Nurses Knowledge About Pharmacological and Nonpharmacological Pain Management in Children

Transcription

1 Vol. 18 No. 4 October 1999 Journal of Pain and Symptom Management 289 Original Article Nurses Knowledge About Pharmacological and Nonpharmacological in Children Sanna Salanterä, MNSc, RN, Sirkka Lauri, PhD, RN, Toivo T. Salmi, MD, and Hans Helenius, MSc Departments of Nursing Science (S.S., S.L.) Biostatistics (H.H.), University of Turku, Turku; and Department of Pediatrics (T.T.S.), Turku University Hospital; Turku, Finland Abstract The purpose of this study was to investigate the knowledge base and practices of Finnish nurses in the area of children in pain. The convenience sample consisted of 265 nurses working on children s wards in university hospitals. Data were collected using an instrument designed for the study. The results showed that there remain gaps in the knowledge base of nurses with regard to both pharmacological and nonpharmacological in children. The education and the area of expertise were significant influences on knowledge scores. Nurses used a fairly wide range of nonpharmacological pain alleviation methods but most of these were such that the nurse was in an active role and the child was passive. There is a clear need for further education. Nurses should take a more active role in seeking new information and also should be encouraged to use nonpharmacological methods that let the children be active participants in their own care. J Pain Symptom Manage 1999;18: U.S. Cancer Pain Relief Committee, Key Words Nurse, nursing, knowledge,, nonpharmacological, pharmacological, child, children Address reprint requests to: Sanna Salanterä, RN, Department of Nursing Science, University of Turku, Turku, Finland. Accepted for publication: November 30, Introduction The purpose of this study was to investigate the knowledge base and practices related to children in pain of Finnish nurses working on children s wards in university hospitals. To perform high-quality nursing care, nurses need to know about the pain medication they administer to children. It is not enough that nurses comply with orders; they should also be able to analyze the consequences of those orders. Specifically, it is important to know about different medications, their effects and side effects, and possible complications. Lack of knowledge and negative attitudes may lead to undermedication and undertreatment of pain. 1 4 There also exists a wide range of nonpharmacological methods for alleviating pain. Together with pain medication, they form the basis for the care of children in pain. Nurses are close to the children the whole day and they have a chance to use nonpharmacologic U.S. Cancer Pain Relief Committee, /99/$ see front matter Published by Elsevier, New York, New York PII S (99)

2 290 Salanterä et al. Vol. 18 No. 4 October 1999 methods in their work. It is important to know if nurses take advantage of this possibility. Nurses Knowledge About Children s There are few studies available on nurses knowledge about children s. Instruments to measure nurse s knowledge of children s are lacking. There are far more studies and instruments available investigating nurses and other health care professionals knowledge about among adult patients, and cancer patients in particular Some studies indicate that nurses lack knowledge in the area of pharmacological pain management. 1,15 17 A recent study by Pederson and Parran, 18 which used an investigator-developed 48-item questionnaire that studied a special group of pediatric nurses (N 20) working with children having bone marrow transplants, showed that these nurses had high knowledge level related to. Pederson et al. 19 studied pediatric critical care nurses (N 19) with an investigator-developed Knowledge Test. Their results showed that these nurses had a mean score of 63% correct answers. The researchers suggested that with this type of test the gaps in knowledge can be detected and education can be offered. Lebovits et al. 20 reported that nurses, physicians, pharmacists, and medical/nursing students (N 686) had an overall correct score of 56% of the 17 items measuring their knowledge of children s. Clarke et al. 11 investigated nurses (N 120) knowledge, attitudes, and clinical practice regarding in nine clinical units in a university-affiliated teaching hospital. Results from the nursing knowledge and attitudes survey on pain revealed knowledge deficits and inconsistent responses in many areas related to. There were significant differences according to nurses degrees and type of unit. In the same study, demographic data revealed that education about pain was most inadequate in areas of nonpharmacological interventions to relieve pain, the difference between acute and chronic pain, and the anatomy and physiology of pain. Nurses seem to be reasonably well aware of the obstacles to proper. Both nurses and physicians in Broome et al. s 17 study agreed that the younger the child, the less effective was in their institution. The best treated group was thought to be that of school-aged children and adolescents, whose was rated at 7.5 on a scale from 1 to 10. Pederson and Harbaugh 21 asked 54 registered nurses about obstacles to the use of nonpharmacological and found that workload, lack of proper material, lack of knowledge and skills, and not knowing the child were the most common problems. Likewise, the nurses (N 120) in the study by Clarke et al. 11 felt that they received very little education on nonpharmacological. According to the chart audit data from the same study, 90% had no documented evidence of the use of any nonpharmacological modalities to relieve pain. Nurses Use of Nonpharmacological Methods in Effective in children requires knowledge of both nonpharmacological and pharmacological methods. Such nonpharmacological methods as distraction, relaxation, guided imagery, massage, thermal therapy, transcutaneous electrical nerve stimulation (TENS), rocking, pacifiers, therapeutic play, hypnosis, and music are widely used in alleviating pain in children of different ages. 17,21 27 Therapeutic massage and humor have also been recommended for this purpose. 28,29 Children themselves are eager to use both cognitive and physical nonpharmacological interventions, such as distraction, imagery, cold compresses, hot baths, hot packs, and massage. 30 However, the research evidence on nonpharmacological is contradictory; the same method is sometimes found to be effective, sometimes not. 31,32 There is still very little systematic research in the area of nonpharmacological and biobehavioral pain research. 33,34 Carroll and Seers 35 and Seers and Carroll 36 have presented two systematic reviews of randomized controlled trials about relaxation for the relief of chronic and acute pain. None of the studies reviewed were in the area of children s pain. The reviews revealed that less than half of the 16 studies concluded that relaxation had beneficial impacts for pain relief. On the other hand, Ellis et al. 32 reported in their review that cognitive behavioral interventions for chil-

3 Vol. 18 No. 4 October 1999 Nurses Knowledge of Children s 291 dren s distress during bone marrow aspirations and lumbar punctures were found helpful in several studies. Pederson and Harbaugh 21 conducted a descriptive exploratory study among 54 pediatric nurses and found that nurses use nonpharmacological techniques mainly with children undergoing painful procedures. However, lack of time and heavy workload impede the use of these techniques. Nurses also found it helpful to involve parents in implementing nonpharmacological techniques. Broome et al. 17 conducted a nationwide survey in U.S. teaching hospitals in which they studied pediatric pain practices of nurses and physicians. Among other things, they asked the 113 respondents about the use of nine nonpharmacological techniques. Over 50% of the respondents mentioned that they used such techniques as relaxation, distraction, imagery, positioning, and massage often or sometimes. Techniques such as behavioral therapy (35%), thermal modalities (33%), TENS (18%), and hypnosis (18%) were reported as being administered sometimes. Factors That Influence Nurses Knowledge and Implementation of Interventions in Children s It has been found that nurses characteristics, such as age, knowledge, experience, intuition, attitudes and beliefs, as well as nurses personal experience with pain, influence their implementation of analgesic interventions and knowledge about pain. 1,11,12,37,38 Halfens et al. 39 reported that level of education is related to pain assessment, and Margolius et al. 40 found that nursing education correlated positively with beliefs and perceptions about children in pain, whereas years of experience and age did not. On the other hand, Fothergill-Bourbonnais and Wilson-Barnett 7 discovered that there were only few differences between novices and experts in terms of their knowledge about pharmacological and nonpharmacological aspects of pain and its management. Purpose of the Study and Research Questions The purpose of this study was to investigate the knowledge base and practices about pain management in children of Finnish nurses working on children s wards in university hospitals. The following research questions were addressed: 1. What do nurses know about nonpharmacological in children? 2. What do nurses know about pharmacological in general and about anti-inflammatory drugs, opioids, and regional anesthesia in children? 3. What methods of nonpharmacological do nurses use in practice? 4. Do the knowledge base and methods used differ according to nurses age, time of graduation, education, institute, ward, working experience, or nurses own opinions of their knowledge? Methods In Finland, all registered nurses have two and half years of general nursing education after high school, equal with the bachelor s degree. After this education, nurses can specialize into several fields, such as child care, public health care, operating room and anesthesiology, or medical surgical care. This specialization takes 1 year. A masters degree in nursing science takes an additional 3 years. Nurses in this study were either general registered nurses or were specialized in one of the fields mentioned and they all worked in children s wards. Finland is a small country with a population of 5.5 million. There are five University hospitals in the country and they all have children s departments which offer specialist care. Nurses in children s wards normally work on two or three shifts and there is a small percentage (1 3%) of nurses working only during the night shifts. The target population of this study consisted of registered nurses who had at least a bachelor-level education, who worked on children s wards at any of the five Finnish university hospitals, and who primarily worked and had daily contact with children (just over 900 nurses). The convenience sample consisted of all nurses at work during one working shift (7 A.M. to 3 P.M.) in any of the children s wards at the five hospitals. The questionnaire was given to 303 nurses, which represents one-third of the target population. The nurses on the same

4 292 Salanterä et al. Vol. 18 No. 4 October 1999 wards filled in the questionnaires at the same time. Participating in this study was voluntary and the information obtained was handled anonymously. The response rate was 87%, with 267 nurses returning the questionnaire. Two of the questionnaires returned had to be excluded because of missing data, and the final sample consisted of 265 nurses. The instrument was designed on the basis of a review of the research literature concerning pain on both adults and children. To improve content validity, the instrument was pilot tested and revised by a group of experts who had at least 5 years of experience in children s pain management, who were considered as experts by their colleagues and superiors, and who had been involved in research or development programs related to children s pain. One pediatrician and one anesthesiologist also took part in revising the instrument. The study was approved by the research committees of each hospital, and the nurses received a personal letter informing them about the research. The instrument consisted of a demographic data sheet, nine general questions about nonpharmacological pain alleviation, and 23 questions about pharmacological (see Appendix A). In addition there were 21 questions about different nonpharmacological methods and four questions about the nurse s own opinions of her knowledge and possibilities to manage children s pain. Nurses were also asked what type of education they had had and what type of literature they had read during the last 2 years in the area of pain and. The demographic items included age, education, field of specialization, place of work, the age of children with whom the nurses work, and nursing experience. The five-point Likert-type scales ranged from Agree, Agree to some extent, Don t know, Disagree to some extent to Disagree. In the last section on the nurses opinion concerning their knowledge and possibilities of, the scale ranged from good and fairly good through don t know to fairly poor and poor. Knowledge scores were combined to evaluate nurses knowledge in the areas of nonpharmacological, general knowledge of pharmacological, anti-inflammatory pain medication, opioids, and regional anesthesia, and to evaluate the association between nurses own opinions of their knowledge and knowledge scores. The scores are given as percent of correct answers out of the possible total. The answers agree and agree to some extent, or when the item was incorrect, disagree or disagree to some extent, were scored as correct answers and were worth one point, while all other options were scored as zero. Comparisons were done with nonparametric Kruskal-Wallis analysis of variance (ANOVA). Pairwise comparisons with the Wilcoxon-test were conducted in those areas which showed statistically significant differences. P-values of less than 0.05 were interpreted as significant. The data were entered twice into the program to avoid errors in data input. The SAS system for Windows, release 6.2/1996, was used for data analysis. Results Demographic Data The nurses were employed at one of the five university hospitals. Their ages ranged from 20 to 59 years, the mean (SD) being 39 (8.8) years. The corresponding figures for nursing experience were from 0.5 to 35 years, with a mean (SD) of 14.5 (8.8) years. Only 4% had been in nursing for less than 2 years, and 30% had more than 20 years experience. Most of the nurses (56%) were specialized (3.5 to 4.5 years of education) in children s care, 16% were specialized in anesthesiology or operating room (OR) nursing, 15% had some other specialization, and 13% of the nurses had no specialization (2.5 years of education). All nurses were registered. Their places of work are listed in Table 1. Most nurses had had some education on during the last 2 years. Still, Table 1 Nurses Place of Work (N 265), Missing Data 11 Wards on which nurses work: n 254 Outpatient 19% Neonatal intensive care 12% Children s intensive care 8% Medical 11% Surgical 14% Operating theater 17% Other 19%

5 Vol. 18 No. 4 October 1999 Nurses Knowledge of Children s 293 about 30% of them had had no education at all in this area. Most of the education had taken place in nurses own wards but a few nurses had also attended national education days. Close to 30% of the nurses had read at least one research article or report in the area of pain in the past 2 years and many nurses (45%) had received information about pain from professional journals. Nurses Knowledge About Nonpharmacological Knowledge scores percent of correct answers were calculated for each participant and then compared to different background variables. In the section on nonpharmacological (total of nine items) 79% of the nurses had 50% or more correct answers, 11% had more than 80% correct answers, and 21% had less than 50% correct answers. The mean (SD) of correct answers was 63% (16.9) the median of 67%. The nurses received high scores on such items as In the treatment of pain in children, medication is not the only method needed for the alleviation of pain, and Pain in children cannot be totally eliminated by conversation aimed at helping them to relax. The lowest scores were attained on the item: Massage is a good way of alleviating pain associated with tumors in children. The associations between the different nurse characteristics and the knowledge scores are shown in Table 2. Nurses knowledge differed according to their age, education, and place of work. Nurses aged between 46 and 55 years had the highest scores, and all groups younger than 46 had lower scores. Nurses who specialized in children s nursing scored highest and those specializing in anesthesiology and operating room nursing scored the lowest points. Nurses specializing in public health also had fairly low scores, but there were only eight nurses with such an education. Nurses in outpatient clinics and surgical wards had the highest number of correct answers concerning nonpharmacological methods, nurses in operating theatres and children s intensive care units (CICU) had least correct answers on this subject. There were no significant Nurse characteristics Table 2 Nurses Knowledge Scores Compared with Related Nurse Characteristics df Nonpharmacologic (9 items) General aspects of pharmacologic (6 items) Knowledge areas Anti-inflammatory pain medication (8 items) Opioids (6 items) Regional anesthesia (3 items) Nurses age below 26, 26 35, 36 45, 46 55, above 55 Year of graduation , , , 1990 Education General nurse, child care, public health care anesthesiology, other specialization P P NS NS NS 3 NS NS NS NS NS NS NS , P 0.09 a , P Institute (5 hospitals) 4 NS NS NS NS NS Place of work Outpatient, NICU, CICU, medical, surgical, operating theatre, other P , , Work experience (0 1, 2 4, 5 10, 11 20, 20 yr) in a) health care b) child care c) present position 3 a) NS b) NS c) NS a) , p b) NS c) NS a) NS b) NS c) NS a) NS b) NS c) NS , a) NS b) NS c) NS NS nonsignificant, P a P values lower than 0.1 are shown.

6 294 Salanterä et al. Vol. 18 No. 4 October 1999 differences between nurses own opinions about their knowledge of nonpharmacological and their correct scores, but there was a difference between nurses opinions about their knowledge of pharmacological or its side effects and the correct scores. The nurses who thought they had good knowledge about pharmacological and its side effects scored lower in the area of nonpharmacological pain management than those who thought their knowledge was poor. Nurses Knowledge About Pharmacological The instrument contained 23 items about pharmacological, measuring general knowledge about pharmacological (six items), knowledge about anti-inflammatory drugs (eight items), opioids (six items), and regional anesthesia (three items). In this section, only 2% of the nurses had over 80% correct answers and 53% had 50 80% correct answers. Over 40% of the nurses had more than 50% incorrect answers in the section concerning pharmacological. The mean (SD) of correct answers was 51% (17.4), the median being 52%. The comparisons between the background data and pharmacological are shown in Table 2. The highest scores were obtained for the item Pain medication is equally effective whether given before the onset of pain or when the child is already experiencing pain. The lowest scores were obtained for the item: The most common reason for the increased need of painkillers in the treatment of children with cancer is the child s increasing tolerance, causing painkillers to lose their effect. Knowledge about general aspects of pharmacological differed significantly according to nurses age, place of work, experience, and their own opinions of what they know about nonpharmacological and pharmacological and its side effects. Here the mean (SD) of the correct answers was 60% (20.8) and median 67%. Nurses aged between 26 and 35 years and between 36 and 45 years had the highest scores and those aged 46 to 55 and over 55 the lowest scores. The highest scores were recorded on surgical wards and medical wards and the lowest in outpatient clinics and neonatal intensive care units (NICU). Nurses with 5 10 and years of experience in the field of health care had the most correct answers, nurses with 0 1 years or over 20 years experience the least. The nurses who thought that their knowledge about pharmacological was neither good nor poor scored highest and those who thought their knowledge was fairly poor lowest. There was also a significant difference between nurses who thought their knowledge about the side effects of pain medication was fairly good and those who thought their knowledge was either poor or fairly poor. Nurses knowledge about anti-inflammatory pain medication, opioids, and regional anesthesia also differed significantly according to education, place of work, nurses own opinion of their knowledge and nurses views on their unit s possibilities to offer effective (see Table 3). The mean (SD) proportion of correct answers was 49% (19.8) and median 50% in the area of anti-inflammatory pain medication; 49% (26.6) and 50%, respectively, in the area of opioids; and 42% (37.9) and 33%, respectively, in regional anesthesia. In these three areas, the highest scores were recorded for the following items: Paracetamol is well-suited for the treatment of pain in children, Long-term continuing opioid medication almost always causes physiological dependence in child patients and Regional anesthesia is a good method of after surgery. The lowest scores were recorded on the following items: Buprenorphine is absorbed well through the stomach, Respiratory depression is very rare in children who have received long-term continuing opioid medication and Regional anesthesia is wellsuited for the management of cancer pain. Nurses education influenced their knowledge about opioids and regional anesthesia. The highest scores were recorded by nurses specializing in operating room nursing and anesthesiology, the lowest scores by registered nurses with no specialization. Nurses on surgical wards and in children s intensive care had the highest proportion of correct answers, those working in neonatal intensive care and outpatient clinics the least correct answers in the field of anti-inflammatory pain medication. The situation was the same for opioids. Knowledge about regional anesthetics was highest

7 Vol. 18 No. 4 October 1999 Nurses Knowledge of Children s 295 Nurse s own opinion about her/his knowledge Table 3 Nurses Knowledge Scores Compared with Nurses Own Opinions on Their Knowledge Knowledge areas df Nonpharmacologic (9 items) General aspects of pharmacologic (6 items) Anti-inflammatory pain medication (8 items) Opioids (6 items) Regional anesthesia (3 items) Pharmacologic Side effects of pharmacologic Nonpharmacologic Nurse s view on her unit s possibilities to offer effective NS P 0.09 a P 0.03 P , , P NS , P 0.06 a NS , 4 NS NS P a 4 NS NS NS , , , , P NS NS nonsignificant, P a P values lower than 0.1 are shown. among operating room nurses and in children s intensive care units. The lowest scores were again achieved in outpatient clinics. Nurses own opinions of what they knew about pharmacological and its side effects were both significant factors when compared with the knowledge scores in the areas of anti-inflammatory pain medication, opioids, and regional anesthesia. In all these areas, nurses who thought their knowledge was good or fairly good also scored higher than those who thought their knowledge was poor or fairly poor. Those nurses who thought their knowledge about nonpharmacological was good also scored significantly higher in knowledge about opioids and regional anesthetics. Nurses Use of Nonpharmacologic Pain Management Methods The second part of the questionnaire consisted of a list of 20 nonpharmacological pain alleviation methods. The nurses were asked to say how often they used these methods with children experiencing chronic pain. There were five preset options: With all or almost all children experiencing pain, With many children experiencing pain, Don t know, With some children experiencing pain, and With hardly any or no children experiencing pain. Over 50% of the nurses used the following methods with many or with all children experiencing chronic pain: being close to the child (98%), talking to the child (97%), changing body posture (92%), smiling to the child (83%), rocking (82%), distraction by turning the child s attention away from pain (69%), reading to the child (54%), listening to music (54%) and massage (52%). The following methods were also quite popular: watching videos (49%), humor (46%), using the child s own imagination (44%), singing to the child (39%), relaxing breathing (37%), relaxing the muscles (36%), and cold bandages (35%). The methods used least often were: warm bandages (19%), turning the child s attention to the procedure (12%), using cassettes for relaxation (5%), and TENS (1%). Hypnosis is not common and not used by nurses in Finland. The nurses were also asked to list any other methods they may have used. Only seven nurses mentioned methods outside the list given. The nurses used a mean (SD) of 9.4 (3.4) methods out of 20, with half of the nurses using 9 out of 20 methods with many or with all children experiencing pain. Of these methods, 70% were such in which the nurse was in charge and active. Nurses education (Kruskal-Wallis , df 4, ), work experience ( , df 4, P 0.018), and the unit in which they worked ( , df 6, ) showed a statistically significant association with the amount of alleviating methods they used. Nurses who specialized in child care used most methods and nurses specializing in anesthesiology and operating room nursing used the least methods. Nurses

8 296 Salanterä et al. Vol. 18 No. 4 October 1999 with the longest experience (over 20 years) used more methods than others, and those with 2 4 years of experience used fewer methods than other groups. Nurses working on medical and surgical wards applied the widest range of pain alleviation methods, whereas nurses working in operating rooms and neonatal intensive care units had the least methods in use. The methods of pain alleviation were divided into two groups according to who would conduct the method, the child or the nurse. The nurses tended to use such methods in which they were in charge. Nurses age ( , df 4, P 0.001), education ( , df 4, ), year of graduation ( , df P 0.007), experience ( , df 4, P 0.003), and the unit in which they worked ( , df 6, P 0.001) showed a significant association with the type of methods they used. The older the nurses were, the longer the time since they had graduated, and the longer their working experience, the more they used such methods that allowed the child to be in charge of the situation. Also nurses with no specialization and working on medical and surgical wards applied more often such methods in which the child was in charge. Discussion Validity and Reliability of This Study This study provides an informative and detailed picture of registered nurses knowledge about and certain practices in all five university hospitals in Finland. The sample size was quite large, representing one-third of the population. The response rate was also high (87%), and the number of responses excluded because of missing data very low. The instrument was designed for this study and has not been tested in other populations. This is a limitation. Also, since the subject was fairly broad, it is possible that some areas of remain uncovered. Using a questionnaire for data collection allows for anonymity and helps to avoid interviewer bias, and it also simplifies the respondent s task. At the same time, however, important information may be missed. In this study, there were a few questions that were difficult to interpret and the right answers were difficult to determine. On the other hand there were many questions and the weight of one single item is therefore not so big. Nurses Knowledge about Children s The results showed that there remain some gaps in the knowledge base of Finnish university hospital nurses with regard to both pharmacological and nonpharmacological pain management in children. The results are consistent with the findings of several other studies. 1,15 17,20 The nurses received higher scores in the area of nonpharmacological. This result contradicts the findings of Clarke et al. 11 The nurses themselves were well aware of their lack of knowledge: their evaluations of their own knowledge base were well in line with their actual knowledge scores. Similar results have been reported by Broome et al. 17 and by Pederson and Harbaugh. 21 The question that has to be asked here is that if nurses are aware of their lack of knowledge, why do they not actively seek new knowledge and information? Such factors as year of graduation and place of work had no significant effect on the nurses knowledge scores. Their views on their possibilities to offer effective, on their knowledge about nonpharmacological as well as nurses age was significant only in some areas of knowledge. In this study nurses age was an important factor with respect to knowledge about nonpharmacological and general knowledge, but the effect was not systematic. There are some other studies that have found nurse s age to be an important factor. 1,37 Nurse s education was a more significant factor. Nurses who specialized in children s nursing knew more about nonpharmacological pain management than other groups and nurses specializing in operating room nursing and anesthesiology knew most about opiates and regional anesthetics. Nurses with no specialization had usually the lowest scores. The results are logical and show that education makes a difference. These results are similar to the findings of Halfens et al. 39 and Margolius et al. 40 The knowledge scores were also consistent with the area of expertise in which the nurses worked. For instance, nurses working in operating rooms and in anesthesiology had the highest knowledge scores on regional anesthetics, and nurses working on surgical wards knew most about all other aspects of that were measured. On the other hand,

9 Vol. 18 No. 4 October 1999 Nurses Knowledge of Children s 297 nurses working in outpatient clinics scored lowest in all other areas of knowledge except nonpharmacological. This was surprising in view of the fact that they work with children who have many types of acute pain (such as that associated with traumas) and who have to undergo procedures that are treated with pain medication. The scores of nurses working on medical wards were mainly in the intermediate range; the only area where they scored highest was general knowledge about pharmacological. In medical wards nurses have to work with a wide range of patients who have numerous types of problems that are not typically associated with pain. Nurses working in neonatal intensive care units scored fairly low in all areas. Theirs is a very special group of patients, and their low scores can be explained by reference to the fairly general nature of the questions. On the other hand, the low scores may also mean that pain is still not recognized in infants and that pain remains undertreated in neonatal intensive care units. We may speculate about the reasons for the low scores: There is still not enough information available about even at university hospitals, and nurses seem to have no tradition of actively and independently seeking new information in a rapidly developing area. In Pederson s and Parran s 18 study nurses received quite high knowledge scores and it is possible that knowledge about children s pain among nurses is gradually growing. On the other hand the studied group of nurses was quite special and the sample was quite small. There is also a lack of teaching resources in rapidly expanding areas of knowledge. Some of the research especially in the area of nonpharmacological is confusing and not easy to implement in practice. 31,32 Nurses Use of Nonpharmacologic Pain Management Methods Nurses used a fairly wide range of nonpharmacological pain alleviation methods. Most of these methods were such that the nurse was in an active role and the child was passive. The more experienced and the older the nurses, the more they allowed the child to take an active part in their own pain alleviation. The literature suggests that children like to have some responsibility for their own care; it helps to make them feel more secure and independent. 30 The nurses in this study were not very keen to use methods such as TENS. This may be due to a lack of know-how. The methods that were most widely used are easy to apply and do not require any special equipment. Clinical and Research Implications More research is needed in the area of nonpharmacological. Different methods of pain alleviation should be tested reliably so that the results could be generalized. Also children should have a more active role in pain alleviation. According to this research there is a need for professional extension training in in children. The knowledge gaps should be recognized and dealt with. Nurses should be encouraged to actively seek new information. It is possible that the university hospitals do not offer easy access to new research knowledge and that the nurses might not have the capability to utilize this knowledge. Children are taken care of in other than university-affiliated hospitals with children s wards and the know-how in such hospitals can be even worse. Similar research should be conducted in local hospitals as well. It is possible that other groups of health care professionals in Finland also lack knowledge in taking care of children in pain, and this type of research could also be aimed at them. References 1. Ross RS, Bush JP, Crummette BD. Factors affecting nurses decisions to administer PRN analgesic medication to children after surgery: an analog investigation. J Pediatr Psychol 1991;16: Elander G, Hellstrom G. Analgesic administration in children and adults following open heart surgery. Scand J Caring Sci 1992;6: Juhl IU, Christensen BV, Bülow HH, Wilbek H, Dreijer NC, Egelund B. Postoperative pain relief, from the patients and the nurses point of view. Acta Anaesthesiol Scand 1993;37: Tesler MD, Wilkie DJ, Holzemer WL, Savedra MC. Postoperative analgesics for children and adolescents: prescription and administration. J Pain Symptom Manage 1994;9: Diekmann JM, Wassem RA. A survey of nursing students knowledge of cancer pain control. Cancer Nurs 1991;14: Fife BL, Irick N, Painter JD. A comparative study of the attitudes of physicians and nurses toward the

10 298 Salanterä et al. Vol. 18 No. 4 October 1999 management of cancer pain. J Pain Symptom Manage 1993;8: Fothergill-Bourbonnais F, Wilson-Barnett J. A comparative study of intensive therapy unit and hospice nurses knowledge on. J Adv Nurs 1992;17: Hamilton J, Edgar L. A survey examining nurses knowledge of pain control. J Pain Symptom Manage 1992;7: Vortherms R, Ryan P, Ward S. Knowledge of, attitudes toward, and barriers to pharmacologic management of cancer pain in a statewide random sample of nurses. Res Nurs Health 1992;15: Ferrell BR, Dean GE, Grant M, Coluzzi P. An institutional commitment to. J Clin Oncol 1995;13: Clarke EB, French B, Bilodeau ML, Capasso VC, Edwards A, Empoliti J. Pain management knowledge, attitudes and clinical practice: the impact of nurses characteristics and education. J Pain Symptom Manage 1996;11: Closs SJ. Pain and elderly patients: a survey of nurses knowledge and experiences. J Adv Nurs 1996;23: Kortesluoma R-L, Aavarinne H. Minimizing venipuncture pain and fear in children of age six years. Hoitotiede 1992;4: Mercadente S, Salvaggio L. Cancer pain knowledge in southern Italy: data from a postgraduate refresher course. J Pain Symptom Manage 1996;11: Read JV. Perceptions of nurses and physicians regarding of pediatric emergency room patients. Pediatr Nurs 1994;20: Caty S, Tourigny J, Koren I. Assessment and management of children s pain in community hospitals. J Adv Nurs 1995;22: Broome ME, Richtsmeier A, Maikler V, Alexander MA. Pediatric pain practices: a national survey of health professionals. J Pain Symptom Manage 1996;5: Pederson C, Parran L. Bone marrow transplant nurses knowledge, beliefs, and attitudes regarding. Oncol Nurs Forum 1997;24: Pederson C, Matthies D, McDonald S: A survey of pediatric critical care nurses knowledge of pain management. Am J Crit Care 1997;6: Lebovits AH, Florence I, Bathina R, Hunko V, Fox MT, Bramble CY. Pain knowledge and attitudes of healthcare providers: practice characteristic differences. Clin J Pain 1997;13: Pederson C, Harbaugh B. Nurse s use of nonpharmacologic techniques with hospitalized children. Issues Compr Pediatr Nurs 1995;18: Gedaly-Duff V, Burns C. Reducing children s pain-distress associated with injections using cold: a pilot study. J Am Acad Nurse Pract 1992;4: Engel JM. Relaxation training: a self-help approach for children with headaches. Am J Occup Ther 1992;46: Kortesluoma R-L, Aavarinne H. Minimizing venipuncture pain and fear in children of age six years. Hoitotiede 1992;4: Broome ME, Lillis P, McGahee TW, Bates T. The use of distraction and imagery with children during painful procedures. Oncol Nurs Forum 1992;19: Campos RG. Rocking and pacifiers: two comforting interventions for heelstick pain. Res Nurs Health 1994;17: Manne SL, Bakeman R, Jacobsen PB, Gorfinkle K, Redd WH. An analysis of a behavioral intervention for children undergoing venipuncture. Health Psychol 1994;13: Ferrell-Torry AT, Glick OJ. The use of therapeutic massage as a nursing intervention to modify anxiety and the perception of cancer pain. Cancer Nurs 1993;16: Hunt AH. Humor as a nursing intervention. Cancer Nurs 1993;16: Rhiner M, Ferrell BR, Shapiro B, Dierkes M. The experience of pediatric cancer pain Part II: Management of pain. J Pediatr Nurs 1994;9: Sutters KA, Miaskowski C. The problem of pain in children with cancer: a research review. Oncol Nurs Forum 1992;19: Ellis JA, Spanos NP. Cognitive behavioral interventions for children s distress during bone marrow aspirations and lumbar punctures: a critical review. J Pain Symptom Manage 1994;9: Beyer JE, Bournaki M-C. Assessment and management of postoperative pain in children. Pediatrician 1989;16: Keefe FJ, Jacobs M, Underwood-Gordon L. NIH Workshop Summary: Biobehavioral pain research: a multi-institute assessment of cross-cutting issues and research needs. Clin J Pain 1997;13: Carroll D, Seers K. Relaxation for the relief of chronic pain: a systematic review. J Adv Nurs 1998; 27: Seers K, Carroll D. Relaxation for the relief of acute pain: a systematic review. J Adv Nurs 1998;27: Hamers JP, Huijer-Abu-Saad H, Halfens RJ. Factors influencing nurses pain assessment and interventions in children. J Adv Nurs 1994;20: Abu-Saad HH, Hamers JPH. Decision-making and paediatric pain: a review. J Adv Nurs 1997;26: Halfens R, Evers G, Abu-Saad H. Determinants of pain assessment by nurses. Int J Nurs Stud 1990; 27: Margolius FR, Hudson KA, Michel Y. Beliefs and perceptions about children in pain: a survey: Pediatr Nurs 1995;21:

11 Vol. 18 No. 4 October 1999 Nurses Knowledge of Children s 299 Appendix A. Items measuring nurses knowledge about children s Choices: Agree, agree to some extent, don t know, disagree to some extent, disagree Nonpharmacologic 1. In treating pain in children, other methods of alleviating the pain are needed in addition to medication. (true) 2. Pain in children cannot be totally eliminated by conversation aimed at helping them to relax. (true) 3. Rocking a child in one s arms alleviates pain. (true) 4. The parent s presence usually alleviates the pain experienced by children. (true) 5. Using a child s imagination is an effective way of alleviating mild pain. (true) 6. Play therapy is a useful method of pain alleviation in the treatment of toddlers. (true) 7. Massage is a good method of alleviating pain associated with tumors in children. (false) 8. Cold bandages only help it they are placed upon the painful area. (false) General knowledge about pharmacologic 1. Pain medication is equally effective whether given before the onset of pain or when the child is already experiencing pain. (false) 2. Long-term opioid medication should always be given on regular bases. (true) 3. When the first opioid dose has been administered, the following doses are adjusted according to the child s individual reactions. (true) 4. In treating pain in children only one painkiller should be used at a time. (false) 5. The most common reason for the increased need of painkillers in the treatment of children with cancer is the child s increasing tolerance, causing the painkillers to lose their effect. (false) 6. Sedation is an effective way of eliminating pain in children. (false) Knowledge about anti-inflammatory pain medication 1. Paracetamol is well-suited for the treatment of pain in children. (true) 2. Anti-inflammatory drugs irritate children s digestive system in long-term use. (true) 3. Paracetamol is unsuitable for use with children who have asthma. (false) 4. Anti-inflammatory drugs are well suited for oral use because they dissolve almost completely from the alimentary tract. (true) 5. Indomethacin is an effective treatment of arthritis pain in children because it dissolves quickly into human tissue and synovial fluid. (true) 6. Anti-inflammatory drugs are unsuitable for use with children who have asthma. (true) 7. Acetylsalicylic acid is well-suited for the treatment of children s arthritis pains because it dissolves quickly into human tissue and synovial fluid. (false) 8. Buprenorphine is absorbed well through the stomach. (false) Knowledge about opioids 1. Long-term continuing opioid medication almost always causes physiological dependence in child patients. (true) 2. Opioids do not increase the risk of respiratory depression in children provided that the dosage is correct (true) 3. There exists an antagonist to the threat of respiratory depression caused by opioids. (true) 4. Anti-inflammatory medication and opioid medication mutually reinforce each other s painkilling effect. (true) 5. Respiratory depression is very rare in children who have received long-term continuing opioid medication. (true) 6. Anti-inflammatory drugs do not increase the respiratory effect of opioids. (true) Knowledge about regional anesthetics 1. Regional anesthesia is a good method of after surgery. (true) 2. Regional anesthesia is well-suited for the management of chronic pain. (true) 3. Regional anesthesia is well-suited for the management of cancer pain. (true)