Status of pediatric nurses’ knowledge about pain
Alison Twycross and Stephanie J. Dowden
Nurses’ knowledge about pain in children
The evidence to guide nurses’ pain management practices is readily available in the form of clinical guidelines. However, pediatric nurses’ pain management practices continue to fall short of the ideal (Pölkki et al., 2003; Vincent & Denyes 2004; Twycross 2007) with children often experiencing moderate to severe unrelieved pain (Vincent & Denyes, 2004; Johnston et al., 2005; Taylor et al., 2008). Insufficient knowledge about managing pain in children has been suggested as one reason nurses do not manage pain effectively. Seven studies have examined pediatric nurses’ knowledge about pain in children. A study carried out with pediatric oncology nurses (n=106) in the USA found a lack of understanding of basic pharmacological principles in relation to analgesic drugs (Schmidt et al., 1994). Schmidt et al. (1994) do not provide any information about statistical testing, so these results should be treated with caution; however, as they concur with the results of similar studies (see below), they may provide an accurate insight into nurses’ knowledge.
Salanterä et al. (1999) developed a pain management knowledge questionnaire based on a review of the research literature about pain. This questionnaire was completed by pediatric nurses (n=265) in Finland. For questions relating to non-drug methods the mean score was 69%, while for the items about pharmacological pain management the mean score was 51%. These results indicate that there are gaps in nurses’ knowledge (Salanterä et al., 1999). In another study, final year student nurses (n=73) also completed the same questionnaire. The mean score for the questions about non-drug methods was 68% and for items pertaining to the pharmacological management of pain the mean score was 54% (Salanterä & Lauri, 2000). The similarity between the scores of registered nurses and student nurses suggests that there is a need to evaluate both pre- and post-registration education in this area.
Twycross (2004) used a modified version of Salanterä’s questionnaire (as part of a larger study). Nurses’ (n=12) mean score was 78% (range: 69-89%). Participants had gaps in their knowledge; these were particularly noticeable in relation to analgesic drugs, non-drug methods and the physiology of pain as well as the psychology and sociology of pain. Statistical testing was not carried out due to the small sample size. However, a comparison of the scores of participants with less than 5 years experience in pediatric nursing to scores of participants with more experience suggested that years of experience had no effect on participants’scores. It also appeared that being educated to graduate level may increase the likelihood of a nurse having greater knowledge about pain management.
The Pediatric Nurses’ Knowledge and Attitudes Regarding Pain Survey was completed by nurses (n=274) in Manworren’s (2000) study. The mean score for the questionnaire was 66% (range: 31-98%). Knowledge deficits were apparent in many areas including: pain assessment, the pharmacology of analgesic drugs, the use of analgesic drugs, and non-drug methods. Nurses with a masters degree scored significantly higher than other participants (p<0.05). Nurses (n=67) completed an adapted version of the Nurses’ Knowledge and Attitudes Regarding Pain Survey in Vincent’s (2005) study. The mean score was 76% (range: 48-97%) with participants having knowledge deficits about non-drug methods of pain-relief, analgesic drugs and the incidence of respiratory depression.
Rieman and Gordon (2007) surveyed pediatric nurses (n=295) working in Shriner’s Hospitals in the USA using a revised version of the Pediatric Nurses’ Knowledge and Attitudes Regarding Pain Survey. The questionnaire was modified to ensure that items related to the children being cared for by participants. One item relating to the application of heat/cold was removed as it was not considered applicable to the management of pain resulting from burn injuries, and the wording for 39 questions was altered to ensure they applied to the child being cared for (Rieman et al., 2007). The mean survey score was 74% (range: 37-100%). The 10 questions answered incorrectly by most participants related to pharmacology and the incidence of respiratory depression. Significant differences were found between the scores of nurses with 2 years or less experience in nursing compared to more experienced nurses (p<0.05). Nurses who were active in professional nursing organizations also had significantly higher scores than other nurses (p<0.05).
Ellis et al. (2007) also found limited knowledge about analgesic drugs. Gaps appear to remain in nurses’ knowledge about pain in children, and in particular in relation to pain assessment, analgesic drugs and non-drug methods. This needs further exploration. More research is also needed into factors such as years of experience and level of academic attainment that may affect nurses’ knowledge about pain.
Is knowledge applied in practice?
Looking at nurses’ theoretical knowledge alone does not provide information about the impact of knowledge deficits on practice. Two studies have examined the impact of deficits in pediatric nurses’ knowledge on the quality of pain management practices. Vincent and Denyes (2004) examined the relationship between knowledge and attitudes about children’s pain relief and nurses’ analgesic administration practices. They observed the care of children (n=132), aged 3.5 to 17 years, by nurses (n=67) and found that nurses with enhanced knowledge about pain were no more likely to administer analgesia. In the second study, nurses (n=13) on a children’s surgical ward were observed for 5-hour periods during two to four shifts in Twycross’ (2007) study. Data about postoperative pain management practices were collected using a pain management checklist and field notes. Nurses (n=12) also completed the revised pain management knowledge test (as described by Twycross, 2004). Questionnaire scores were compared to the observational data. No positive relationship was found between individual nurses’ level of knowledge and how well they actually managed pain. Even when the nurses had a good level of knowledge, this was not reflected in their pain management practices.
The results of two studies carried out with adult nurses provide further evidence of knowledge not being used in practice. Dihle et al. (2006) set out to explore how nurses (n=9) contribute to postoperative pain management in two hospitals in Norway. Nurses were observed during two day shifts, two evening shifts and one night shift; the interview was conducted straight after a nurse’s last shift of observation and focused on participants’ reflections about what they did to manage postoperative pain. A gap was found between what nurses said they did and what they actually did. Reported practices adhered to current best practice guidelines but observed practices did not. In another study, Watt-Watson et al. (2001) collected data from 80 nurse-adult patient pairs. No relationship was found between nurses’ knowledge and patients’ ratings of pain and the amount of analgesia administered, even though the nurses had moderately good knowledge levels about pain management. These studies suggest nurses do not appear to apply their theoretical knowledge in practice.
The way forward for education about pain management
There will always be a need to educate nurses about pain management. However, there is increasing evidence that children’s nurses are not using their knowledge in practice (Vincent & Denyes, 2004; Twycross, 2007). A review of literature in this context by Twycross (2002) found that:
Several studies have identified evidence that gaps remain in nurses’ knowledge (Schmidt et al., 1994; Salanterä et al., 1999; Manworren, 2000; Salanterä & Lauri, 2000; Twycross, 2004; Vincent, 2005; Rieman & Gordon, 2007). This may mean that nurses do not understand the rationale for pain-relieving interventions or that they do not know how to assess children’s pain. A lack of knowledge about pain assessment may mean that nurses are unable to assess pain accurately and thus unable to apply their knowledge in practice. Further research is needed in this area; attributing suboptimal practices to a lack of knowledge appears too simplistic an explanation.
Pre- and post-registration nursing curricula content needs evaluation to ensure that nurses have a thorough knowledge of pain, understand the rationale for pain-relieving interventions and know how to assess children’s pain. A review of pain content in pre-registration diploma courses in England found that most pre-registration children’s nursing curricula included less than 10 hours education on pain, providing students with little more than a ‘whistle-stop tour’ of pain management (Twycross, 2000). This concurs with the findings of a study carried in the USA by Graffam (1990) which found that the amount of time devoted to pain in nursing curricula ranged from 2 hours to more than 15 hours. It is perhaps not surprising that knowledge deficits remain. Further research is needed to ascertain the optimum time required on pain management in pre-registration nursing curricula and the most effective teaching methods.
There is a need to develop educational initiatives that promote the use of theoretical knowledge in practice. Several educational strategies have been suggested in this context. Ochieng (1999) describes the use of reflective practice as a method of changing pain management practices. Three months after the start of the project, practices did appear to have changed but there was no evaluation of whether this was sustained long-term. Other suggestions for improving the use of knowledge in practice, which have not yet been tested, include:
Individual nurses’ beliefs and perceptions may also affect their use of knowledge in practice. Vincent’s (2005) study examined nurses’ cognitive representations of pain. The results of this study suggest there may be a relationship between nurses’ cognitive representations of pain and their choices about the administration of analgesic drugs. Further, Johnston et al. (2007) carried out a clustered randomized trial exploring the effectiveness of one-on-one coaching with audit feedback on improving pain management practices. The rate of pain assessment, nurses’ knowledge and non-drug interventions increased in the coaching group. However, as there were significant differences in practices between the study sites not all the differences could be attributed to the coaching. There is a need to further explore the impact of nurses’ beliefs about pain on their practice.
Other factors such as ward culture may also offer an explanation for why nurses do not use their knowledge in practice. Nurses’ need to fit in might mean that they adopt the ward’s (poor) pain management practices, despite having (at least some) knowledge about how children’s pain should be managed and believing that pain management is important. This supposition is supported by the findings of Lauzon Clabo’s (2008) ethnographic study on two adult wards in a hospital in the USA. Participants described a clear pattern of pain assessment on each ward; these patterns were different from each other. The social context appeared to heavily influence nurses’ pain assessment practices. Other studies have also explored the impact of organizational/ward culture on pain management practices (Manias et al., 2002; Manias et al., 2005). The impact of ward culture on pediatric nurses’ pain management practices needs further exploration.
There will always be a need to educate nurses about managing pain in children. However, ensuring this knowledge is used in practice requires other factors, such as ward culture, to be taken into account. Further research is needed to explore the most effective way of educating nurses, and other health care professionals, to ensure that pain management knowledge is used in practice.
Cioffi J. Decision making by emergency nurses in triage assessments. Accid Emerg Nurs 1998;6:184-191. PubMed Abstract
Cioffi J. Clinical simulations: development and validation. Nurse Educ Today 2001;21:477-486. PubMed Abstract
Dihle A, Bjølseth G, Helseth S. The gap between saying and doing in postoperative pain management. J Clin Nurs 2006;15:469-479. PubMed Abstract
Ellis JA, McCleary L, Blouin R, Dube K, Rowley B, McNeill M, et al. Implementing best practice pain management in a pediatric hospital. J Spec Pediatr Nurs 2007;12:264-277. PubMed Abstract
Graffam S. Pain content in the curriculum - a survey. Nurse Educ 1990;15:20-23.
Johnston CC, Gagnon AJ, Pepler CJ, Bourgault P. Pain in the emergency department with one-week follow-up of pain resolution. Pain Res Manag 2005;10:67-70. PubMed Abstract
Johnston CC, Gagnon AJ, Rennick J, Rosmus C, Patenaude H, Ellis J, et al. One-on-one coaching to improve pain assessment and management practices of pediatric nurses. J Pediatr Nurs 2007;22:467-478. PubMed Abstract
Jones DC, Sheridan, ME. A case study approach: developing critical thinking skills in novice pediatric nurses. J Contin Educ Nurs 1999;30:75-78. PubMed Abstract
Kessenich CR, Guyatt GH, DiCenso A. Teaching nursing students evidence-based nursing. Nurse Educ 1997;22:25-29. PubMed Abstract
Khalid SK, Gee HA. A new approach to teaching and learning in journal clubs. Med Teach 1999;21:289-293.
Lauzon Clabo LM. An ethnography of pain assessment and the role of social context on two postoperative units. J Adv Nurs 2008;61:531-539. PubMed Abstract
Lee JE, Ryan-Wenger N. The “Think Aloud” seminar for teaching clinical reasoning: a case study of a child with pharyngitis. J Pediatr Health Care 1997;11:101-110. PubMed Abstract
Manias E, Botti M, Bucknall T. Observation of pain assessment and management – the complexities of clinical practice. J Clin Nurs 2002;11:724-733. PubMed Abstract
Manias E, Bucknall T, Botti M. Nurses’ strategies for managing pain in the postoperative setting. Pain Manag Nurs 2005;6:18-29. PubMed Abstract
Manworren RC. Pediatric nurses’ knowledge and attitudes survey regarding pain. Pediatr Nurs 2000;26:610-614. PubMed Abstract
Ochieng BM. Use of reflective practice in introducing change on the management of pain in a paediatric setting. J Nurs Manag 1999;7:113-118. PubMed Abstract
Pölkki T, Pietilä A, Vehviläinen-Julkunen K. Hospitalized children’s descriptions of their experiences with postsurgical pain relieving methods. Int J Nurs Stud2003;40:33-44. PubMed Abstract
Rieman MT, Gordon M. Pain management competency evidenced by a survey of pediatric nurses’ knowledge and attitudes. Pediatr Nurs 2007;33:307-312. PubMed Abstract
Rieman MT, Gordon M, Marvin JM. Pediatric nurses’ knowledge and attitudes survey regarding pain: a competency tool modification. Pediatr Nurs 2007;33:303-306. PubMed Abstract
Salanterä S, Lauri S. Nursing students’ knowledge of and views about children in pain. Nurse Educ Today 2000;20:537-547. PubMed Abstract
Salanterä S, Lauri S, Salmi TT, Helenius H. Nurses’ knowledge about pharmacological and nonpharmacological pain management in children. J Pain Symptom Manage 1999;18:289-299.
Schmidt K, Eland J, Weiler K. Pediatric cancer pain management: a survey of nurses’ knowledge. J Pediatr Oncol Nurs 1994;11:4-12. PubMed Abstract
Segal S, Mason DJ. The art and science of teaching rounds: a strategy for staff development. J Nurses Staff Dev 1998;14:127-136. PubMed Abstract
Taylor EM, Boyer K, Campbell FA. Pain in hospitalized children: a prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital. Pain Res Manag 2008;13:25-32. PubMed Abstract
Twycross A. Education about pain: a neglected area? Nurse Educ Today 2000;20:244-253. PubMed Abstract
Twycross A. Educating nurses about pain management: the way forward. J Clin Nurs 2002;11:705-714. PubMed Abstract
Twycross A. Children’s nurses’ pain management practices: theoretical knowledge, perceived importance and decision-making. University of Central Lancashire, unpublished PhD Thesis, 2004.
Twycross A. What is the impact of theoretical knowledge on children’s nurses’ post-operative pain management practices? an exploratory study. Nurse Educ Today 2007;27:697-707. PubMed Abstract
Vincent CVH. Nurses’ knowledge, attitudes, and practices: regarding children’s pain. MCN Am J Matern Child Nurs 2005;30:177-183. PubMed Abstract
Vincent CVH, Denyes MJ. Relieving children’s pain: nurses’ abilities and analgesic administration practices. J Pediatr Nurs 2004;19:40-50. PubMed Abstract
Watt-Watson J, Stevens B, Garfinkel P, Streiner D, Gallop R. Relationship between nurses’ pain knowledge and pain management outcomes for their postoperative cardiac patients. J Adv Nurs 2001;36:535-545. PubMed Abstract