Abstract. College of Nursing Boromajonani Sawanprachrak Nakhonsawan, Thailand ** College of Nursing Boromajonani Chonburi, Thailand ***

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1 35 Research Article The Essential Pain Management (EPM) for Nurses in Thailand Srisuda Ngamkham* Boontuan Wattanakul** Roger Goucke*** Abstract Backgrounds The nurses of Thailand have inadequate training for the assessment of pain management, they may have a little pain management knowledge but incorrect attitude about pain. Many patients are receiving inadequate pain management and are suffering with pain. The EPM program is an 8-hour training course for health care providers to understand pain physiology, mechanisms, assessment and management. Nurses who are taking care of patients need to have a comprehensive understanding about pain. Purpose The study aim was to evaluate nurses knowledge and attitudes about pain after attending the EPM program. Methods The time series descriptive research was conducted in three time measurement in Nakhonsawan (n = 23). The EPM workshop was given in English. Twenty-three participants (mean aged 44 ± 6.80, females = 21) completed the pre-post tests and follow-up 6 months later with the Knowledge and Attitude Survey Regarding Pain developed by Betty Ferell and Margo McCaffery (1996), this was translated into Thai. Descriptive statistics and Friedman tests were used for analyzing the data. Results The findings showed that the posttest mean scores (X = 26.26, S.D. = 5.22) of knowledge and attitudes regarding pain had higher than the pre-test scores (X = 21.70, S.D. = 4.48). The mean scores at the six-month follow-up (X = 27.08, S.D. = 3.37) was slightly increased. There was significant difference between three time series of test scores on knowledge and attitude regarding pain (χ 2 = 26.6, p <.05). * College of Nursing Boromajonani Sawanprachrak Nakhonsawan, Thailand ** College of Nursing Boromajonani Chonburi, Thailand *** Sir Charles Gairdner Hospital, Western Australia corresponding author : Srisuda Ngamkham nsrisuda 05@gmail.com

2 36 Conclusion: Our results suggested that when nurses have pain knowledge and apply the knowledge in their routine work with patients who are suffering with pain that it might help to improve their knowledge and attitude regarding pain assessment and management. This is leading to better pain management and to improve quality of nursing care for pain management. Keywords: Pain, Management, Nurse, EPM Program, Introduction Although nursing care needs to record pain score as the fifth vital sign, nurses in Thailand are limited in pain assessment and management skills, which leads to many patients receiving inadequate treatment for pain. Nurses need to increase pain knowledge, pain assessment and management skills for effective pain assessment and management. Nurses who are taking care of patients need to have a comprehensive understanding about pain. The essential pain management (EPM) program is an 8-hour training course recommended for health care providers to understand pain physiology, mechanisms, assessment and management. The study aim was to assess the effects of the RAT (recognize, assess, treat) model on improvement of nurses knowledge and attitudes about pain after attending the EPM program(morriss & Goucke, 2012). Although knowledge of pain assessment and pain management has rapidly developed in recent years, nurses in Thailand remain inadequate in knowledge and attitudes about pain. Nurses are less self-confident about pain management. Among healthcare providers, nurses do most of the caring for hospitalized patients around the clock. In order to provide the effective pain management, nurses are required to have scientific knowledge about pain assessment and management. Patients would have great benefits if we enabled changes of nurses knowledge and attitude about pain assessment and management. From literature reviews, we found that nurses have a deficit in knowledge and attitudes relating to pain assessment and management (Machira, Kariuki, & Martinadale, 2013; Wang & Tsai, 2010; Watt- Watson, Stevens, Garfinkel, Streiner, & Gallop, 2001). This deficit was one of the most important obstacles to achieving effective pain management. Improving nurses knowledge of pain management techniques is to overcome barriers and apply knowledge to improve clinical practice for patients who are suffering with pain. This improvement gradually leads to the development of better pain management delivery systems and services. Providing an educational program of pain assessment and management might help change nurses knowledge and attitudes (Bishop, 2005; McMillan, Tittle, Hagan, & Small, 2005). Boromarajonani College of Nursing Sawanpracharak Nakhonsawan, Thailand acknowledge the importance of the roles of nurse educators and professional nurses in pain management, since there were limited study reports related to Thai nurses pain knowledge and attitudes.

3 37 Study purpose This study aims to evaluate nurses knowledge and attitudes about pain before and after attending the EPM program and six months later. Methods We conducted the time series descriptive study with three times of the measurement in Nakhonsawan. We measured before and after intervention, and a follow-up 6 months later. The EPM training program was given in English by Australian lecturers. This study received an approval by the Institute Research Board of Boromarajonani College of Nursing Sawanpracharak Nakhonsawan. Setting and Participants Twenty three participants (n = 23, female = 96%) were recruited as a purposive sampling from the various settings including colleges of nursing and hospitals. Participants consisted of staff nurses and nursing instructors holding baccalaureate, master, and doctoral degrees. Participants had an average of 20 ± 7 years of nursing experience and no training in pain management (96%). Most participants did not attend the pain course training (91%) (Table 1). Table 1 Frequency, Percent, Mean, and Standard Deviation of Participants (n = 23) Characteristics Number Percent Age mean = 44, S.D. = 6.9 Gender Male 1 4 Female Education Bachelor 7 31 Master Doctor 4 17 Career Nurse 7 31 Nursing Instructor Working Experience < 10 years years > 21years Pain Training Yes 2 9 No 21 91

4 38 In order to recruit the participants, the study proposal was sent to the colleges of nursing, faculty of nursing, and hospitals under the Ministry of Public Health, and hospitals under Ministry of Education. The inclusion criteria were: nurses who have worked in a pain clinic, have been experienced care givers for patients with pain, and are able to understand and speak English. Instruments The questionnaire of the Nurses Knowledge and Attitude Survey regarding pain developed by Betty Ferrell and Margo McCaffery (Ferrell, & McCaffery, 2008) was used for data collection. The questionnaire contains 40 questions including 22 items of true or false options and 18 items of multiple choice. Permission of the original questionnaire developer has obtained to translate into Thai language and bilingual nurses examined language equivalency. The internal consistency reliability of the Thai version of the Nurses Knowledge and Attitude Survey was adequate by using KR-20 (alpha efficiency = 0.60). Intervention The EPM program using the RAT model for health care providers was developed by Goucke and Morris (Morriss, & Goucke, 2012). After attending the EPM program, all participants increased pain knowledge, understanding simple framework to manage pain, and to address pain management barriers. The program is eight hours in length. The teaching methods of the EPM program consist of a series of short, interactive lectures, brainstorming, and group discussions. The content of the program is composed of an introduction, pain definition, classification of pain, pain physiology and pathology, the RAT (Recognize, Assess, Treat) framework, pain assessment, and pain management. The last session of the program provides a forum for discussion about the variety of pain problems and strategies to overcome barriers to treatment. Procedure All participants completed the questionnaire to measure their knowledge and attitudes three times, at the beginning and the end of the workshop, and six months after attending the EPM workshop. The EPM workshop in the morning session consisted of a series of short, interactive lectures and group discussions. The program provided an introduction of the pain situation in Thailand, pain definitions, classification of pain, pain physiology and pathology. Most sessions in the afternoon were spent in a series of small groups, case discussions, where the RAT framework was used to consider the assessment of pain and the management of various pain problems. The group then brainstormed some strategies for overcoming pain management barriers. At the end of the one-day workshop, all participants completed the Nurses Knowledge and Attitude Survey. Analysis The data was re-identified and analyzed with frequency, percentage, descriptive statistics, and Friedman tests were applied to compare the scores on three points of time. Results The findings showed that the posttest mean scores of knowledge and attitudes regarding pain ( x = 26.26, S.D. = 5.22) had higher than the pre-test mean scores ( x = 21.70, S.D. = 4.48). The mean scores on the knowledge and attitude at the six-month follow-up ( x = 27.08, S.D. = 3.37) was slightly increased. There was significant difference of scores on knowledge and attitude regarding pain among the three points of time series (χ 2 = 26.6, p <.05). (Table 2).

5 39 Table 2. Difference of Mean Score between Pre and Post Test of Participants (n = 23) Knowledge and Attitude Mean S.D. χ 2 Pre-test * Post-test Six months later *p <.05 Discussions The results illustrated that attendants of the EPM workshop, pain knowledge and attitudes were significantly improved in the long run. These findings were similar to the earlier studies reported in other countries. The results showed that after attending the pain program, participants pain knowledge increased (Bishop, 2005; Machira, et al., 2013; McMillan, et al., 2005). That might infer that the EPM allows nurses to understand the pain mechanism and management. They could apply their pain knowledge and attitude and apply to their routine work with the patients who suffer with pain. The Essential Pain Management (EPM) program is appropriate and beneficial for both Thai nurses and nurse instructors because the RAT simple framework provides an approach to patients living with pain. Nurses acquire more knowledge in pain assessment and management techniques, whereas nurse instructors are provided with a variety of teaching methods to assist in delivering education on difficult topics. Hospitals would benefit from providing the EPM program to a multidisciplinary team, so that all levels of health care workers are able to consistently apply knowledge of pain assessment and management techniques in the hospital. The low pre-test scores of participants may reflect the limited opportunities that Thai nurses have to attend pain courses during working and after graduation. Additionally, when looking at the undergraduate-nursing curriculum in Thailand, only 2-3 hours of pain content was provided in each class of adult, pediatric, and obstetric nursing. Both nurses and nursing students have to update the pain knowledge and attitude that establish trust of patients (Matthews & Malcolm, 2007) since the Thai Nursing council set pain as the fifth vital sign. Pain knowledge, thus, needs to be added in the nursing course for nursing students. In addition, nurses should have the pain course training on-site place of work and have refresher pain training. The authors promote the RAT model for approaching a patient with pain to nursing students because the teaching methods of the EPM program are worthy. The various teaching methods of the EPM workshop provided a good example of how to encourage and facilitate nursing students to enjoy learning about pain as it is a difficult topic. To the authors knowledge, this is the first time the EPM program has been delivered and evaluated in Thailand, a developing country. The findings of this study were similar to the studies using pain education programs in the other countries (Machira et al., 2013; McMillan et al., 2005). To maximize the impact of pain education in nurses and other health care providers, the basic content and continuing education course must be required (Hunter et al., 2008; Machira, et al., 2013). A well-designed pain curriculum can significantly improve pain knowledge (Hunter, et al., 2008). When the EPM program was able to increase nurses pain

6 40 knowledge and change their attitudes, further study should be pursuing in multiple larger settings. A longitudinal study to examine the sustainability of nurses pain knowledge and attitude would be interesting. Limitations Although the study had limitations including small participants and methodology, the project was repeatable in different parts of Thailand independent of instructor. The results of nurses pain knowledge and attitudes were comparable. Implication These results suggest the EPM program is an effective pain course for training health care providers in Thailand. In particular, the RAT model provides a simple and practical method of approaching patients living with pain. Therefore, nurses and other clinicians should participate in the EPM program in order to improve their knowledge and attitude regarding pain. The more health care providers in Thailand that can attend the EPM workshop, the better pain management will be. Conclusion Nurses pain knowledge and attitude have had a positive change that is the important key to achieve pain management development for patients in Thailand. We now hope that the EPM program can run and RAT model could benefit patients in Thailand. In order to contribute to the effective pain assessment and management in Thailand, nurses needed to attend the pain course to improve the quality of care and quality of life of patients who are suffering with pain in Thailand. Acknowledgements: Boromarajonani College of Nursing Sawanpracharak Nakhonsawan, Thailand would like to acknowledge Betty Ferrell and Margo McCaffery, developers of the Nurses Knowledge and Attitudes Survey Regarding Pain Instrument for allowing others to use it to improve pain management in their settings. We would like to acknowledge Wayne Morris who co-developed the EPM program. And also, we would like to thank Peter Cox, Yoo Kuen Chan, and Pongparadee Chadakchedtrin who helped us arrange the project in Nakhonsawan. Finally, we would like to thank the International Association for the Study of Pain (IASP) who supported the funding for both workshops. References Bishop, D. (2005). Nursing knowledge and attitudes regarding the pain management of cancer patients. Master of Science in Nursing, Florida State University. Ferrell, B., & McCaffery, K. (2008). Knowledge and attitudes survey regarding pain, city of hope pain & palliative care resource center, from Hunter, J., Watt-Watson, J., Macgillion, M., Ramann- Wilms, L., Cockbune, L., Lax, L., Salter, M. (2008). An Interfaculty pain curriculum: lesson learned from six year experience. Pain, 140, Machira, G., Kariuki, H., & Martinadale, L. (2013). Impact of an educational pain management programe on nurses pain knowledge and attitude in Kenya. International Journal of Palliative Care, 19(7),

7 41 Matthews, E., & Malcolm, C. (2007). Nurses knowledge and attitudes in pain management practice. British Journal of Nursing, 16(3), McMillan, S. C., Tittle, M., Hagan, S. J., & Small, B. J. (2005). Training pain resource nurse: Change in their knowledge and attitudes. Oncology Nursing Forum, 32(4), doi: / 05.ONF Morriss, W., & Goucke, R. (Eds.). (2012). Essential pain management (1st Edition ed.). Christchurch: Faculty of Pain Medicine, Australian and New Zealand College of Anesthetists. Wang, H. L., & Tsai, Y. F. (2010). Nurses knowledge and barriers regarding pain management in intensive care units. Journal of Clinical Nursing, 19, doi: /j x Watt-Watson, J., Stevens, B., Garfinkel, P., Streiner, D., & Gallop, D. (2001). Relationship between nurses pain knowledge and pain management outcome for postoperative cardiac patients. Journal of Advanced Nursing, 36(4),