Student Nurses Knowledge, Attitudes, and Self-Efficacy of Children s Pain Management: Evaluation of an Education Program in Taiwan

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1 82 Journal of Pain and Symptom Management Vol. 32 No. 1 July 2006 Original Article Student Nurses Knowledge, Attitudes, and Self-Efficacy of Children s Pain Management: Evaluation of an Education Program in Taiwan Li-Chi Chiang, RN, PhD, Hsiu-Jung Chen, RN, MSN, and Lichi Huang, RN, EdD School of Nursing (L.-C.C., L.H.), China Medical University; and School of Nursing (H.-J.C.), Taiwan National University, Taiwan, Republic of China Abstract The purpose of this study was to examine the effectiveness of a pediatric pain education program (PPEP) for student nurses. The sample consisted of 181 licensed student nurses who were enrolled in a nursing school in Taiwan. Student nurses attended a 4-hour PPEP that involved case scenario discussion, video, and lecture. Data were collected by an extensive questionnaire that assessed student nurses knowledge of, attitudes toward, and self-efficacy in pediatric pain assessment and pharmacological and nonpharmacological pain management. The results demonstrated that student nurses gained significant knowledge of pediatric pain, expressed more appropriate attitudes, and reported greater self-efficacy in children s pain management after attending PPEP. Their knowledge of analgesic pharmacotherapy did not significantly improve. These results suggest that PPEP should be integrated into pediatric nursing curricula to enhance knowledge and skills regarding children s pain management during the early stage of a nursing career. J Pain Symptom Manage 2006;32: Ó 2006 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Pain education, student nurses knowledge and attitudes of children s pain, evaluation research, nurses self-efficacy in pain management Introduction Pain due to illnesses and procedures is one of the most common symptoms that children experience in the hospital. Nurses play an important role in assessing and managing Address reprint requests to: Lichi Huang, RN, EdD, School of Nursing, China Medical University, 91 Hsueh-Shin Road, Taiwan, Republic of China. lichi@mail.cmu.edu.tw Accepted for publication: January 16, Ó 2006 U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved. children s pain during hospitalization. Nurses knowledge of, attitudes toward, and self-efficacy in children pain management affect nursing care. Although many studies have focused on general and pediatric nurses knowledge of and attitudes toward patients pain overall and children s pain management, few studies have focused on the education of student nurses in children s pain management The results from these earlier studies indicated that nurses, pediatric nurses, and student nurses lack good knowledge of pain management and confidence about /06/$--see front matter doi: /j.jpainsymman

2 Vol. 32 No. 1 July 2006 Evaluation of a Pain Program on Children s Pain 83 pharmacological and nonpharmacological management. A program to improve nurses knowledge of and attitudes toward children s pain management is urgently needed. Some educational programs have been successful, 15,16 but success rates are conflicting. 17,18 Scholars have suggested that attitudes toward pain management are often developed at an early stage in a nurse s career. 11 Therefore, courses that focus on pediatric pain assessment and management have been part of the pediatric nursing curriculum for almost 10 years in Taiwan. However, the effectiveness of these kinds of programs has never been studied. This study was conducted for the purpose of evaluating a pediatric pain education program (PPEP). This program was designed to teach student nurses about pediatric pain management, and to increase their confidence to meet the needs of practicing nurses. Nurses Knowledge About Children s Pain Management Clinical management of children s pain poses a challenge to pediatric nurses competency. Some studies have shown that there is a deficit of children s pain management skills among nurses. 3,4,10 Although scientific knowledge about children s pain is increasing, the undertreatment of pediatric pain is still a serious problem, both in America 19 and in Taiwan. 20 Undermedication is a common problem because of a lack of knowledge, fear of patient addiction, and inadequate assessment skills. 21 Only 50%--79% of nurses respond correctly to questions about pain management. 3,4,10, Nurses have insufficient knowledge of both pharmacological and nonpharmacological pain management. 11 Studies by Manworren and Hayes 8 found that pediatric nurses pain knowledge was deficient, especially regarding assessment skills and pharmacological usage. Some studies have evaluated the effects of pediatric pain education. Nurses who attended pediatric pain classes administered more opioids than those who did not. 25 Educational programs on children s pain successfully increased nurses knowledge, assessment, and management of children s pain. 10 Pederson 16 designed a two-hour program to train nurses in five nonpharmacologic pain management techniques; the 35 nurses exposed to the training reported that they had better knowledge of and comfort with the techniques and continually increased the usage of the techniques in practice during the two-month training period. Simons 15 reported that a one-day pain education program improved nurses confidence in managing children s pain. Other studies have failed to prove the effectiveness of pediatric pain management programs. 21,26 Knoblauch and Wilson 26 examined the influence of a hospital in-service on pediatric pain management on nurses administration of analgesics to children who had tonsillectomies. In contrast to what was expected, after the educational program there was an increased length of time before the first dose of analgesic was given and between doses of analgesics given to patients. Mackintosh and Bowles examined the impact of an acute pain service on nurses knowledge and beliefs in the surgical area. 21 The findings demonstrated a consistent but statistically nonsignificant trend toward improved knowledge and more appropriate beliefs about pain. Nurse s Self-Efficacy The concept of self-efficacy, as developed by Bandura, 27 refers to the confidence in one s ability to perform a certain action successfully. 28 Knowledge is a basic element for selfefficacy. An effective pain education program should not only provide accurate information about pain management but also should enhance nurses confidence in assessing and managing children s pain. An appropriate pain education program in the early stage of a nurse s career could establish the skills needed to provide high-quality health care. At present, there is still a lack of information about the influence of pediatric pain education on student nurses knowledge, attitudes, and self-efficacy. The purpose of this study was to explore student nurses knowledge of, attitudes toward, and self-efficacy in assessing and managing children s pain prior to and after implementation of a pain education program. Methods A quasi-experimental design was used to examine the effectiveness of a PPEP.

3 84 Chiang et al. Vol. 32 No. 1 July 2006 Questionnaires were anonymously delivered to student nurses before the pain education program. The post-test questionnaire was administered one month after completion of the program. Subjects Subjects were recruited by convenience sampling of 243 student nurses from four classes in one nursing school in Taichung. Informed consent was obtained from each subject. Some of the participants did not finish the questionnaire. The reasons included absenteeism, tardiness, and unwillingness to cooperate. A total of 192 student nurses completed the questionnaire at the pretest (78.6%), and a total of 181 student nurses returned the post-test questionnaire one month after completion of the program (94.27%). All of the respondents held associate nursing degrees and nursing licenses and were enrolled in a two-year baccalaureate nursing program. Most of the students had studied pain management while in their associate nursing programs. The student nurses ranged in age from 22 to 28 years. All of the students had more than one year of clinical experience in a hospital or clinic. Pediatric Pain Education Program We developed a four-hour program intended to instruct student nurses about children pain assessment and management. The education program focused on: 1) misconceptions about children s pain; 2) various pain assessment tools for children; 3) pharmacological pain management for children; and 4) nonpharmacological pain management for children. All of the sessions included a didactic presentation and interactive discussion of case scenarios. One 28-minute video was presented to demonstrate various pain assessment tools and nonpharmacological pain management. Teaching materials included pediatric pain assessment tools and explanatory memoranda. The same instructor taught all four classes to ensure consistency of the teaching process. Instrument A questionnaire comprising 41 items measured student nurses pediatric pain knowledge, attitudes, and self-efficacy in managing pain. Thirty-five questions were adopted and modified from those proposed by McCaffery and Ferrell, 6 and Manworren. 21 These questions were translated into Chinese. Content validity of the translated instrument was documented using a panel of three pediatric experts. Each expert reviewed the initial items independently, and this was followed by a panel discussion made up of all experts. A broad range of pain-related topics was covered in the instrument, including general pain misconceptions, cultural considerations, pain assessment, and pharmacological and nonpharmacological management. McCaffery and Ferrell 6 suggest that the test should avoid distinguishing items as measuring either knowledge or attitudes. The score computed from all of the 35 items represents nurses knowledge of and attitudes toward children s pain management. There were 22 true/false items and 13 multiple-choice questions, and scores ranged from 0 to 35 points. Manworren 21 established the reliability and validity of this instrument in a series of studies. Test-retest reliability was established (r > 0.67) by repeat testing of pediatric nurses (n ¼ 247). Internal consistency reliability was established (Cronbach s alpha ¼ 0.72) with items reflecting both knowledge and attitude domains. In this study, the reliability of internal consistency of 35 items by KR20 was 0.46 at pretest and 0.68 at post-test. Nurses self-efficacy in managing children s pain was measured by 5-point Likert scales. The measurements comprised three items on pain assessment, two items on pain management, and one item on cooperation with the health care team. Internal consistency, measured by Cronbach s alpha, was 0.88 at pretest and 0.91 at post-test. Content validity was established by three pain experts in pediatric nursing. Statistical Analysis Standard scores were derived by applying the following equation: the average of correct score/total score 100. Because most of the items were dichotomous, nonparametric Wilcoxon matched-pairs signed-ranks tests were used to compare the changes before and after implementation of the pain education program. The criterion for significance (alpha) was set at 0.05 (two-tailed). The power analysis is based on a population effect size so that the discrepancy percentage falls into 20 points.

4 Vol. 32 No. 1 July 2006 Evaluation of a Pain Program on Children s Pain 85 This effect was selected as the smallest effect that would be important to detect, in the sense that any smaller effect would not have clinical significance. It was also assumed that an effect of this magnitude could be anticipated in this field of research. With a sample size of 180, the study had a power of 77.1% to yield a statistically significant result. Results Knowledge and Attitudes The results showed that nurses knowledge of and attitudes toward children s pain management improved following a pain education program (Table 1). Only 57% of the questions (20 items of 35) were answered correctly at the pretest. Before the pain education, the standard score of total students pain knowledge and attitudes was After the pain education program, 91.4% questions (32 items of 35) were answered correctly. The standard score of 74.1 was significantly better than the pretest score (P < 0.001). There were 10 questions (Nos. 5, 10, 11, 12, 16, 18, 19, 21, 26, 31) that did not have different responses before and after the program. Seven of these 10 questions were answered correctly at pretest. Question 11 ( The duration of action of morphine IV ) and Question 26 ( Morphine dose exchange from IV to oral ) were answered incorrectly by most nurses even after the PPEP. In response to Question 34 ( What do you think is the percentage of children who overreport the amount of their pain ), 152 (84.4%) student nurses at the pretest responded that more than 10% of children overreport their pain. Although participants knowledge about pain assessment improved after pain education, there were still 86 (47.5%) student nurses who did not believe children who report pain after the PPEP. The correct responses to Question 35 ( rate of opioid addiction ) significantly increased from 39 (21.4%) to 162 (89.5%) after pain education. Self-Efficacy Before the pain education, the standard score for self-efficacy was 73.37, indicating that student nurses were fairly confident at assessing and managing children s pain. Nonetheless, the total standard score of self-efficacy at posttest was 87.07, indicating that nurses selfefficacy in managing children s pain significantly (P < 0.001) increased after the pain education program (Table 2). Discussion Nurses Knowledge of and Attitudes Toward Children s Pain Management Nurses currently lack sufficient knowledge about pharmacological pain management. For example, pain knowledge scores were in Brunier et al. s 2 study of 260 Canadian nurses, 63.9 in Hamilton and Edgar s study of 318 Canadian nurses, 29 and 68 in Cason et al. s 3 study of 217 American nurses. The standardized pain knowledge score in this study was 55 before education, which is low compared to those studies. Although the pain knowledge score improved to 74.1 after the pain education in this study, the knowledge about and attitudes toward pain management still was not satisfactory; therefore, the PPEP used in this study needs to be improved to emphasize the principles of pharmacological management. Previous studies have shown that nurses have a particularly poor understanding of basic pharmacokinetic principles and analgesic agents. 3,6,8,9 The study by Manworren and Hayes 8 found that Items 10, 26, and 31 were the questions most frequently answered wrong by participants. In our study, those items referring to pharmacological management (Nos. 10, 11, 12, 26, 31) did not increase after the education program. Although nurses tend to depend on doctors prescriptions, Pederson et al. 30 found that 50 pediatric critical care nurses wanted to better understand analgesic medications, and Manworren reported that nursing curricula should include advanced knowledge of pharmacological pain management. 8,21 Furthermore, PPEP should emphasize nurses ability to manage children s pain by cooperating with other health care team members. Only 15.6% of student nurses in our study stated that they believed children who reported pain. This response was much lower than that reported in other studies, which ranged from 50% to 74%. 6,30,31 Even after

5 86 Chiang et al. Vol. 32 No. 1 July 2006 Questions Table 1 Improvement in Pain Knowledge and Attitudes (n ¼ 181) Answer Pretest, M (SD) Post-test, M (SD) Z-Value P-Value 1. Observable changes in vital signs must be relied upon to F (.458) (.363) verify a child s statement that he has severe pain. 2. Because of an underdeveloped neurological system, F (.440) (.147) children under 2 years of age have decreased pain sensitivity and limited memory of painful experiences. 3. If the child can be distracted from his pain, this usually F (.374) (.218) means that he does NOT have high pain intensity. 4. Children may sleep in spite of severe pain. T (.440) (.328) Comparable stimuli in different people produce the same F (.332) (.285) intensity of pain. 6. Ibuprofen and other nonsteroidal anti-inflammatory agents F (.496) (.501) are NOT effective analgesics for bone pain caused by metastases. 7. Nondrug interventions (e.g., heat, music, imagery) are very F (.421) (.498) effective for mild-moderate pain control but are rarely helpful for more severe pain. 8. Respiratory depression rarely occurs in children who have T (.374) (.416) been receiving opioids over a period of months. 9. Aspirin 650 mg PO is approximately equal in analgesic T (.501) (.488) effect to codeine 32 mg PO. 10. The World Health Organization pain ladder suggests using F (.475) (.491) single analgesic agents rather than combining classes of drugs (e.g., combining an opioid with a nonsteroidal agent). 11. The usual duration of action of analgesia of morphine IV F (.407) (.423) is 4--5 hours. 12. Research shows that promethazine (Phenergan Ò )is F (.387) (.268) a reliable potentiator of opioid analgesics. 13. Children with a history of substance abuse should not be F (.485) (.437) given opioids for pain because they are at high risk for repeated addiction. 14. Beyond a certain dosage of morphine, increases in dosage F (.434) (.472) will NOT increase pain relief. 15. Children cannot tolerate opioids for pain relief. F (.487) (.259) Children with pain should be encouraged to endure as F (.174) (.074) much pain as possible before resorting to a pain relief measure. 17. Children less than 11 years cannot report pain with F (.407) (.285) reliability and therefore, the nurse should rely on the parents assessment of the child s pain intensity. 18. Based on one s religious beliefs, a child may think that T (.380) (.314) pain and suffering is necessary. 19. After the initial recommended dose of opioid analgesic, T (.102) (.147) subsequent doses are adjusted in accordance with the individual child s response. 20. The children should be advised to use nondrug F (.451) (.346) techniques alone rather than concurrently with pain medications. 21. Giving children sterile water by injection (placebo) is often F (.443) (.400) a useful test to determine if the pain is real. 22. To be effective, heat and cold should only be applied to F (.501) (.486) the painful area. 23. What is the recommended route of administration of Oral (.421) (.494) opioid analgesics to children with prolonged cancerrelated pain? 24. What is the recommended route of administration of Intravenous (.500) (.383) opioid analgesics to children with brief, severe pain? 25. Which of the following analgesic medications is considered the drug of choice for the treatment of prolonged moderate to severe pain for children with cancer? Morphine (.488) (.392) (Continued)

6 Vol. 32 No. 1 July 2006 Evaluation of a Pain Program on Children s Pain 87 Table 1 Continued Questions Answer Pretest, M (SD) Post-test, M (SD) Z-Value P-Value 26. Which of the following IV doses of morphine administered over a four-hour period would be equivalent to 15 mg of oral morphine? 27. Analgesics for postoperative pain should initially be given 28. What is the likelihood of the child developing clinically significant respiratory depression? Morphine 5mgIV (.485) (.468) Around (.501) (.363) the clock <1% (.456) (.293) Analgesia for chronic cancer pain should be given Around (.480) (.383) the clock 30. What is the most likely explanation for why a child with Pain (.498) (.412) pain would request increased doses of pain medication? increasing 31. Which of the following drugs are useful for treatment of All (.492) (.490) cancer pain? Ibuprofen, hydromorphone, amitriptyline. 32. Who is the most accurate judge of the intensity of the Children (.313) (.180) children s pain? 33. Which of the following describes the best approach for Individual (.252) (.328) cultural considerations in caring for patients in pain? assessment 34. What do you think is the percentage of children who 0 or (.364) (.501) overreport the amount of pain they have? 35. How likely is it that opioid addiction will occur as a result if treating pain with opioid analgesics? <1% (.411) (.307) Total score of knowledge/attitude (3.39) (3.35) Standard score of total knowledge/attitude SD ¼ standard deviation; PO ¼ oral route of administration; IV ¼ intravenous injection. attending the PPEP, 47.5% (86) of student nurses still did not believe children who reported pain. The PPEP in this study used the definition of pain developed by McCaffery 32 who stated, Pain is whatever the experiencing person says it is and exists whenever s/he says it does. This concept of pain is used in most nursing areas. The PPEP began by discussing misconceptions about children s pain. The mechanism of pain is controversial and complicated, but may include sensory, physical, psychological, and cognitive factors. Children s pain also is compounded by the following factors: constant development, relatively limited cognitive ability, limited verbal skills, and limited behavioral competencies. 33 Nurses do not believe pain reported by children because they might think that children s understanding of pain is limited. Although a creative and more reliable pain assessment tool was developed a few years ago, nurses still do not entirely believe children s responses. A study that investigated the factors influencing nurses pain assessment and interventions in children found Table 2 Improvement in Self-Efficacy (n ¼ 181) Self-Efficacy Pretest, M (SD) Post-test, M (SD) Z-Value P-Value 1. How confident are you that you could assess (1.007) (.855) children s pain across developmental stages? 2. How confident are you that you could choose (.917) (.847) appropriate pain assessment methods? 3. How confident are you that you could use the (.988) (.857) pediatric pain assessment tool for your patients? 4. How confident are you of your ability to give the 3.94 (1.087) (.854) correct pain controller to patients? 5. How confident are you of your ability to provide (.94) (.827) nonpharmacological pain management to children? 6. How confident are you of your ability to cooperate (.958) 4.58 (.796) with the medical team to relieve children s pain? Total score of self-efficacy (4.67) (4.20) Standard score of total self-efficacy

7 88 Chiang et al. Vol. 32 No. 1 July 2006 that the nurses mainly rely on children s vocal expressions, especially crying, to administer analgesics. 34 The result indicated the PPEP teaching strategies and contents should focus more on changing the misconceptions nurses have about children s pain. A good strategy would be to provide evidence from different studies and implement case discussion scenarios. Nurses Self-Efficacy No research has been conducted about nurses self-efficacy in pediatric pain assessment and management. Self-efficacy of student nurses in children s pain management increased after participation in PPEP. Prior to the PPEP, the scores on self-efficacy items were higher than the scores reflecting knowledge of and attitudes toward pain management. This result revealed a very dangerous situation: most nurses thought they were able to manage pain even though they possessed limited information about pain management. After the PPEP, the scores on self-efficacy significantly increased to 87.7, which showed that the pain education program influenced participants self-efficacy in children s pain. Student nurses reported feeling more confident in assessing and managing children s pain after PPEP. Limitations Several limitations inherent to this study should be mentioned. First, the study was conducted in only one nursing school; the results may not be an accurate representation of nurses in Taiwan. Second, although this program increased the student nurses knowledge of and attitudes toward managing children s pain, some concepts were missed and teaching strategies must be modified. Last, behavior change was not measured in this study. A longitudinal study would allow for a better understanding of the behavior change over time. Continued observation of the effectiveness of pain education for student nurses in the clinic is needed. Conclusions This four-hour PPEP increased student nurses knowledge of, attitudes toward, and self-efficacy in children s pain management. We recommend that a PPEP be included in pediatric nursing curricula. The content should focus on nurses understanding of children s pain, pharmacological pain management, and other topics. Pain education should not only be taught in the classroom, but also in clinical practicum. Perhaps one-on-one role modeling with a pediatric pain expert could lead to more effective results and reduce the theory-practice gap. Acknowledgments The authors would like to thank all of the participants who took part in this study. The authors are especially grateful to Dr. Savedra, who assisted with the study design. References 1. Brown ST, Bowman JM, Eason FR. Assessment of nurses attitudes and knowledge regarding pain management. J Contin Educ Nurs 1999;30: Brunier G, Carson G, Harrison DE. What do nurses know and believe about patients with pain? Results of a hospital survey. J Pain Symptom Manage 1995;10: Cason CL, Jones T, Brock J, et al. Nurses knowledge of pain management: implications for staff education. J Nurs Staff Dev 1999;15: Coyne ML, Reinert B, Cater K, et al. Nurses knowledge of pain assessment, pharmacologic and nonpharmacologic interventions. Clin Nurs Res 1999;8: Heath DL. Nurses knowledge and attitudes concerning pain management in an Australian hospital. Aust J Adv Nurs 1998;16: McCaffery M, Ferrell BR. Nurses knowledge of pain assessment and management: how much progress have we made? J Pain Symptom Manage 1997; 14: Polkki T, Vehvilainen-Julkunen K, Pietila AM. Nonpharmacological methods in relieving children s postoperative pain: a survey on hospital nurses in Finland. J Adv Nurs 2001;34: Manworren RCB, Hayes JS. Pediatric nurses knowledge and attitudes survey regarding pain. Pediatr Nurs 2000;26: McInerney M, Goodenough B, Jastrzab G, et al. Paediatric nurses knowledge and attitudes concerning suboptimal pain management for children. Neonatal Pediatr Child Health Nurs 2003;6:

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