overall aim of the current mixed methods study was to explore the knowledge and attitudes of oncology nurses towards the management of pain in the KSA healthcare sector. This paper presents the findings from the quantitative phase. Oncology nurses were selected because relieving pain in the presence of identified and diagnosed concerns is one of the central goals of many oncology nursing interventions (Espinosa et al., 2008). However, it is argued that many of the frameworks, intervention protocols and assessment tools have not been used
M. Alqahtani, L.K. Jones / European Journal of Oncology Nursing 19 (2015) 44e49
effectively by oncology nurses to improve the care of patients experiencing pain (Cohen et al., 2008). The main objectives were (a) to measure the nurses' knowledge and attitudes towards pain management in oncology units at five KSA hospitals using the KASRP; and (b) to determine the extent to which the KASRP scores varied with respect to the nurses' demographic characteristics (gender, age, religion and nationality) and contextual characteristics (education, years of experience, participation in research, conference attendance and attendance at pain management courses). The latter objective was important because the nurse population in the KSA is a multinational assemblage, exhibiting considerable racial, cultural, religious and professional diversity (Van Rooyen et al., 2010). This situation has arisen because the KSA is faced with a chronic shortage of Saudi nurses, accompanied by high rates of turnover. Consequently, expatriate nurses currently form a large proportion of the nursing workforce in Saudi healthcare facilities (Almalki et al., 2011). The final objective of this study was to apply the findings to provide managerial and practical recommendations for health-service providers in the KSA that may help to promote improvements in the nursing healthcare of cancer patients.
Methods The inclusion criteria for the sample were registered nurses aged 21e60 years with at least three months' work experience in adult oncology units at Five large (>500 bed) hospitals in the KSA. Nurses working in paediatric oncology units were excluded because children have unique and special needs. Directors of nursing services, associate degree nurses and patient care assistants were also excluded because their knowledge would not be equivalent to nurses who cared for adult patients in oncology units. Recruiting began after ethical approval was obtained from the Human Research Ethics Committee at RMIT University (BSEHAPP 37e11 ALQAHTANI). The researcher contacted the director of nursing of each hospital to seek permission to access the oncology unit managers. The researcher then met with the oncology unit managers of each hospital and explained the purpose of the study, the data collection tool, and the time required for nurses to complete the questionnaire. Subsequently, the oncology unit managers facilitated the recruitment of nurses within their unit. The nurses were then screened for their eligibility to participate. Nurses who met the inclusion criteria were provided with a package through the unit manager including a cover letter and copy of the questionnaire. Participants were asked to return the questionnaire to the researcher through a box in the office of the unit manager. A total of 400 packages were distributed, of which 340 were returned, but 20 were incomplete. Three hundred and twenty nurses provided valid responses with no missing values, representing a response rate of 80%. The KASRP was modified by the use of Arabic names in the case studies. A KASRP score for each participant was computed, with the proportion of correct answers being expressed as a percentage. Internal consistency reliability was estimated using the KudereRichardson (KR-20) coefficient, which is equivalent to Cronbach's alpha for tests with dichotomous (correct or incorrect) responses. Pearson's r coefficients were computed to determine whether there were any correlations between the KASRP scores and the age (years), work experience (years) and hospital experience (months) of the nurses. Multifactorial analysis of variance (ANOVA) was conducted to compare the mean KASRP scores between groups of nurses, classified by their demographic and
45
contextual characteristics, assuming homogeneity of variance, confirmed by Levene's test. Results The demographic characteristics of the 320 participants are summarised in Table 1. The sample was dominated by females. Their ages ranged from 24 to 65 years (M ¼ 34.2 years, SD ¼ 8.6). The majority of the nurses were between the ages of 24 and 39 years. Approximately three-quarters were expatriates, mainly Filipino and Indian, and most were Christian. Less than 25% were Muslims from Saudi Arabia or other Middle Eastern nations. The contextual characteristics of the participants are summarised in Table 2. Less than half of the nurses had previously worked in the KSA. Their experience in nursing ranged widely, from 1 to 38 years (M ¼ 10.8, SD ¼ 7.5). Approximately three-quarters had more than two years hospital experience. Most had attended specialist courses for nurses; however, relatively few had participated in research or attended conferences concerned with pain management. Virtually all the nurses had used a pain-assessment scale and/or a pain-grading tool. The frequency distribution of the percentage scores for the KASRP was approximately normal, indicated by a bell-shaped histogram (Fig. 1). On average, the mean scores indicated that the nurses exhibited a relatively poor overall knowledge of pain management (M ¼ 45.1%; 95% CI ¼ 43.9%, 46.2%). Only 26% of the nurses scored >50%. Four nurses (1.2%) with a KASRP score >85% represented extreme outliers. The frequencies of the participants who obtained correct answers for more than 50% of the 37 items are presented in Table 3. The majority of the nurses (>70%) were able to answer questions requiring factual answers about the administration of analgesics and addiction, specifically (in order from highest percentage correct): Item 14, the adjustment of the dose in accordance with the individual patient's response; Item 20, the definition of narcotic/ opioid addiction; Item 23, when analgesic medication is considered
Table 1 Nurses' demographic characteristics. Characteristic
Group
Frequency
Per cent
Gender
Female Male 21e29 30e39 40e49 50e59 60þ Christian Islam Hindu Other religions Philippines India KSA Middle East Other nationality South Africa Pacific Islander Asian Arabic Caucasian American Indian African Single Married Separated Divorced Widowed
284 36 124 123 46 19 8 236 70 7 7 176 90 23 16 9 6 176 96 39 4 3 2 102 201 11 1 5
88.8% 11.2% 38.8% 38.4% 14.4% 5.9% 2.5% 73.8% 21.9% 2.2% 2.2% 55.0% 28.1% 7.2% 5.0% 2.8% 1.9% 55.0% 30.0% 12.2% 1.2% 0.9% 0.6% 31.9% 66.2% 3.4% 0.3% 1.6%
Age (years)
Religion
Nationality
Race
Marital status
46
M. Alqahtani, L.K. Jones / European Journal of Oncology Nursing 19 (2015) 44e49
Table 2 Nurses' contextual characteristics.
Table 3 KASRP items answered correctly by >50% of the nurses.
Characteristic
Group
Frequency
Per cent
Item
Per cent correct
Previously worked in KSA?
Yes No 1e4 months 4e8 months 8e12 months 12e24 months >24 months 25 Diploma BSc MSc Yes No Pain management Chemotherapy Patient safety Multiple courses None Yes No Yes No Yes No
132 188 18 20 22 22 238 45 157 57 26 15 20 110 206 4 48 272 38 57 36 120 69 104 216 314 6 303 17
41.2% 58.8% 5.6% 6.2% 6.9% 6.9% 74.4% 14.1% 49.1% 17.8% 8.1% 4.7% 6.3% 34.4% 64.4% 1.2% 15.0% 85.0% 11.9% 17.8% 11.2% 37.5% 21.6% 32.5% 67.5% 98.1% 1.9% 94.7% 5.3%
14. After an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with the individual patient's response. 20. Narcotic/opioid addiction is defined as a chronic neurobiologic disease, characterised by behaviours that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. 23. Analgesic medication is considered the drug of choice for the treatment of prolonged moderate to severe pain for cancer patients. 25. Analgesics for post-operative pain should initially be given …. 31. The time to peak effect for morphine given IV is …. 6. Combining analgesics that work by different mechanisms (e.g., combining an opioid with an NSAIDa) may result in better pain control with fewer side effects than using a single analgesic agent. 22. The recommended route administration of opioid analgesics for patients with brief, severe pain of sudden onset such as trauma or post-operative pain. 29. The most accurate judge of the intensity of the patient's pain is …. 5. Respiratory depression rarely occurs in patients who have been receiving stable doses of opioids over a period of months. 11. Elderly patients cannot tolerate opioids for pain relief. 27. The most likely reason a patient with pain would request increased doses of pain medication is …. 13. Patients' spiritual beliefs may lead them to think pain and suffering are necessary. 19. Benzodiazepines are not effective pain relievers unless the pain is due to muscle spasm. 12. Patients should be encouraged to endure as much pain as possible before using an opioid.
83.1%
Hospital experience (months)
Work experience (years)
Education
Participated in research? Attended pain-related courses?
Attended conferences? Used pain-assessment scale? Used pain-grading tool?
the drug of choice; Item 25, when analgesics for post-operative pain should initially be given; Item 31, the time to peak effect for morphine; Item 6, combining analgesics that work by different mechanisms; and Item 22, the recommended route administration of opioid analgesics for patients with brief, severe pain. Between 50% and 70% of the participating nurses were able to answer further questions concerning their knowledge and beliefs about the administration of analgesics, including: Item 5, respiratory depression; Item 11, elderly patients' tolerance of opioids for pain relief; Item 27, the most likely reason a patient with pain would request increased doses of medication; Item 13, patients' spiritual beliefs; Item 19, the effectiveness of Benzodiazepines; Item 12, how much pain patients should be encouraged to endure before using an opioid. The frequencies of the participants who obtained correct answers for 50% or less of the 37 items are presented in Table 4. Very
Fig. 1. Frequency distribution of the percentage of correct answers for the KASRP obtained by oncology nurses (N ¼ 320) at Five KSA hospitals.
a
80.9%
79.7%
79.4% 76.3% 74.7%
71.6%
71.3% 66.9%
63.4% 62.2% 61.3% 59.4% 55.9%
Non-steroidal anti-inflammatory drug.
few (less than 25%) of the participants could answer correctly those questions that involved making value judgements rather than providing factual answers concerning analgesic administration, including: Item 24, which doses of morphine administered over a four-hour period would be equivalent to 30 mg of oral morphine given in 24 h?; Item 1, whether vital signs are always reliable indicators of the intensity of patients' pain; Item 34, circling a number that represents an assessment of Mohammad's pain; Item 37, checking an action that they would take; Item 3, whether patients may sleep in spite of severe pain; Item 17, opioids should not be used during the pain evaluation period; Item 33, manifestation of physical dependence on opioids; Item 26, the likelihood of the patient developing clinically significant respiratory depression in the absence of new comorbidity; Items 35 and 36, checking an action that they would take; and Item 21, the recommended route of administration of opioid analgesics for patients with persistent cancer-related pain. No significant Pearson's r correlations were found at a ¼ 0.05 between the KASRP scores and the age, work experience or hospital experience of the nurses. The results of multifactorial ANOVA are summarised in Table 5. The non-significant (p > 0.05) effects of gender, religion, race, education and conference attendance were excluded from the ANOVA model. The significant effects (p < 0.05) on the mean KASRP scores with respect to the nurses' nationality, attendance at pain-related courses and participation in research are illustrated in Fig. 2. Nurses from South Africa and other countries achieved the highest mean KASRP score (49.6%), followed by nurses from the KSA and Middle East (46.8%), the Philippines (45.9%) and India (41.9%). The mean KASRP score of the
M. Alqahtani, L.K. Jones / European Journal of Oncology Nursing 19 (2015) 44e49 Table 4 KASRP items answered correctly by 50% of the nurses. Item
Per cent correct
30. How likely is it that patients who develop pain already have an alcohol and/or drug abuse problem? 18. Anticonvulsant drugs such as gabapentin (Neurontin) produce optimal pain relief after a single dose. 15. Giving patients sterile water by injection (placebo) is a useful test to determine if the pain is real. 4. Aspirin and other non-steroidal anti-inflammatory agents are NOT effective analgesics for painful bone metastasis. 16. Vicodin (hydrocodone 5 mg þ acetaminophen 500 mg) PO is approximately equal to 5e10 mg of morphine PO. 2. Patients who can be distracted from pain usually do not have severe pain. 28. Which of the following is useful for treatment of cancer pain?.. 10. Morphine has a dose ceiling (i.e., a dose above which no greater pain relief can be obtained). 8. Research shows that promethazine (Phenergan) and hydroxyzine (Vistaril) are reliable potentiators of opioid analgesics. 32. The time to peak effect for morphine given IV orally …. 36. Circle the number that represents your assessment of Ahmad's pain. 7. The usual duration of analgesia of 1e2 mg morphine IV is 4e5 h. 9. Opioids should not be used in patients with a history of substance abuse. 24. Which of the following IV doses of morphine administered over a four-hour period would be equivalent to 30 mg of oral morphine given over 4 h?
50.0% 47.2% 46.6% 45.9% 44.7% 44.4% 40.9% 39.4% 38.4%
34.7% 34.4% 33.1% 29.4% 24.7%
nurses who had attended pain-related courses (45.9%) was 3.8% higher than the nurses who had not attended such courses. The mean KASRP score of the nurses who had participated in research (50.9%) was 7.2% higher than the nurses who had not participated in research. There were no significant interactions, implying that the mean KASRP scores for all nationalities increased in parallel with respect to attendance at pain-related courses and participation in research. Discussion The mean KASRP score among the sample of 320 nurses was 45.1%, which was low in comparison to international standards. Although all of the participants were experienced registered nurses, their mean KASRP score was found to be little more than that achieved by student nurses in Iran (Rahimi-Madesh et al., 2010) and Jordan (Al-Khawaldeh et al., 2013). These results supported a previous suggestion (Kaki et al., 2009) that the knowledge of pain management among nurses in the KSA is generally deficient. Further, the results of this study were not consistent with other studies in which the KASRP scores were found to be significantly higher among nurses with longer working experience (Lui et al., 2008; Tafas et al., 2002; Tse and Chan, 2004; Wang and Tsai, 2010; Yildirim et al., 2008) and nurses with the highest qualifications (Duke et al., 2013; Plaisance and Logan, 2006). However, the results were consistent with the conclusion that nurses who Table 5 Multifactorial ANOVA to compare the mean KASRP scores with respect to the effects of nationality, participation in research and attendance at pain-related courses of the oncology nurses (N ¼ 320) at five KSA hospitals. Effect
F
p
Nationality Attend pain-related courses Participation in research
4.63 5.10 19.05
0.003a 0.025a
