Pain is one of the most common symptoms. Pain management in Jordan: nursing students knowledge and attitude. Abstract

Transcription

1 Pain management in Jordan: nursing students knowledge and attitude Murad Al Khalaileh and Mohammad Al Qadire Abstract Pain management requires knowledgeable and trained nurses. Because nursing students are the nurses of the future, it is important to ensure that students receive adequate education about pain management in nursing schools. The purpose of this study is to evaluate nursing students knowledge and attitudes regarding pain management. A cross-sectional survey was used. The sample comprised 144 students from three nursing colleges in Jordan. Sixty-one percent were female and the average age was 21.6 years (SD 1.7). The students Knowledge and Attitudes Survey Regarding Pain was used. The rate of correct answers ranged from 11.1% to 64%. Students showed a low level of knowledge regarding pain management the average score was just 16 (SD 5.11) out of 40. Students were weak in their knowledge of pain medications pharmacology (actions and side effects). Less than half of students (47.9%) recognised that pain may be present, even when vital signs are normal and facial expressions relaxed. Finally, students showed negative attitudes towards pain management, believing that patients should tolerate pain as much as they can before receiving opioids; almost half (48%) of students agreed that patients pain could be managed with placebo rather than medication. In conclusion, Jordanian nursing students showed lower levels of pain knowledge compared with other nursing students around the world. This study underlines the need to include pain-management courses throughout undergraduate nursing curricula in Jordan. Key words: Pain management Nursing Students Education Jordan Curriculum Pain is one of the most common symptoms experienced by patients, as well as a universal human experience (Berry and Dahl, 2000). Pain control is a vitally important goal, as neglected pain can cause patients to lose hope, impede their response to treatment and damage their quality of life (Portenoy and Lesage, 1999; Sykes et al, 2003; Al-Atiyyat, 2008). But barriers to pain management are abundant and can be related to patients and healthcare providers. Health professionals in particular Murad Al Khalaileh is the Vice Dean of the Nursing School, Al Al-Bayat University, Mafraq-Jordan; Mohammad Al Qadire is Assistant Professor at the School of Nursing, Al Al-Bayat University, Mafraq-Jordan Accepted for publication: October 2013 have been found to lack appropriate knowledge to assess and manage types of pain (Johnson et al, 2005; Al Qadire and Al Khalaileh, 2012). Of all health professionals, nurses usually spend the longest time with patients and play an important role in pain management (Chiang et al, 2006; Duke et al, 2010). It is therefore important to ensure that student nurses receive adequate education about pain management in nursing schools. A large number of studies have examined health professionals knowledge of managing patients pain (Bernardi et al, 2007; Lui et al, 2008; Yildirim et al, 2008; Al Qadire and Al Khalaileh, 2012). For instance, there was a study in Hong Kong to examine the knowledge and attitudes regarding pain among 147 nurses working in medical floors (Lui et al, 2008). The nurses completed the Nurses Knowledge and Attitudes questionnaire (NKA). It was found that nurses lacked the knowledge required to manage pain optimally and held negative attitudes towards patients pain. However, nurses with longer working experience seemed to have better knowledge of pain management (Lui et al, 2008). Nevertheless, most of these studies indicated the lack of knowledge and negative attitudes among health professionals and nurses in particular (Bernardi et al, 2007; Lui et al, 2008; Yildirim et al, 2008; Al Qadire and Al Khalaileh, 2012). Research has revealed that there may be inadequate pain education and training in nursing schools (Keyte and Richardson, 2011). However, few studies have examined undergraduate nursing students knowledge of, and attitudes towards, pain management (Duke et al, 2010). Duke et al (2010) carried out a survey to examine the pain-management knowledge of nursing students (n=178) and faculty (n=178). They found that students answered 63% of the questions correctly and the nursing faculty 71%. They also found that nursing students tended to assign higher pain scores and administer higher doses of morphine to symptomatic patients (i.e. those who were moaning, crying and shouting) compared with asymptomatic ones. Another study explored nursing students myths and misconceptions about pain management (Shaw and Lee, 2010). Nursing students in their first, second and third years of study were included in the survey (n=430). Findings indicated that all students from the three levels held some misconceptions about pain management. The main misconceptions included believing that: chronic pain may be a result of depression rather than real pain (64%); patients are likely to become addicted if given opioids (45%); and patients with chronic pain normally tolerate their pain and hence do not need medication (38%). However, they also found 1234 British Journal of Nursing, 2013, Vol 22, No 21

2 pain management that students misconceptions tended to decrease as they progressed through their course from the first to the third year (Shaw and Lee, 2010). It is clear that the most common misconception about pain management is the belief that the use of opioids leads to addiction (Allcock and Toft, 2003). McCaffery and Ferrell (1995) reported that most nurses in five countries (Australia, Canada, Japan, Spain and USA) do not know the correct likelihood of addiction among patients who are on opioids treatment (McCaffery and Ferrell, 1995). For instance, another study evaluated the changes in nursing students attitudes and misconceptions during the first 18 months of their nursing programme. A total of 217 students were surveyed twice and 14 interviewed about the experience of managing patients pain. Seventy-six percent of the students overestimated the risk of addiction in patients with pain (who were mostly treated with opioids). At the end of the 18 months, over half (55%) the students were still overestimating the risk of addiction (Allcock and Toft, 2003). A study in the USA found that student nurses have poor knowledge of pain-medication classification, route of administration and side effects (Plaisance and Logan, 2006). Most of the surveyed students (n=313) also have an unnecessary fear that patients will become addicted (Plaisance and Logan, 2006). Despite the limitations of the available evidence (small sample, single settings, convenience sampling and considerable threats to external and internal validity), this may highlight the need to evaluate the content and quality of pain education that is being given to students in nursing school. For example, Briggs et al (2011) evaluated the quality, content and teaching styles used to teach pain management to undergraduates on different healthcare courses, including nursing courses in the UK. It was found that nurses received just 10 hours of instruction in pain education during the whole course (3 4 years). In addition, what many regard as an old-fashioned teaching method lectures was used in 88% of the universities (Briggs et al, 2011). A study done in the UK (Twycross and Roderique, 2011) to evaluate the pain content in paediatric undergraduate courses and the teaching methods used confirmed the weakness of nursing education (too few topics, superficial knowledge). Usually courses were taught by means of lectures and without interactive methods (Twycross and Roderique, 2011). It is believed that lectures may be effective in improving knowledge levels, but do not necessarily change attitudes or clinical practice (Simons and MacDonald, 2006; Zhang et al, 2008). Twycross and Roderique (2011) indicated the need for further nursing research in this area to improve the quality and nature of pain education in nursing curricula. The current optimal pedagogical technique of teaching pain to nurses is to use the problem-based teaching model to integrate theory in practice (Keyte and Richardson, 2011). A Canadian research team surveyed health science faculties to evaluate time spent teaching students about pain during their courses (Watt-Watson et al, 2009). Ten main health science faculties were included. The study found that most curricula (67%) had no specific time (in hours) designated for pain education. In addition, it found that veterinary science allotted more time to pain education (mean time 87 hours) than the majority of health science faculties (mean time hours for all levels). It also reported that the focus of courses was on pain pathophysiology and pharmacological management, while misconceptions, pain assessment and follow-up received the least attention (Watt-Watson et al, 2009). Finally, another examination of pain content in medical-school curricula in North America showed that Canadian medical students received more pain education than their American colleagues. However, pain education in both countries is still believed to be inadequate (Mezei and Murinson, 2001). Furthermore, it was found that cancer, paediatric and geriatric pain were too little weight in the medical schools courses (Mezei and Murinson, 2001). The last two studies (Mezei and Murinson, 2001; Watt-Watson et al, 2009) provided fair evidence, were comprehensive and included a representative sample. It was not possible to find literature on pain education in Jordanian nursing schools. However, based on the authors experiences, it could be said that there is no formal structure for pain education in Jordan. Students are usually given one formal lecture about pain. This lecture is only one hour long and covers pain physiology; other areas of pain received little or no attention. Overall, although pain education in Jordanian nursing curricula varies from setting to another, it seems to be superficial and limited in scope. All previous work suggests the weakness of nursing students knowledge of pain management and the inadequacy of their education in this area (Duke et al, 2010; Shaw and Lee, 2010; Briggs et al, 2011; Twycross and Roderique, 2011). Thus, the first step in improving the quality of students skills and knowledge in pain management is to assess their needs. This study aims to evaluate Jordanian fourth-year nursing students knowledge and attitudes regarding pain treatment. In Jordan, this subject has not yet been thoroughly explored, so this study will help establish baseline information about Jordan and may contribute to wider efforts to improve pain-management practice. This information could guide nursing courses development and future plans in terms of pain-management content. By scrutinising the effectiveness of nurse education, it could also identify its strengths and help correct its weaknesses. Methods Aims This study aims to evaluate fourth-year nursing students knowledge and attitudes regarding pain management. Design The cross-sectional survey method was used to evaluate students knowledge and attitudes. This design is useful for exploring attitudes, beliefs and knowledge-related topics. Also, a descriptive design is appropriate for this study because there is no intention to examine any cause-and-effect relationship (Gerrish and Lacey, 2010). Sample All fourth-year students in the selected nursing schools in governmental universities were invited to participate in the study (total population estimated to be 200 students). Thus, 200 questionnaires were distributed and 153 were returned. British Journal of Nursing, 2013, Vol 22, No

3 Then, after exclusion of incomplete questionnaires, 144 were analysed. Private universities were excluded because they may apply different teaching standards and measures. A separate study may therefore be required to rule out any confounding variables. Settings This survey was carried out in three nursing schools from three governmental universities. Instruments The demographic data sheet (DDS) The DDS includes questions designed to elicit information about participants (students) demographic characteristics, such as sex, age and previous pain education. The knowledge and attitudes survey (KAS) regarding pain A 40-item questionnaire was developed to assess nurses knowledge and attitudes towards pain management (Ferrell et al, 1993). It consisted of 22 True or false questions and 18 multiple-choice questions. Howell et al (2000) acknowledge that the KAS is the only available instrument to measure nurses knowledge and attitudes about pain management. The content validity of KAS has been established by a panel of pain experts. The KAS content was based on the pain management guidelines of the American Pain Society, the World Health Organization and the Agency for Health Care Policy and Research. The KAS Cronbach s alpha is 0.7 and test-retest reliability is greater than 0.8 (Howell, 2000; Vallerand et al, 2004). It has been extensively used in research that aimed to evaluate health professionals knowledge and attitudes regarding pain management (Lai et al, 2003; Chiang et al, 2006; Bernardi et al, 2007; Lui et al, 2008; Duke et al, 2010). However, the names of drugs mentioned in the questionnaire were checked for their availability and use in Jordanian hospitals, since this tool was developed and used in the USA and Europe. It was found that all medications are available and used in Jordan under the same names, except for Vicodin (hydrocodone 5 mg + acetaminophen 500 mg), which is known as Revacod, and acetaminophen, which is known as paracetamol. Thus, these names were changed in the questionnaire. No permission is required to use the questionnaire, as stated by the authors. It was written in English, since nursing education and examination in Jordan is conducted in English. Procedure The recruitment procedure was applied after obtaining ethical approval from the settings ethical committees by visiting the particular nursing schools. With the help of the schools nursing faculties, the questionnaires were distributed to students in the class rooms. Then a five-minute presentation was given to explain the study aims, procedure and participants role. Students who agreed to participate then signed a written consent form and completed the questionnaire. Finally, completed questionnaires were collected in person (by the researchers). Data were collected in the period between February and June Ethical considerations The research team believed that maintaining the confidentiality and anonymity of participants was crucial to this study. Ethical committee approval was obtained from each university before the study started. However, it is the responsibility of the researcher to protect the participants confidentiality and to be aware of all possible ethical concerns that arise during the course of the study. Students can be vulnerable when participating in research projects conducted by their teachers. Students autonomy might be compromised if, for example, they fear failing the course if they decide not to participate (Gerrish and Lacey, 2010). Thus, measures to ensure students freedom of choice were taken among them, the researchers did not collect data directly from students enrolled in courses that they were teaching; they used a third party (another instructor) to collect the questionnaires; students did not need to give their names when participating and were encouraged to contact the dean of the school to report any misconduct; and no student was recruited without a signed consent form. In addition, participation in this study was voluntary and participants were informed that they were free to withdraw at any time. Furthermore, the identities of participants (no names requested) were not revealed, only aggregate data were reported, and participants were assured that their responses would remain confidential. The completed questionnaires were accessed only by the research team. Data analysis Data were entered into the Statistical Package for the Social Sciences (SPSS) (version 17). Descriptive statistics, such as percentages and frequencies were used to describe the sample characteristics. Unpaired t-test was used to examine the differences between different categories of participants. Results Sample characteristics In total, 144 students completed questionnaires (a response rate of 72%). The results show that 62.5% of participants (n=90) were female and the average age was 21.6 (SD 1.7). Most students (61%, n=89) reported that they did not receive previous pain education. Nurses knowledge and attitudes regarding pain management The percentages of the correctly answered items in the questionnaire are shown in Table 1. The mean score of total correct answers was 16 (SD 5.1) out of a possible 40. The rate of correct answers ranged from 11% (for the worstanswered item, 38, response to case A) to 64% (for the bestanswered item, 22, opioid addiction is defined as a chronic neurobiological 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). Many items were incorrectly answered (indicating a low level of knowledge), as shown in Table 1. These were mainly related to: The likelihood of the patient developing clinically significant respiratory depression in the absence of co-morbidities 1236 British Journal of Nursing, 2013, Vol 22, No 21

4 pain management Table 1. Correctly answered items in the questionnaire Item Correct responses no. Item content n % True or false questions (with correct answers) 1 Vital signs are always reliable indicators of the intensity of a patient s pain (F) Because their nervous system is underdeveloped, children under two years of age have decreased pain sensitivity and limited memory of painful experiences (F) 3 Patients who can be distracted from pain usually do not have severe pain (F) Patients may sleep in spite of severe pain (T) Aspirin and other nonsteroidal anti-inflammatory agents are NOT effective analgesics for painful bone metastases (F) 6 Respiratory depression rarely occurs in patients who have been receiving stable doses of opioids over a period of months (T) 7 Combining analgesics that work by different mechanisms (e.g. combining an opioid with an nonsteroidal anti-inflammatory drug) (NSAIDs) may result in better pain control with fewer side effects than a single analgesic agent (T) 8 The usual duration of analgesia of 1 2 mg morphine IV is 4 5 hours (F) Research shows that promethazine (Phenergan) and hydroxyzine (Vistaril) are reliable potentiators of opioid analgesics (F) 10 Opioids should not be used in patients with a history of substance abuse (F) Morphine has a dose ceiling (i.e. a dose above which no greater pain relief can be obtained) (F) Elderly patients cannot tolerate opioids for pain relief (F) Patients should be encouraged to endure as much pain as possible before receiving an opioid (F) Children younger than 11 years old cannot reliably report pain, so nurses should rely solely on the parent s assessment of the child s pain intensity (F) 15 Patients spiritual beliefs may lead them to think pain and suffering are necessary (T) After an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with the individual patient s response (T) 17 Giving patients sterile water by injection (placebo) is a useful test to determine if the pain is real (F) Revacod (hydrocodone 5 mg + acetaminophen 500 mg) per os (PO) is approximately equal to mg morphine PO (T) 19 If the source of the patient s pain is unknown, opioids should not be used during the pain evaluation period, as this could mask the ability to diagnose the cause of pain correctly (F) 20 Anticonvulsant drugs such as gabapentin (Neurontin) produce optimal pain relief after a single dose (F) Benzodiazepines are not effective pain relievers unless the pain is due to muscle spasm (T) 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 (T) Multiple choice questions (with correct answers) 23 The recommended route of administration of opioid analgesics for patients with persistent cancerrelated pain is: (oral) 24 The recommended route administration of opioid analgesics for patients with brief, severe pain of sudden onset, such as trauma or postoperative pain is: (intravenous) 25 Which of the following analgesic medications is considered the drug of choice for the treatment of prolonged moderate to severe pain for cancer patients? (morphine) 26 Which of the following IV doses of morphine administered over a 4 hour period would be equivalent to 30 mg oral morphine given q 4 hours: (morphine 10 mg IV) 27 Analgesics for postoperative pain should initially be given: (around the clock on fixed schedule) A patient with persistent cancer pain has been receiving daily opioid analgesics for 2 months Yesterday the patient was receiving morphine 200 mg/hour intravenously. Today he has been receiving 250 mg/hour intravenously. The likelihood of the patient developing clinically significant respiratory depression in the absence of new co-morbidity is: (less than 1%) 29 The most likely reason a patient with pain would request increased doses of pain medication is: (the patient is experiencing increased pain) 30 Which of the following is useful for treatment of cancer pain? (all of the above) British Journal of Nursing, 2013, Vol 22, No

5 31 The most accurate judge of the intensity of the patient s pain is: (the patient) Which of the following describes the best approach for cultural considerations in caring for patients in pain: (patient should be individually assessed to determine cultural influence) 33 How likely is it that patients who develop pain already have an alcohol and/or drug-abuse problem? (5-15%) 34 The time to peak effect for morphine given IV is: (15 minutes) The time to peak effect for morphine given orally is: (1 2 hours) Following abrupt discontinuation of an opioid, physical dependence is manifested by the following: (sweating, yawning, diarrhoea and agitation when the opioid is abruptly discontinued) Case studies (with correct answers) 37 Patient A: Andrew is 25 years old and this is his first day following abdominal surgery. As you enter his room, he smiles at you and continues talking and joking with his visitor. Your assessment reveals the following information: BP=120/80; HR=80; R=18; on a scale of 0 to 10 (0=no pain/discomfort, 10=worst pain/discomfort), he rates his pain as 8. On the patient s record you must mark his pain on the scale below. Circle the number that represents your assessment of Andrew s pain: (8) 38 Your assessment, above, is made 2 hours after he received morphine 2 mg IV. Half-hourly pain ratings following the injection ranged from 6 to 8 and he had no clinically significant respiratory depression, sedation, or other untoward side effects. He has identified 2/10 as an acceptable level of pain relief. His physician s order for analgesia is morphine IV 1 3 mg q 1 hour as needed (PRN) pain relief. Check the action you will take at this time: (administer morphine 3 mg IV now) 39 Patient B: Robert is 25 years old and this is his first day following abdominal surgery. As you enter his room, he is lying quietly in bed and grimaces as he turns in bed. Your assessment reveals the following information: BP=120/80; HR=80; R=18; on a scale of 0 to 10 (0=no pain/discomfort, 10=worst pain/discomfort) he rates his pain as 8. On the patient s record you must mark his pain on the scale below. Circle the number that represents your assessment of Robert s pain: (8) 40 Your assessment, above, is made 2 hours after he received morphine 2 mg IV. Half-hourly pain ratings following the injection ranged from 6 to 8 and he had no clinically significant respiratory depression, sedation, or other untoward side effects. He has identified 2/10 as an acceptable level of pain relief. His physician s order for analgesia is morphine IV 1 3 mg q 1 h PRN pain relief. Check the action you will take at this time: (administer morphine 3 mg IV now) The recommended and preferred route of opioid administration Manifestations of opioid, physical dependence Responses to cases A and B; ability to differentiate between addiction, tolerance and physical dependency. Less than half of students (47.9%) recognised that pain may be present, despite normal vital signs and relaxed facial expressions. Two-thirds (66.8%) of students indicated that the patient is the only reliable source for pain report. Moreover, it was clear that nursing students showed weak knowledge regarding pharmacological management of patients with pain and pain-assessment reporting. One area in which students showed a particularly low level of knowledge was pain assessment: for example, 65% of students (n=94) did not know that patients can sleep despite their pain. Furthermore, only 14% of students were correctly able to rate the patient s pain score in case scenario A. Although the authors of the NKA survey recommended not splitting the tool items into knowledge and attitudes subscales, some items indicated negative attitudes toward pain management. For instance, over half (52%) of students believed that patients should tolerate pain as much as they can before starting opioid treatment (item 13) and 48% also agreed the patients pain could be managed with placebo (sterile water injections) only (item 17). Unpaired t-test showed no significant differences in the mean score of total knowledge and attitude with regard to participant gender (Table 2). P values were >0.05 and the 95% confidence interval (CI) of the difference (-2.90 to 0.78) includes zeros, which is consistent with the t-test results. In addition, no significant differences in the mean of total knowledge and attitude scores were found between students who received pain education and those who did not (P>0.05, 95% CI). The difference (-2.70 to 0.92) includes zeros, which is consistent with the t-test results. Discussion The aim of this study was to identify fourth-year nursing students knowledge and attitudes toward pain management. This study indicated poor knowledge among Jordanian undergraduate nursing students. Out of the 40 questions answered in the questionnaire, the average score of correct answers was 16 (SD 5.1). These results were congruent with previous studies, which found a deficit in students knowledge (Sheeman et al, 1992; Chui et al, 2003; Patiraki et al, 2006; Plaisance and Logan, 2006; Shaw and Lee, 2010). The results revealed that nursing students showed weaknesses in pharmacological management of patients with pain. These results were consistent with Plaisance and Logan (2006), who found that the knowledge gap and misconceptions were related to medications actions, side effects and administration. Furthermore, Duke et al (2010) found that the nine most frequently missed items were primarily related to knowledge about pain medications and administration (Duke et al, 2010) British Journal of Nursing, 2013, Vol 22, No 21

6 pain management The results of the current study showed that nursing students are weak in their knowledge of pain assessment and reporting. These findings were congruent with the results of Patiraki et al s (2006) study, which indicated limitations with regard to pain assessment and management. Lofmark et al (2003) also found that students showed a lack of knowledge of pain-assessment techniques. In addition, nursing students displayed negative attitudes toward using opioids; would encourage patients to tolerate more pain before administering them; and would use placebo instead of pain medications. These findings can be explained by the fact that nursing students mistakenly believed that the use of pain medications may lead to addiction. This is consistent with Allcock and Toft (2003), who reported that administering opioids induces anxiety in students, and that they tend to have exaggerated fear of patients addiction, perhaps owing to their limited knowledge of medications pharmacological properties. Nursing students knowledge deficit regarding pain management might be explained by the fact that little time is allocated to pain education in their curricula. Thus, undergraduate nurses receive limited and inadequate education and training. Briggs et al (2011) found that paineducation content in undergraduate courses for health professionals in the UK accounted for less than 1% of the course hours for some disciplines, with educational content largely fragmented throughout the curricula. Furthermore, Twycross and Roderique (2011) indicated the limitation of pain-management content in nursing curricula, with several institutions not covering pain management at all. Shaw and Lee (2010) indicated that no explicit educational material was designed in nursing curricula to teach students about pain and pain management. Lofmark et al (2003) evaluated nursing students (n=32) pain assessment and management skills. Students were exposed to simulated clinical situations and their responses videotaped. Content analyses of the tapes revealed that students lacked the knowledge to conduct adequate and systematic pain assessment. Overall, Lofmark et al recommend greater emphasis on closing the gap between theory and clinical courses, with students practising pain-assessment procedures systematically. Students poor pain assessment and management skills may be a result of weak education and training. This fact was previously reported by Watt-Watson et al (2009), who found that most (67%) curricula have no specific time (in hours) designated for pain education. They also reported that the focus of courses was on pain pathophysiology and pharmacological management, while misconceptions, pain assessment and follow-up received negligible attention. In this study, we found that nursing students had low knowledge scores and negative attitudes regarding pain management. Pain-assessment, management and misconceptions seem not to be fully addressed: nursing students show a considerable number of misconceptions about pain management and fear of addiction was prevalent. Watt-Watson et al s (2009) findings were similar; they recommend including pain assessment and management in nurses competency exams, which are a prerequisite for starting nursing practice in clinical settings. However, in Table 2. Independent t-test results analysing the difference in mean total nurse knowledge score with regard to students gender and exposure to previous pain education Variable t df p 95% CI of the difference Mean (SD) Gender Male Female Previous pain education Yes No to to 0.92 the light of our study findings and those of Watt-Watson et al (2009), pain education could be improved through development of a structured pain curriculum for nursing students which covers pain-assessment skills, pharmacological treatment and the myths and misconceptions around pain management. In addition, pain education should be given as a separate course, rather than scattered through different courses. The practising of pain assessment and management skills should also be considered for nursing students, and having a clinical part for pain-management courses is highly recommended. Finally, lecturing, as a teaching method, might improve knowledge but it does not necessarily change attitudes. A new method of teaching pain management, such as the problem-based teaching model, which can integrate theory in practice and enrich learning, is suggested (Keyte and Richardson, 2011). This study shows no significant difference in the mean scores of students who had previous pain education and those who did not. This may be because some students consider discussing pain management in some courses as equivalent to being educated in pain management. Thus, no difference was evident in their responses to the questionnaire. In addition, since most pain education is limited and fragmentary, this may render students unable to recall the correct information at the time of the survey. This study does have limitations, including: sample selection bias, its cross-sectional design and the fact that some students did not respond to the survey (despite the high response rate). In addition, using the English version of the questionnaire could hinder students understanding of some items, which might affect the study s internal validity (which is why an Arabic version is recommended for any prospective work in the field). Further, while it is important to assess knowledge, this does not necessarily relate directly to patient care and daily practice. Moreover, three nursing schools were involved in this study, so the results cannot be extrapolated to other private schools that might have different curricula and teaching methods. Nevertheless, this study provides valuable information, since it was conducted in several schools and included an adequate number of students. Conclusion The findings of this study show that nursing students have low knowledge levels of pain management. Jordanian nursing students expressed a lower level of pain knowledge than other nursing students around the world, so implementation of pain assessment and management courses for undergraduate 16.7 (4.6) 15.7 (4.4) 16.4 (4.7) 15.5 (5.9) British Journal of Nursing, 2013, Vol 22, No

7 Key points Pain is one of the most common symptoms experienced by patients and is currently under-medicated in Jordan One of the barriers to optimal pain management is nurses lack of knowledge in assessing and managing different types of pain Nursing students in Jordan showed poor knowledge of pain assessment and of reporting pain-related issues Pain assessment and management courses are needed and recommended for undergraduate nursing students nursing students is needed and recommended. Such courses should include lectures and case-based seminars about pain management. In summary, this study underscores the need to reform undergraduate curricula by including painmanagement courses. BJN Acknowledgments: the authors thank the administration, faculty and forth-year students in each of the included universities. Conflict of interest: none Al-Atiyyat NM (2008). Patient-related barriers to effective cancer pain management. 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