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Evaluating knowledge and attitudes of undergraduate nursing students regarding pain management

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Title:
Evaluating knowledge and attitudes of undergraduate nursing students regarding pain management
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English
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Latchman, Jessica
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University of South Florida
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Subjects / Keywords:
Nursing
Pain
Pain Management
Students
Dissertations, Academic -- Nursing -- Masters -- USF   ( lcsh )
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non-fiction   ( marcgt )

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Abstract:
ABSTRACT: ABSTRACT Unmanaged pain is a widespread problem that many cancer patients face on a daily basis. Cancer pain, which can either be caused by complications due to the disease process itself or from treatment measures used, has devastating effects on the quality of life for these patients and their caregivers. This study examined the knowledge and attitudes of undergraduate students regarding pain management. The sample in this study consisted of 41 undergraduate students at the University of South Florida College of Nursing. The students sampled were predominantly white, (n=30), female (n=37), seniors (n=41) taking Leadership and Management in Nursing. After volunteering to participate, students completed the demographic data form, the nurses' attitude survey and the Pain Management Principles Assessment Tool. The mean age of students was 22.46 years, with a range from 18 to 42 years. One student indicated that he or she had a bachelor's degree in another field with the majority of students being first time college students (n=31). The results of the study showed that a mean score of 19.4 (SD= 3.0) out of a possible 31(63%) was achieved on the knowledge of the students regarding pain management while, a mean score of 17.0 (SD=2.6) out of 25 (68%) was achieved on the Nurses' Attitude Survey. The data showed that nursing students demonstrated inadequate knowledge regarding pain management, and had mixed attitudes towards pain management. However, a weak to moderate relationship between knowledge and attitudes was found (r=0.33, p=0.038) due to the fact that students lacked the fundamental knowledge, and understanding as to why they were practicing certain pain management skills. Although the sample size was relatively small and not ethnically or demographically diverse, the response from the sample was sufficient in providing statistically meaningful data for this study. The results were seen to be consistent with previous studies that show poor management of pain. The findings of this study suggest the need for the development of specific strategies to effectively teach students about pain management, as well as integrate pain management as a major component of the undergraduate-nursing curriculum to improve patient outcomes.
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Thesis (MS)--University of South Florida, 2010.
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Includes bibliographical references.
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by Jessica Latchman.
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Evaluating Knowledge and Attitudes of Undergraduate Nursing Students Regarding Pain Management by Jessica Latchman A thesis submitted in partial fulfillment of the requirements for the degree of Master in Science College of Nursing University of South Florida Major Professor: Susan C. McMillan, Ph.D., ARNP Cecile A. Lengacher, Ph.D., RN Cindy Tofthagen, Ph.D., ARNP Date of Approval: April 29, 2010 Keywords: Nursing, Pain, Pain Management, Students Copyright 2010, Jessica Latchman

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Dedication This is dedicated to all the people in my life who were monumental in making this dream come through for me. To my family, who have always encouraged me to be the best that I can be. To my sister Dru, who had more faith in me than I had in myself when I went into nursing. To my fianc Prem, who has always been my rock whenever I needed him. My love and deepest appreciation to all of you.

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Acknowledgements I would like to express my sincere appreciation to Dr. Susan McMillan and Dr. Cindy Tofthagen, who worked tirelessl y with me on making this possible. You have both been wonderful mentors and I t hank you for being patient with me through my entire program. I will always be grateful for your assistance and support. Special thanks also to Dr. Cecile Lengacher for being on my committee and giving me your expertise and insight on pain management. Special thanks to Ms. Lisa Huhn for allowing me to use her class time to conduct my study.

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i Table of Contents List of Tables iii Abstract iv Chapter I: Introduction 1 Problem Statement 2 Assumptions 4 Research Questions 4 Definition of Terms 5 Pain 5 Pain Management 5 Knowledge 5 Pain Attitude 5 Significance to Nursing 6 Chapter II: Review of Literatu re 7 Knowledge About Pain Management 7 Attitudes Toward Pain Managem ent 11 Summary of the Literature Re viewed 13 Chapter III: Methods 15 Sample 15 Instruments 16 Nurses’ Attitude Survey 16 Pain Management Principles Assessmen t Tool 16 Demographic Data Form 17 Approval 17 Procedures 18 Data Analysis 18 Chapter IV: Results, Discussion and C onclusions 20 Results 20 Sample 20 Knowledge of Pain Management Principles 22 Attitudes Toward Pain Management 23 Relationship Between Knowledge and A ttitudes 24

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ii Discussion 27 Sample 27 Knowledge of Pain Management Principles 28 Attitudes Toward Pain Managem ent 30 Relationship Between Knowledge and A ttitudes 32 Conclusions 33 Implications for Nursing 34 References 35 Appendices 38 Appendix A: Nurses’ Attitude Surv ey 39 Appendix B: Pain M anagement Principles Assessment Tool 42 Appendix C: Demograp hic Data Form 49 Appendix D: Letter of Appr oval USF College of Nursing 51 Appendix E: Letter of Approval USF Inst itutional Review Board 52

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iii List of Tables Table 1. Frequency and Percent of Gender Ethnicity, Educational Level, Work Experience, and Pain Managem ent Training of Students 21 Table 2. Frequency and Percent of Sc ores on the Knowledge Test 23 Table 3. Frequency and Percent of Students: Correct Responses by Knowledge Questions 25 Table 4. Frequency and Percent of St udents: Positive Attitude Responses by Questions 26

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iv Evaluating Knowledge and Attitudes of Undergraduate Nursing Students Regarding Pain Management Jessica Latchman ABSTRACT Unmanaged pain is a widespread problem that many cancer patients face on a daily basis. Cancer pain, which can either be caused by complications due to the disease process itself or from treatment measures used, has devastating effects on the quality of lif e for these patients and their caregivers. This study examined the knowledge and attitudes of undergraduate student s regarding pain management. The sample in this study consis ted of 41 undergraduate students at the University of South Florida College of Nursing. The students sampled were predominantly white, (n=30), female (n =37), seniors (n=41) taking Leadership and Management in Nursing. After vol unteering to participate, students completed the demographic data form, the nu rses’ attitude survey and the Pain Management Principles Assessment Tool. The mean age of students was 22.46 year s, with a range from 18 to 42 years. One student indicated that he or she had a bachelor’s degree in another field with the majority of students being first time college students (n=31).

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v The results of the study showed that a mean score of 19.4 (SD= 3.0) out of a possible 31(63%) was achieved on t he knowledge of the students regarding pain management while, a m ean score of 17.0 (SD=2. 6) out of 25 (68%) was achieved on the Nurses’ Attitude Survey The data showed that nursing students demonstrated inadequate knowle dge regarding pain management, and had mixed attitudes towards pain managemen t. However, a weak to moderate relationship between knowledge and atti tudes was found (r=0.33, p=0.038) due to the fact that students lacked t he fundamental knowledge, and understanding as to why they were practicing certain pain management skills. Although the sample size was relati vely small and not ethnically or demographically diverse, the response from the sample was sufficient in providing statistically meaningf ul data for this study. The results were seen to be consistent with previous studies t hat show poor management of pain. The findings of this study suggest the need for th e development of specific strategies to effectively teach students about pai n management, as well as integrate pain management as a major component of t he undergraduate-nursing curriculum to improve patient outcomes.

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1 Chapter I Introduction Unmanaged pain has become a focal area of concern for many healthcare professionals in the oncology setting, as millions of cancer patients suffer from pain caused by disease, surgery, or trauma on an everyday basis (Deandrea, Montanari, Moja & Apol one, 2008). This focus has led to tremendous advancements in evidence-based guide lines, and research regarding the treatment and management of pain, within acutely and chronically ill cancer patients (National Comprehensive Cancer Network, 2010). Despite these recent improvements, the num ber of cancer patients suffer ing from unrelieved pain has been growing at an exponential rate (Americ an Cancer Society, 2009). In fact, the issue has become so problematic t hat pain has now earned the title of the fifth vital sign (American Academ y of Pain Management, n.d.). In the oncology population, unmanaged pain has been identified as a major barrier in the overall care of the onc ology patient. It is estimated that more than 75% of patients with canc er will at some point during the course of their disease experience breakthrough pai n (American Pain Foundation, 2010). Cancer pain, which can be caused by numerous complications, has devastating effects on the quality of life for these patients, and their caregivers as well

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2 (American Cancer Society, 2009). Theref ore, in 1992, the Ad Hoc Committee on cancer pain of the American Society of Clinical Oncology (ASCO) stated that 70% of patients diagnosed with c ancer would, at some point in the course of their disease, experience considerable pain, with more than 80% receiving ineffective treatment. Therefore, the committee developed necessary and much needed guidelines for better pain management in the oncology population by fostering better pain assessment and treatment skills as well as formal instruction and education of healthcare professional s regarding pain management (ASCO, 1992). In 2001, the Agency for Healthcare Research and Quality also updated their 1994 recommendations on the management of cancer pain. This was also aimed at developing better cancer pain management skills, owing to the extensive view that many cancer patient s were still given ineffective pain relief measures. However, although all these guidelines exist for effectively managing the pain of cancer patients, unmanaged pain is still a widespread problem. Problem Statement Pain literally affects all levels of psychophysiological capabilities and influences almost every aspect of a pati ents’ life, including relationships with others, activities of daily living, as we ll as their job performance abilities. Pain accounts for an estimated cost of 90 bil lion dollars in economic resources as a result of disability, lost time from work, and reduced productivity (Turks, 2006). According to the American Nurses Asso ciation (ANA), nurses are required to maintain current knowledge in pain assessment and management (ANA, 2001).

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3 Therefore, if pain is the most common reason for seeking medical intervention, why then is it the most inadequately managed? According to many experts in the field, one reason that patients continue to needlessly suffer from improper pain management is the lack of expertise of nurses and physicians (Lasch, Greenhill, Wilkes, Carr, Lee, & Blanchard, 2002). Many health care professionals lack the proper knowledge and attitude for effe ctively managing pain, leaving many patients to endure a reduced qua lity of life (American Cancer Society, 2009). This lack of knowledge begins in basic educational programs. Synthesis of the lit erature over the past severa l years has shown that the medical, as well as the nursing curriculu m itself, lacks the educational content to prepare students to effectively address t he pain needs of their patients. This issue may be due to the fact that nursi ng faculty themselves are inadequately prepared to educate students on pain management, either owing to the fact that they were not knowledgeable about pai n management, or failed to keep abreast with current evidence-based practices (F errell, McGuire, & Donovan, 1993). In addition to this, since many of these inadequately prepared nursing students later became nurses, this educational flaw may have influenced nurses’ negative attitude towards patients seeking pain tr eatment. For instance, many nurses had insufficient knowledge about basic mec hanisms of action of medications, dosages and uses of certain pharmaceut icals, in addition to other pain management interventions (Lasch, et al., 2002).

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4 With regard to the undergraduate-nur sing curriculum, few studies have focused on baccalaureate-nursing students’ abi lities and attitudes in effectively managing the pain of their patients (Die kmann & Wassem, 1991). There has also been a vast lack of knowledge among thes e students, due to a deficiency in information provided to them in their cu rriculum. This curriculum deficiency may be a result of insufficient instruction by faculty due to their own lack of knowledge on this subject matter, as well as out dated educational material in textbooks (Ferrell et al., 1993). The combined effects of these play a huge role in hindering successful pain management among baccal aureate nursing students. Therefore, the purpose of this study was to ex amine the knowledge and attitudes of undergraduate students regarding pain management, since there are few studies that focus on this issue, and many student s still lack the ability to effectively manage the pain of their patients. Assumptions Two assumptions made in this study are: 1. Pain in not well managed in the oncology patient population. 2. There will be an improvement in pain management by educating nursing students. Research Questions The research questions that are addressed in this study are: 1. What is the level of knowledge of pain management possessed by nursing students at the baccalaureate level?

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5 2. What are nursing students’ attit udes toward pain management in the oncology patient? 3. Is there a significant relationshi p between knowledge and attitudes among baccalaureate students related to pain management in cancer patients? Definition of Terms For the purpose of this study the following terms are defined: 1. Pain Management: According to the Am erican Pain Society Quality of Care Task Force, (2005), pain management encom passes all interventions used to understand and ease pain, and alleviat e the origin of the pain. 2. Pain: According to the American Ac ademy of Pain Management (n.d), pain is defined as a neural transmission and s ensory transduction, which is a complex mix of emotions, culture, exper ience, spirit and sensation. In other words, pain is a complex psychological and physical occurrence that is unique to each patient experiencing it. 3. Knowledge: Comprehension of facts, ideas, and information, gained through experience, instruction, and learning for a distinct use (Merriam-Webster Online Dictionary, 2009). 4. Pain attitudes: A persisting set of beliefs and values that affect how one responds or reacts when pain is involv ed (McMillan, Tittle, Hagan, Laughlin, & Tabler, 2000).

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6 Significance of Study The intent of this study was to pr ovide insight into the knowledge and attitudes toward pain management am ong baccalaureate nursing students. Because, nurses spend most of their time at the patient’s bedside as compared to other healthcare professionals, they perform an instrumental role in the assessment and evaluation of pain. Theref ore, nurses must become the primary agents of change for better pain m anagement outcomes within patient populations. Consequently, if nurses are insufficiently educated and ill prepared to effectively relieve pain, the patient ul timately suffers. For this reason, student nurses must be well educated and k nowledgeable about pain and pain management to improve patient outcomes and collaborate efficiently with other healthcare professionals to successfully manage pain.

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7 Chapter II Review of Literature The purpose of this chapter is to pr esent the review of the relevant literature. The literatur e identifies numerous impedi ments to effective pain management and, therefore, demonstrates their impact on patient outcomes. Barriers analyzed include, the lack of knowledge, as well as, the negative attitudes of nurses, nursing facult y and baccalaureate nursing students. Knowledge About Pain Management Insufficient knowledge by nurses, nur sing students, and nursing educators has emerged as the most significant barri er to effective pain management (Chiu, Trinca, Lim, & Tuazon 2003). In fact, the lack of knowledge reported in studies from the early 1990’s is still cl early evident in more rec ent literature as well. For instance, based on the criterion for mini mally acceptable scores in many pain management questionnaires, there were deficiencies noted in students’ responses in categories such as physi ology of pain, assessment parameters, differentiating addiction from toler ance and physical dependence (Goodrich, 2006). Rather than simply asking pati ents for pain intensity ratings, nurses should obtain a more through assessment of pain. In addition to this, discrepancies were noted in the depth of pain information in lectures. Most

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8 studies analyzed indicated that more t han 50% of nurses did not believe that patient’s were the best judge of their own pain (Bernardi, Catania, Lambert, Tridello & Luzzani, 2007; Rieman, 2006). In fact, most educ ators and students also stated that they were unsure w hether to believe that patients were accurately giving them pain scores. In such cases, nurses and students documented lower pain scores than repor ted and administered lower dosages of medications (Goodrich, 2006; Lasch et al., 2002; McMillan et al, 2000). Diekman and Wassem (1991) also illustra ted that many nursing programs had little or no content on cancer pain management and students were ill prepared to use appropriate measures to alleviate pain. Goodrich (2006) determined that there ar e numerous gaps in nursing education regarding pain management and students (both medi cal and nursing), which communicated the need for better integration of pain m anagement content into their program curriculum. Students also remarked that they received little or no education concerning pain management and thus, felt unprepared to implement pain management tasks (Ferrell et al., 1993; Lasch et al., 2002). Consequently, in the study by Chiu and colleagues (2003), resu lts indicated that Australian students and Philippine students also received mi nimal pain education, and thus, were unable to adequately address pa in in patients. In earlier studies, only a few facult y members were also noted to be knowledgeable in pain management. In fac t, both faculty and students felt that they were inadequately educated to implement pain management procedures,

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9 and adjunct therapies to effectively treat patients’ pain. Faculty members also agreed that introduction of pain, and c ancer pain management would better prepare their students for general practice (Ferrell et al., 1993;Lasch et al., 2002). Conjointly, Ferrell and colleagues, (1993) also indicated that only a few educators identified changes in pain manag ement practices for the past 20 years and were unaware of the fact that there were new gui delines put in place to address the pain needs of pat ients. In addition to this less than one-third of schools taught their students’ current research practices on pain management, with educators only moderately meeting the pain educational needs of their students (Lasch et al., 2002). Overall, most studies indicated that nursing faculty must acknowledge that their curricula lacks the necessary course content to effectively instruct their students on pain management (Goodrich, 2006; Ferrell et al., 1993; Lasch et al., 2002). Therefor e, reevaluation of current nursing programs is essential to facilitate be tter pain management skills in students and curricula revisions are essential to necessitate this. Analysis of the literature also showed that students scored lowest on medication related questions such as mec hanism of action, dosage, side effects and administration (Plaisance & Logan, 200 6). Therefore, despite advancements in pain management protocols, students di splayed insufficient knowledge in pharmacology to effectively manage pain. In most instances, opioids were generally under-used by physicians, nurse s, and students, to better relieve pain (Lasch et al., 2002; McMillan et al., 2005). Da ta also indicated that most nurses

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10 had insufficient knowledge about the World Health Organization pain ladder, and were not aware that a combination of drugs could be used synergistically to alleviate pain in a safe manner, wit hout patients developing respiratory depression (Bernardi et al., 2007). Overa ll, deficiencies were noted in nurses, and students’ responses in classes regarding; understanding ceiling dose of certain analgesics, calculation of analgesic dosages, as well as, the mechanism of action, and dosages of analgesi cs in pain management (Goodrich, 2006; McMillan et al., 2005; McMillan et al., 2000) In addition, nurses were unaware of the fact that pain was better controlle d by around the clock pain medications, rather than waiting fo r patients to verbalize pain (B ernardi et al., 2007). Further, faculty members lacked knowledge on the ce iling effect of opioids, as well as, differentiating addiction from physical dep endence, and tolerance (Lasch et al., 2002). Statistically, no changes in scores were seen on the use of opiates for pain management since respiratory depre ssion was also thought to be a major side effect of opioid medica tions if given over a 24-hour period (Bernardi et al., 2007; McMillan et al., 2005). Overall, continuing education was found to be a solution to inadequate knowledge, and poor attitudes. McMill an and colleagues, (2005) found that continuing education in intensive pain management was an effective means in improving the knowledge and attitudes of nurses. However, nurses must continuously stay abreast wit h current treatment guidelines if they are to provide competent care and improve patient outcomes (Diekmann et al., 1991). Although

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11 further studies are required to address integrating new educational modules in instructing nurses on pain and pain manag ement, considering that knowledge regarding pain management is a key aspect of effective nursing practice, most studies illustrated that there was littl e significance between educational levels and being better at effectively managing pai n (McMillan et al., 2005; Plaisance & Logan, 2006). Thus, faculty should implement new educational strategies to adequately prepare nursing students at all levels, and themselves on managing pain in patients. In fact, when pain educ ational programs were given, nurses, students, and educators felt more confident in assessi ng pain as well as using the correct measurements and procedures in effectively relieving pain (Lasch et al., 2002; McMillan et al., 2005; Wilkes Lasch, Lee, Greenhill & Chiri, 2003). In two studies, it was noted that on cology nurses were more formally educated on pain management guideli nes when compared to non-oncology nurses (McMillan et al., 2005; Rushton, Eggett & Sutherland, 2003). In both studies, data showed that oncology prepar ed nurses had better patient outcomes regarding pain management and were mo re knowledgeable about recommended practice guidelines than non-oncology nur ses. However, the pharmacology of medications used to manage cancer pai n was poorly understood by both groups of nurses (Bernardi et al., 2007; McMillan et al., 2000). Attitudes Toward Pain Management Negative attitudes by students and healthcare professionals are yet another barrier to effective pain management. Although many students and

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12 nurses correctly identified that most canc er patients experience pain at some point during the course of their illne ss, very few believed that pain could effectively be relieved by medication or that it was appropriate for cancer patients to receive maximum tolerated treatment to become pain free (Diekmann et al., 1991). Further, if a patient was cheerful during visiting times with the nurses, a lower pain rating was documented and reduced pain medication dosages were given because, nurses believed that pati ents over-estimated their pain levels (McMillan et al., 2000). Second barrier, in younger and older pat ients, pain rating and medication dosages were also decreased, as most nur ses would allow concerns of addiction to affect their administration (McMillan et al., 2005; Rushton et al., 2003). A similar trend was noticed when around the clock analgesics were prescribed for patients. Nurse would allow their belie f that patients should experience pain before administering medication to influenc e how they dispensed pain medication (Ferrell et al., 2003; McMillan et al., 2000). Correspondingly, students and faculty also expressed the fear that administe ring too much opioid medication could facilitate addiction, which was a major deterrent for them in administering analgesics to patients ( Lasch et al., 2002). Another factor hindering positive atti tudes for effective pain management was inadequate nursing educ ation. Since nursing fa culty themselves were insufficiently knowledgeable on the prin ciples of pain management, they were mostly likely to perpetuate their own negat ive beliefs onto students (who later

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13 became nurses) regarding the pharmacology of medications and physiology of pain (Ferrell et al., 1993; La sch et al., 2002). It was also in teresting to note that if faculty and students were not better educ ated on pain management they were most likely to implement their own biases onto patients as well (Lasch et al., 2002). However, it was unclear from t he literature whether oncology nurses had more positive attitudes towards pati ents with pain than non-oncology nurses. Finally, administration of educational modules s howed a vast improvement on attitude questions by nurses. It was al so noted that changes in attitudes on charting patients’ pain was si gnificantly enhanced, indica ting that education is an important aspect of pain manage ment (McMillan et al., 2005). Summary of Literature In summary, review of the empirical literature has shown that the nursing curriculum lacks the educational content to prepare its students to effectively address the pain needs of thei r patients. This issue may be due to the fact that nursing faculty themselves are ina dequately prepared to educate students on pain management. Studies analyzed i ndicated that nursing faculty was either lacking knowledge about pai n management or failed to keep abreast with current evidence-based practices. In addition to this, since many of these inadequately prepared nursing students later became nurse s, this educational flaw may have transferred into their practice, reflecting highly negative attitudes and poor pain management skills. Therefore, more em phasis must be placed on educating

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14 students on basic mechanisms of action of medications, dosages, and uses of certain pharmaceuticals, in addition to other pain management interventions.

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15 Chapter III Methods In this chapter the methods of the st udy are presented. Th is includes the characteristics of the sample such as the inclusion criteria for participation, variables under investigation, and a description of t he instruments of measurement used to collect data. In addi tion, the procedures for data collection and the method of analysis also are discussed. Sample For the purpose of this study, t he targeted populatio n was undergraduate nursing students, while the sample c onsisted of consenting undergraduate students, currently pursuing a Bachelor of Science degr ee in Nursing (BSN), at the University of South Florida (USF). The inclusion criteria for participation was based on; being an undergraduate student in the BSN Program in their senior year at USF, enrolled in the Leader ship and Management in Nursing course, over the age of 18 years, able to read and write English, and having completed undergraduate pharmacology and pathophysiology courses. The sample size was estimated usi ng power analytic techniques. With power of 0.80 and an alpha set 0.05 for a Pearson correlation, a sample size of 30 should yield significant results.

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16 Instruments The instruments that were utilized in this study were the Nurses’ Attitude Survey (NAS) and the Pain Management Principles A ssessment Tool (PMPAT), in addition to a demographic data questionnaire Both tools were chosen for the study as they clearly distinguish be tween knowledge deficits and attitudinal barriers in pain management, which m ade them appropriate for the study. Nurses’ Attitude Survey The NAS, created by McMillan and Tittl e (2000), is a 25-item instrument, which uses a four-point Likert type fo rmat to assess attitudes toward pain management. Responses for the instrum ent ranged from str ongly disagree to strongly agree, with item raw scores varying from 1 to 4 for each item. The higher the score, the more positive attitudes nur ses had. The survey included items on scheduling analgesics, use of opiates pain assessment, goals of pain assessment, misconceptions about pain management and non-pharmacologic management of pain (Appendix A). Validity and Reliability Internal consistency reliability was found using Cronbach’s alpha (r=0.70), which was adequat e. Validity was also demonstrated by a significant difference (p<.01), after it was pre-tested and posttested among nursing students (McMillan et al., 2000). Pain Management Princi ples Assessment Tool The PMPAT is a 31-item multiple-choi ce test with four response choices per question. The questionnaire was des igned to test pain management

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17 knowledge regarding physiology, pharmacology, characteristics of pain such as addiction, physical dependence, tolerance, and principles of assessment and management. Scores for the survey ranged from 0 to 31, or 0 to 100%, with higher scores meaning more questi ons were answered correctly. Validity and Reliability The tool was designed based on a blueprint from previous research studies attesting to its content validity. Validity of the instrument was also tested using a pr e and post-test method among 28 nursing students before and after administering a three-hour pain management course. Validity was found to be significantly high fr om pre to post test (t=6.76, p<0.01). Reliability was also discovered to be signi ficantly high (r=0.84, p=0.00) (McMillan et al., 2000) (Appendix B). Demographic Data Form Each participant was also asked to complete a demographic data form. The form incorporated questions on age, gender, ethnicity, current semester in the BSN program at USF, highest level of education achieved, work experience, and current work status, and if they have ever received any type of training in pain management (Appendix C). Approval Approval to conduct the study was obt ained from both the USF College of Nursing (Appendix D) to approach students to participate in the study, and the USF Institutional Review Board (Appen dix E). Permission was requested from the instructor of the Leadersh ip and Management in Nursing course to administer

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18 the surveys to students during class. In addition to this, a letter explaining the purpose of the study, as well as the inclusion criteria fo r participation, was given to each participant. The letter also stat ed that filling out the questionnaires implied consent, and that participati on was confidential and voluntary. Procedures The questionnaires were given to each student during class period. Prior to the administration of the questionnaires, the instructor of the Leadership and Management in Nursing course was ask ed to leave the classroom, while the investigator remained in the room to s upervise the study, distribute the surveys as well as collect them. A brief explanat ion was given regarding the study, noting that there were no risks or benefits to par ticipants from taking part in the study, apart from enriching nursing research on t he topic of pain management. Students were also given the opportunity to ask any pertinent questions they had regarding the study. In addition, students were asked to carefully read the instructions given and work individually on their questionnaires without the aid of textbooks or colleagues. Data Analysis Demographic data was anal yzed using descriptive statistics, such as frequencies, percentages, means and standar d deviations. Microsoft Excel, as well as, the Statistical Package for Social Sciences (SPSS) was utilized to analyze the level of knowledge students had, their attitudes towards pain management, and the correlation bet ween knowledge and attitudes.

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19 To answer Research Question 1; What is the level of knowledge of pain management principles possessed by nursing students at the baccalaureate level, means and standard devia tions were calculated? To answer Research Question 2; W hat are nursing students’ attitudes toward pain management in the oncology patient, means and standard deviations were calculated? To answer Research Question 3; Is there a significant relationship between knowledge and a ttitudes among baccalaureate students in pain management in cancer patients, P earson Correlations was calculated?

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20 Chapter IV Results, Discussion and Conclusions This chapter presents the results of the knowledge and attitudes surveys given to undergraduate nursing students at t he University of South Florida to determine their level of knowledge, and current attitudes towards pain management. In addition to the results of the variables, discussion of the relationship between the knowledge and attitude scores is also presented. Further, the limitations of this study, conclusions and suggestions for future research are also discussed in this chapter. Results Sample The sample for this study c onsisted of 41 undergraduate students currently in their senior year, pursuing a Bachelor of Science degree in Nursing at the University of South Florida. Of the 41 participants, 90% (n=37) was female, while 10% (n=4) were males (Table 1). The mean age of students was 22.5 years with a range from 18 to 42 years. The majority of participants, (73%, n=30) were of NonHispanic White ethnicity, wh ile 7% (n=3) were African American, 15% (n=6) were of Hispanic origin, and 5% (n=2) Asian orig in (Table 1). On analysis, years of formal educati on ranged from 15% of students having

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21 associates degrees before attending USF, while 2% (n=1) had Bachelors’ degree in other fields than nursing (Table 1). The ma jority stated that they were full time nursing students with no jobs (75%, n=31), while 15% (n=6) were working as nurse technicians, and 10% (n=4) were cert ified nursing assistants (Table 1). In the area of pain mana gement, 20% (n=7) of students had pain management training, while 80% (n=34) had no training at all other than that give in their nursing program (Table 1). Table 1. Frequency and Percent of Gender, Ethnicity, Educational Level, Work Experience, and Pain Management Training of Students Demographic Content Frequency Percent Males 4 10 Females 37 90 Asian 2 5 African American 3 7 Hispanic 6 15 Non Hispanic White 30 73 Associates Degree 6 15 Bachelor's Degree 1 2 Nursing Student 31 75 Nurse Technician 6 15 Certified Nursing Assistant 4 10 Pain Management Training 4 10

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22 Knowledge of Pain Management Principles In order to answer the first research question, to assess the knowledge of undergraduate nursing student s regarding pain managem ent, the raw scores of the PMPAT were tabulated and analyz ed (McMillan et al., 2000). The mean score on knowledge was 19.4 (SD= 3.0) out of 31 items, or 63%. The raw scores indicated that the number of correct responses for the 41 students ranged from 39% to 81%. If a passing score of 70% was used, only 7 students or 17% of students passed the pain management k nowledge test, with 30 or 73% of students scoring between 50% to75%, and 4 or 10% of students scoring less than 50% (Table 2). On analyzing the responses to indivi dual knowledge questions it was noted that students had low sco res, 39% or less in ar eas of pain physiology, pharmacology of pain medications, appropriate time to medicate for pain, use of cutaneous stimulations as a measure of pain relief and total pain relief as the main goal of pain management practices. Conversely, subject areas in which items received a score of 100% were firs t, patients as the most accurate, and reliable judge of their own pai n, and, second, the definit ion of tolerance. Other areas in which scores were 90% or higher were, patients should be in charge of their own pain management regimen, nur ses should call the physician when a patients’ pain increases on the maxi mum dose of analgesic prescribed, and distraction as an approach to pai n management (Table 3).

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23 Table 2. Frequency and Percent of Scores on the Knowledge Test Score Range Frequency Percent Greater than 70% 7 17 50%-70% 30 73 Less than 50% 4 10 Attitudes Toward Pain Management Attitudes were measured using the Nurses’ Attitude Survey (NAS). Responses for the instrument ranged fr om strongly disagree to strongly agree, with item raw scores varying from 1 to 4 for each item. The higher the score, the more positive attitude nurses had. On analys is of the raw scores from the attitude survey given to the sample, a mean score of 17.1 (SD=2.6) was calculated with a range of 48% to 88% of students havi ng positive attitudes towards pain management. Results of an item analysis of the NAS, showed that 100% (n=41) of students agreed that; distraction and dive rsion could decrease patients’ pain level, lack of pain expression does not mean lack of pain, and continuous assessment of pain and medication effectiveness is necessary for good pain management. In addition to this, 95% of students agreed that patients may be hesitant to use pain medication due to f ears about opioid use, and if a patient continues to have pain the nurse should co ntact the physician. This was followed by 85% agreed that a constant level of analgesic should be maintained in the blood to control pain effectively, 78% agr eed that patients should be maintained

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24 in a pain-free state, and 71% agreed that cancer pain could be relieved with appropriate anti-cancer drugs radiation therapy and/or pain relieving drugs. Also, 39% agreed that the cancer pat ient and family should have more control over the schedule for analgesics than the health ca re professional and 15% agreed that patients in pain can tolerate high doses of opioids without sedat ion or respiratory depression (Table 4). Conversely, in terms of the questions that were graded as disagreed, 98% of students disagreed t hat an estimation of pain by the physician or nurse is a more valid measure of pain than pati ent the self-report, 78% of students disagreed that patients should experience pain before getting their next dose of pain medication, while, 73% of students di sagreed that patients receiving opioids around the clock for cancer pain are lik ely to become addicted. Subsequently, 29% of students stated that cancer patients receiving as needed pain medication should receive pain medication befor e the pain returns along with, 5% disagreeing that patients receiving around the clock opioids are at risk for sedation and respiratory depression (Table 4). Relationship Between Knowledge and Attitudes To determine if there is a signific ant relationship between knowledge and attitudes among baccalaureate students rela ted to pain management in cancer patients, a Pearson correlation was ca lculated between the total scores for knowledge and the total scores for attitudes Results of the Pearson correlation

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25 r=0.33 (p=0.038), showed a weak to moderate but significant degree of correlation between these two variables. Table 3. Frequency and Percent of Student s: Correct Responses by Knowledge Questions Knowledge Content Frequency Percent Patient most reliable judge of pain 41 100 Definition of tolerance 41 100 An example of distraction 39 95 Patient in control over Pain Management 38 93 Nurse should call physician when pain increases on maximum dose 37 90 Use of combination analgesics 34 83 Cancer patients who suffer from pain 30 73 Cancer patients with pain 25 61 Physicians and nurses under medicate 19 46 Nurse should not base pain administration on objective assessment 13 32 Goal of pain management 10 24 Occurrence of addiction Less than 1% 10 24 Physiology of Pain Mechanism action of opioid 36 88 Opiate receptors 31 76 Level of analgesics 28 68 Symptoms of chronic pain 27 66 Symptoms of Acute Pain 22 54 Gate Control Theory 15 37 C fibers of nerves 8 20 Pharmacology of Pain Pain due to decrease in analgesic 28 68 Disadvantage of Merperidine 25 61 Best method to achieve steady state of analgesic 24 59 Drug with longest duration of action 9 22 Preferred route of administration 6 15 Cutaneous Stimulation Example of cutaneous stimulation 33 80 Cutaneous stimulation as a method of pain relief of any intensity 16 39 Cutaneous stimulation for any type of pain 16 39

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26 Table 4. Frequency and Percent of Student s: Positive Attitude Response by Questions Attitude Content Frequency Percentage Positive Attitude Continuous assessment necessary for good pain management 41 100 Agreed Lack of pain expression does not necessarily mean lack of pain 41 100 Agreed Distraction/ diversion of attention can decrease perception of pain 41 100 Agreed Estimation of pain by MD/RN is a more valid than patient self-report 40 98 Disagreed Patients/family members hesitant to use pain medications due to fears 39 95 Agreed Nurse should contact MD if patient has continuous pain 39 95 Agreed Nurse can make a more accurate assessment of patient’s pain than patient/family 39 95 Disagreed A constant level of analgesic should be maintained in the blood to control pain effectively. 35 85 Agreed Patient should experience discomfort prior to getting the next dose of pain medication. 32 78 Disagreed Patients should be maintained in a pain-free state. 32 78 Agreed Patients receiving narcotics around the clock for pain are likely to become addicted 30 73 Disagreed Cancer pain can be relieved with appropriate treatment 29 71 Agreed Cancer patient/family should have more control over the schedule of analgesics than MD/RN 16 39 Agreed Patient in pain is receiving PRN medication, at what level of discomfort would it first be appropriate for the patient to request additional pain medication? 12 29 Agreed Patients in pain can tolerate high doses of narcotics without sedation or respiratory depression 6 15 Agreed Patients receiving around the clock narcotics are at risk for sedation and respiratory depression 2 5 Disagreed

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27 Discussion Sample The response from the convenience sample of students (n=41) from the undergraduate Bachelor of Science in Nu rsing program at USF who participated in this study was sufficient in providing statistically meaningful and sufficient data for this study. The sample demonstrated a strong cross-sectio nal view of the students who are currently pursuing a Bach elor of Science degree in Nursing at USF. However, since the data was onl y collected in one geographical area and had limited representation fr om other ethnic groups, re sults gathered from this study may not be generalized to include t he entire population of undergraduate nursing students in Florida or the U.S. Also, since the sample mainly consisted of Non Hispanic Whites, there was very littl e minority participation in this study. Therefore, the lack of r epresentation from other et hnicities and cultures may have incurred a bias with an unknown effect to data gathered, since ethnicity and culture influence knowledge and attit udes regarding pain management. Another limitation of this study wa s that all students were asked to participate instead of being randomly selected, and it is therefore unclear as to the effect this may have on the data gathered as well. The item regarding pain management training in the demographic data form was flawed as st udents may have interpreted this to mean content taught in class as opposed to actual formal training on pain management by a professional.

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28 Knowledge of Pain Management Principles The mean score on knowledge test wa s 19.4 (SD=3.0) or 63%. The data showed that nursing students demonstrated inadequate knowledge regarding pain management. These scores were similar to those obtained by McMillan and colleagues for nurses (2000), and Plai sance and Logan (2006). The mean score obtained by McMillan and colleagues, (2000) was 18.8 (SD=2.9) or 61%, while Plaisance and Logan (2006) had an overall score of 64%. Thus, although the focus on pain continues as a national priori ty, nurses may not be learning critical information in their basic nursing programs. Although the overall kn owledge scores were re latively low, students showed strength in certain areas of the pain management knowledge test. For instance, 100% of the students accurately responded that patie nts are the most accurate and reliable judge of their own pain, while 93% replied that patients should be in charge of their own pain mana gement regimen. This was consistent with the data derived by McMillan and co lleagues, (2000), who obtained scores of 96% and 81%, and inconsistent with data derived by Bernardi and colleagues, (2007), where only 56% of nurses believed t hat patients were the most accurate judge of their own pain. This signified that the current u ndergraduate curriculum at USF does place some emphasis on pain management. This correlated well with the NAS where 98% of the students disagreed that an estimation of pain by the physician or nurse is a more valid m easure of pain than a patients’ self-report of pain.

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29 In terms of pharmacologic managem ent, most students were able to; accurately define tolerance, state t he action of naloxon e, and the use of combined analgesics to achieve pain cont rol. The fact th at 100% of students were able to define tolerance was consis tent with the findings of McMillan and colleagues (2000), who repor ted a score of 89%. Ho wever, in the study conducted by Goodrich (2005), a threshol d of less than 80% was achieved in differentiating addiction from tolerance and dependence. Another strength of this study was the fact that 93% of students stated that pat ients should be in control of their pain management regimen, wh ich was much higher than the score obtained ten years earlier by McMill an and colleagues, (2000) of 81%. Although the data analyzed showed few ar eas of competency, there were numerous areas in which significant knowledge gaps existed among students. These areas mostly included questions pertaining to the physiology and pharmacology of pain. This is consistent with previous research studies (Bernardi et al., 2007; Diekmann & Wassem, 1991; Fe rrell et al., 1993; Goodrich 2005; McMillan et al., 2000; Plaisance and Logan, 2006). For instance, only 20% of students had the knowledge that Cfibers were responsible for dull, and aching pain sensations, 29% of student correctly identified that the most appropriate time to administer pain medication was before pai n began, whereas only 37% knew about the Gate Control Theory. In terms of pharmacol ogy; only 14% of students knew that the prefe rred route of medication ad ministration was orally, 22% of students knew that methadone was the opioid with the longest duration of

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30 action, and less than 60% knew that meperdine had central nervous system toxicities. However, it was also noted that less than 24% of students stated that the overall goal of pain management was the tota l relief of pain, and less than 1% of cancer patients become addicted to pain m edication. There was also a lack of understanding that the use of non-pharmaco logic techniques such as cutaneous stimulation can be used for any level of pain. Therefore, o wing to the lack of understanding of basic physiology and pharma cology of pain by students, it is now clearer why nurses perform poorly in managing the pain of patients. This data also suggest that pain management will continue to be a problem when this new generation of nurses begins working. Attitudes Toward Pain Management Principles On analysis of the raw scores derived from the test given to the sample, a mean score of 17.1 (SD=2.6) out of 25 was calculated. The fact that many students had a poor understanding of the physiology of pain and pharmacology of opioids, may have had an effect on the attitudes they have toward pain management. For instance, only 5% of students disagreed with the statement that patients receiving around the clock opi oids are at greater risk for sedation and respiratory depression, which corresponded with the low responses on patients in pain being able to tolerate hi gh doses of opioids without sedation or respiratory depression. T herefore, if students had a better understanding of the physiology of pain and the pharmacology of opioids, they might know that

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31 increasing opioid doses are due to t he tolerance of opioids and do not necessarily lead to sedation and respir atory depression. These results were similar to previous studies and clear ly show that there has been little improvement in this area by student s and nurses over the past decade. It was also interesting to note that the sample of students studied were committed to being strong patient advocates and felt strongly that a patient’s selfreport of pain was more valid than that es timated by the physician or nurse. This strongly correlated to the knowledge question where 100% of students agreed that patients were the bes t judges of their own pain. However, only 39% of students agreed that the cancer patients and their family members should have more control over the schedule of analges ics than the healthcare professional. Hence, this belief that the physician or nurse should have control over the schedule of analgesics is misguided sinc e cancer patients and their family members spend the majority of time m anaging chronic pain outside the realm of the physicians’ or nurses’ control. Therefore, we see that if nurses developed a better understanding of the physiology of pain and the pharmacology of analgesics, a more positive attitude regarding pain management might emerge. In addition to this, students can facilitate better relationships with thei r patients and ultimately better patient outcomes if students understand the need to better educate patients on managing their own pain and allowing family members and patients to be in more control over their pain treatment plans.

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32 Relationship between Knowledge and Attitudes Although the Pearson correlation value illustrated a weak to moderate relationship between knowledge and attitudes (r=0.33, p=0.038), the result was significant and data gathered showed t hat students who generally had high scores on the knowledge test, had corres ponding high scores on the attitude test as well. However, there appear to be some discrepancies between similar questions on the knowledge survey and a ttitude questionnaire For example, a lack of understanding of ther apeutic levels seems to be area in which students have poor knowledge on but yet showed go od attitudes. For instance, although only 29% of students accurately stated on the knowledge questionnaire that additional pain medication on an as needed schedule should be administered before pain returns, but this was inc onsistent with the 78% of students who disagreed that patients should experience discomfort prior to getting the next dose of pain medication. This may i ndicate that students are somewhat unfamiliar in understanding the difference between as needed analgesic medications and scheduled anal gesic treatment plans. Another area in which there seems to be confusion is in whether total pain relief is a goal. On the knowledge survey, only 24% of students believed that all patients should have complete pain relie f, while 78% of students on the attitude survey agreed that patients should be mainta ined in a pain free state. This may indicate that although students had the pos itive attitudes required for good pain

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33 management practices, they lack the k nowledge and rationales in understanding the need for total pain relief for patients. Addiction is yet another subject in which students had difficulty. Even though 100% could accurately define tole rance, only a small percentage (24%) knew that less than 1% of cancer pati ents became addicted to pain medication. On the attitude test, 73% of students di sagreed that patients receiving opioids around the clock for cancer pain are likel y to become addicted. Therefore, we see that on the subject of addiction, bot h knowledge and attitudes scores seem to be unrelated. It is unclear how thes e conflicting knowledge and attitude scores may ultimately impact patient care by these nurses. Conclusions Although pain management has been an area of study for many decades, lack of knowledge by students seems to be a major hindrance in good pain management practices. Because i nadequate knowledge and some negative attitudes were found in this study, it can be deduced that better educating students on the physiology of pain and pharmacology of analgesics is a much needed enterprise. Although in many instances, students had the positive attitude required for good pain management techniques, they lacked the fundamental knowledge, and understanding as to why they were practicing certain skills. Therefore, it can be su rmised that educating nurses and students is a step in the right direction to bette r pain management practices. Hence, a change in the current undergradu ate curriculum is required if we are to improve

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34 the pain management education that students receive. For this reason, topics addressing pharmacology, pain physiology, in addition to better understanding of concepts such as tolerance, dependence and addiction would be beneficial to improving the knowledge of students and t heir care of patients who suffer from chronic pain. It is therefor e, imperative that strat egies be identified to better educate students if we are to set the stage for enhanced pain management practices for patients. Implications for Nursing The findings of this study have several implications for nursing. Future studies should include multiple educat ional institutions from different geographical areas and a diverse ethnic populat ion to yield more accurate results on evaluating the knowledge and atti tudes of undergraduate students regarding pain management. In addition to this, nursing research should also focus on the development of specific strategies to effectivel y teach students about pain management and integrate pain management as a major component throughout the undergraduate-nursing curriculum. This will undoubtedly afford students the opportunity to provide effective care for c ancer patients with chronic pain, as well as, stimulate better patient out comes regarding pain management.

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35 References Agency for Healthcare Research and Quality (2001). Management of cancer pain. Summary, evidence report/tec hnology assessment: Number 35. AHRQ Publication No. 01-E033 Retrieved March 1, 2009, from http://www.ahrq.gov/clinic/epcsums/canpainsum.htm American Academy of Pain Management (n.d.). Pain issues: Pain is an epidemic Retrieved February 19, 2009, from http://www.aapainmanage.or g/literature/Articles/PainAnEpidemic.pdf American Cancer Society. (2009). American cancer society cancer action network fights for better pain care Retrieved April 1, 2010 from http://action.acscan.org/site /PageServer?pagename=pain_campaign American Nurses Association. (2001). Code of ethics for nur ses with interpretive statements. Retrieved March 12, 2009, from http://wvvw.ana.org/ ethics/chcode.htm American Pain Society recommendations fo r improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. (2005). Archives of Internal Medicine 165 1574-1580. American Pain Foundation. (2010). Breakthrough cancer pain survey Retrieved March 30, 2010 from http:/ /www.painfoundation.org/ Bernardi, M., Catania, G., Lambert, A ., Tridello, G., & Luzzani, M. (2007). Knowledge and attitudes about cancer pain management: A national survey of Italian oncology nurses. European Journal of Oncology Nursing 11 272-279. Chiu, L. H., Trinca, J., Lim, L. M., & Tuazon, J. A. (2 003). A study to evaluate the pain knowledge of two sub-populations of final year nursing students: Australia and Philippines. Journal of Advanced Nursing 41 (1), 99-108. Deandrea, S., Montanari, M., Moja, L., & Apolone, G. (2008). Prevalence of undertreatment in cancer pain: A review of published literature. Annals of Oncology, 19 (12), 1985-1991.

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36 Diekmann, J., & Wassem, R. A. (1991). A survey of nursing students’ knowledge of cancer pain control. Cancer Nursing 14 314-320. Ferrell, B., McGuire, D., & Donovan, M. (1993). Knowledge and beliefs regarding pain in a sample of nursing faculty. Journal of Professional Nursing 9 (2), 79-88. Goodrich, C. (2006). Student s’ and faculty members’ knowledge and attitudes regarding pain management: A descriptive survey. Journal of Nursing Education 45 (3), 140-142. Lasch, K., Greenhill, A., Wilk es, G., Carr, D., Lee, M., & Blanchard, R. (2002). Why study pain? A qualit ative analysis of medi cal and nursing faculty and students’ knowledge of and attitudes of cancer pain management. Journal of Palliative Medicine 5 (1), 57-82. McMillan, S., Tittle, M., Hagan, S., & Sma ll, B. (2005). Traini ng pain resource nurses: Changes in their knowledge and attitudes. Oncology Nursing Forum 32 (4), 835-842. McMillan, S., Tittle, M., Hagan, S., Laugh lin, J., & Tabler, R. E., Jr (2000). Knowledge and attitudes of nurses in veterans hospital about pain management in patients with cancer. Oncology Nursing Forum 27 (9), 1415-1423. Merriam-Webster Online Dictitionary. (2009). Knowledge Retrieved March 14, 2009 from http://www.merriam-webster.com/dictionary/knowledge National Comprehensive Cancer Network. (2010). Adult cancer pain Retrieved March 14, 2010 from http://www.nccn.org/professionals/physician_gls/PDF/pain.pdf Owens, K. (2000). Effects of nursi ng education on students’ pain management knowledge. Nurse Educator 25 (1), 33-37. Plaisance, L., & Logan, C. (2006). Nurs ing students’ knowledge and attitudes regarding pain. Pain Management Nursing 7 167-175. Rieman, M. T. (2007). Pain management competency evidenced by a survey of pediatric nurses’ knowledge and attitudes. Pediatric Nursing 33 (4), 307312.

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37 Rushton, P., Eggett, D., & Sutherland, C. (2003). Knowledge and attitudes about cancer pain management: A compar ison of oncology and nononcology nurses. Oncology Nursing Forum 30 (5), 849-855. The Ad Hoc Committee on cancer pain of the American Society of Clinical Oncology. (1992). Cancer pain a ssessment and treatment curriculum guidelines. Journal of Clinical Oncology 10 1976-1982. Turks, D. C. (2006). Pain hurts individuals, si gnificant others, and society Retrieved February 19, 2009, from http://www.ampainsoc.org/ pub/bulletin/win06/pres1.htm Wilkes, G., Lasch, K. E., Lee, J. C., Gr eenhill, A., & Chiri, G. (2003). Evaluation of a cancer pain education module. Oncology Nursing Forum 30 (6), 10371043.

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38 Appendices

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39 Appendix A: Nurses Pain Management Attitude Survey NURSES PAIN MANAGEMENT ATTITUDE SURVEY KEY Directions: Circle the response that best descr ibes your attitude toward the following statements. We are interested in your current beliefs. CODES: SD = Strongly Disagree D = Disagree A = Agree SA = Strongly Agree 1. Giving opioids on a regular schedule is preferred over a prn schedule fo r continuous pain. SD D A SA 2. A patient should experience discomfort prior to getting the next dose of pain medication. SD D A SA 3. Continuous assessment of pain and medication effectiveness is necessary for good pain management. SD D A SA 4. Patients (and/or family members) have a right to expect total pain relief as a goal of treatment. SD D A SA 5. Patients (and/or family members) may be hesitant to ask for pain medications due to their fears about the use of opioids. SD D A SA 6. Patients receiving opioids on a prn basis are more likely to develop clock-watching behaviors. SD D A SA 7. Estimation of pain by a MD or RN is a more valid measure of pain than patient self report. SD D A SA 8. Patients in pain can tolerate high doses of opioids without sedation or respiratory depression. SD D A SA 9. Patients can be maintained in a pain free state. SD D A SA 10. If a patient (and/or fa mily member) reports pain relief and euphoria, the patient should be given a lower dose of the analgesic. SD D A SA

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40 Appendix A: Nurses Pain Managem ent Attitude Survey (Continued) 11. Patients with chronic pain should receive pain meds at regular intervals with or without the presence of discomfort. SD D A SA 12. Patients receiving around the clock opioids are at risk for sedation and respiratory depression. SD D A SA 13. Patients having severe chronic pain need higher dosages of pain meds co mpared to acute pain. SD D A SA 14. Patients should be maintained in a pain-free state. SD D A SA 15. Lack of pain expression does not necessarily mean lack of pain. SD D A SA 16. Cancer pain can be relieved with appropriate treatment with anti-cancer drugs, radiation therapy and/or pain relieving drugs. SD D A SA 17. If a patient continues to have pain after receiving pain relieving medicati on(s), the nurse should contact the physician. SD D A SA 18. Patients receiving opioi ds around the clock for cancer pain are likely to become addicted. SD D A SA 19. Distraction and diversion of patient’s attention (use of music, relaxation) c an decrease the perception of pain. SD D A SA 20. A constant level of analgesic should be maintained in the blood to control pain effectively. SD D A SA 21. Increasing analgesic requirements and physical symptoms are signs that the patient is becoming addicted to the opioid. SD D A SA 22. The cancer patient and family should have more control over the schedule for analgesics than the health professional. SD D A SA

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41 Appendix A: Nurses Pain Managem ent Attitude Survey (Continued) 23. The nurse can make a more accurate assessment of the patient’s pain than the patient/family can. SD D A SA 24. Cutaneous stimulation (e.g. heat, massage, ice) are only effective for mild pain. SD D A SA Circle the response that you most agree with. 25. When a patient in pain due to cancer is receiving analgesic medication on a PRN basis, at what level of discomfor t would it first be appropriate for the patient to request additi onal pain medication? 1. Before pain returns 2. When pain is mild 3. When pain is moderate 4. When pain is severe Betty Ferrell, PhD, FAAN Connie Leek, RN, MS, OCN 1990 Revised 8/92 Susan C. McMillan, PhD, RN Mary Tittle, PhD, RN

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42 Appendix B: Pain Management Pr inciples Assessment Test PAIN MANAGEMENT PRINCIPLES ASSESSMENT TEST Parallel Form DIRECTIONS: Circle the letter in front of the one best answer. You may write ON THE TEST. 1. What percentage of cancer patients su ffer pain at some point during their illness? a. 10% b. 30% c. 60% d. 90% 2. What percentage of cancer patie nts suffer pain for longer than one month? a. 20-30% b. 40-50% c. 70-80% d. 100% 3. If the patient continues to have pa in after receiving the maximum ordered dose of analgesics, what should the nurse ALWAYS do? a. Increase the dose, slightly. b. Explain the risks of high doses of opioids to the patient/family. c. Reassure the patient t hat the medication will work. d. Call the physician. 4. The preferred route of administration of opi oid analgesics for cancer patients is which of the following? a. Intravenous b. Intramuscular c. Subcutaneous d. Oral e. Rectal

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43 Appendix B: Pain Management Princi ples Assessment Test (Continued) 5. When a patient having pain due to cancer is receiving analgesic medication on a PRN basis, at what leve l of discomfort would it first be appropriate for the patient to r equest additional pain medication? a. Before the pain returns b. When pain is mild c. When pain is moderate d. When pain is severe e. When the pain is intolerable 6. The most accurate and reliable j udge of the intensity of the cancer patient’s pain is which of the following? a. The treating physician b. The patient’s primary nurse c. The patient d. The pharmacist e. The patient’s spouse or family 7. What percentage of patients receiv ing opioid analgesics around the clock become addicted? a. Less than 1% b. 5-10% c. 25% d. More than 25% 8. Which of the following statements accurately describe the mechanism of action of analgesics? a. Opioids act in the CNS to decrease the transmission/perception of pain. b. Opioids act at the periphery to decrease the transmission of pain. c. Non-opioids act in the CNS to decrease the transmission/perception of pain. d. Opioids work by the Gate Control mechanism. 9. Which kind of pain can be tr eated with cutaneous stimulation? a. Mild pain only b. Moderate pain only c. Severe pain only d. Any intensity of pain

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44 Appendix B: Pain Management Princi ples Assessment Test (Continued) 10. Which of the following st atements accurately reflects principles underlying analgesic administration for perso ns with pain due to advanced cancer? a. Prolonged administration leads to tolerance which requires escalating amounts of analgesic to control pain. b. Prolonged administrat ion often result in addiction, so drug amounts must be carefully limited in the early stages of the disease. c. Opioids should be offered on an “as needed” basis to prevent drug dependence. d. Around the clock administration of opioids (rather than PRN) results in clock-watching in patients and families. 11. Which group of symptoms are mo re related to chronic pain? a. Decreased appetite, decreased energy, sleep disturbances, apathy, decreased blood pressure. b. Grimacing, fast heart rate, fast respiratory rate, elevated blood pressure, sweating. c. Thrashing, grimacing, elevat ed heart rate, cold and clammy extremities. d. Groaning, elevated blood pre ssure, irritability, sweating 12. Which of the following drugs hav e the longest duration of action? a. Codeine b. Methadone c. Meperidine d. Morphine 13. Acute pain is frequently accom panied by which of the following? a. Increased caloric requirem ents, increased temperature b. Increased oxygen requirement s, decreased temperature c. Decreased caloric requirem ents, decreased temperature d. Increased caloric requirem ents, decreased temperature 14. Dull and aching pain sensations ar e the responsibility of which of the following? a. A-delta fibers b. C fibers c. Opiate receptors d. Small myelinated fibers

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45 Appendix B: Pain Management Princi ples Assessment Test (Continued) 15. According to the Gate Control Theor y, the location in the nervous system that is responsible for “gating” is located in: a. The substantia gelatinosa in the spinal cord b. The nociceptors in the skin c. Deep nociceptors in the muscles d. White matter in the brain 16. Pain is modulated by which of the following: a. Opiate receptors mu, gamma, and kappa b. A-delta fibers c. C-fibers 17. Mrs. Colton, a 160 pound female is 24 hours post-op following abdominal hysterectomy. She received a dose of morphine sulfate 8 mg IM at 4:00 pm. It is now 6:30 pm and she is complaining of pain and requesting another injection. Her pain is most likel y related to which of the following: a. Physical dependence on the analgesic b. Tolerance to the pr escribed dose of analgesic c. A decrease in the blood level of the analgesic d. Early onset of addiction to the analgesic 18. Following an abdominal hysterecto my, your pain management goal for Mrs. Colton should be which of the following: a. Enough pain relief to allow he r to cooperate in post-op care b. To provide enough pain relief to keep Mrs. Colton from crying out c. To relieve her pain to a level that she can tolerate d. To provide her complete pain relief 19. Mr. West has prostatic cancer that has spread to the bones. In planning for his care, the primary factor to consider is: a. The likelihood that he will need higher doses later on b. The probability that he wil l become addicted to opioids c. His overall quality of life d. The wishes of his family regarding pain relief

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46 Appendix B: Pain Management Princi ples Assessment Test (Continued) 20. In assessing the patient’s pain, the nurse should take into account which of the following variables which may affect the expression of pain: a. Environment and social consequences of expressions of pain b. Cultural diversity in t he ways patients express their discomfort c. The observable measurabl e actions of the patient d. a and b e. a, b, c 21. The action of naloxone is: a. To enhance the effect of opioid analgesics b. To act as an opioid antagonist c. To act as an opioid agonist d. To act as a respiratory stimulant 22. Research suggests that: e. Physicians underprescribe and nurses undermedicate for pain f. Physicians prescribe appropriately and nurses undermedicate g. Physicians underprescribe and nurses give optimal doses based on those orders h. Physicians prescribe appropriately and nurses medicate appropriately in the majority of cases 23. One significant disadvantage of meperidine is: a. It is more expensive than morphine b. It has more CNS to xicity than morphine c. It is more addict ing than morphine d. It is more difficult to administer than morphine 24. Which of the following methods of opioidadministration provides steady state analgesia? a. Patient controlled analgesia using a pump b. Intravenous drip of opioids c. Intravenous bolus administration of opioids d. Intramuscular injections every two hours

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47 Appendix B: Pain Management Princi ples Assessment Test (Continued) 25. The primary benefit of providing st eady state analgesia is which of the following? a. It is cost effective because it uses less nursing time b. The patient receives less opioids overall c. Respiratory depression is less likely to occur d. The patient is more comfortable 26. A nursing decision to administer pain medication should be based on all of the following EXCEPT: a. The patient’s description of the quality of his/her pain b. The family’s request to keep the patient comfortable c. The nurse’s objective assessment of the intensity of the pain d. The patient’s subjective report of the intensity of her/his pain e. The nurse’s knowledge of the action of opioid analgesics 27. Who should have the most control ov er the patient’s pain management regimen? a. The patient b. The family c. The nurse d. The physician e. The pharmacist 28. DEFINITION: After re peated administration of an opioid, a given dose will begin to lose its effectiveness, resulting in the need for larger and larger doses. This begins with decreased duration of analgesia and then progresses to decreased analgesia. The above is a definition of which of the following? a. Addiction b. Physical dependence c. Tolerance d. Addictive personality 29. Mrs. Easton has metastatic breast canc er with painful lesions in her spine. She is reluctant to take her morphi ne as often as needed because she is afraid of drugs. You offer her a backrub and leave her with a heating pad on her back .This is an example of: a. Cutaneous stimulation b. Distraction c. Diversion d. TLC (tender loving care)

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48 Appendix B: Pain Management Princi ples Assessment Test (Continued) 30. Another approach you might have tried with Mrs. Easton involves concentrating on a task such as needle point or a crossword puzzle or reading a favorite book. This is an example of: a. Cutaneous stimulation b. Avoidance c. Distraction d. TLC (tender loving care) 31. Mrs. Sikes is a 72 year old woman with breast cancer which has metastasized to her pelvis. She also has moderately severe arthritis. Which of the following statements about managing her pain are most likely true? a. Morphine is the drug of choi ce because it will treat pain from any source. b. Morphine and a non-steroi dal anti-inflammatory drug together would get the best re sults with the least side effects. c. A non-steroidal ant i-inflammatory drug alone would probably be best because her primary problem is bone pain. d. Mrs. Sikes should not expect pain relief because of the severity of her disease.

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49 Appendix C: Demogr aphic Data Sheet Demographic Sheet 1. Age What is your age? _________ 2. Sex What is your sex? A. Male B. Female 3. Race/ethnicity How do you describe yourself? (pl ease check the one option that best describes you) A. American Indian or Alaska Native B. Hawaiian or Other Pacific Islander C. Asian or Asian American D. Black or African American E. Hispanic or Latino F. Non-Hispanic White 4. Employment status Are you currently (Select all that apply): A. A Licensed Registered Nurse (RN) B. Nurse Technician C. Certified Nursing Assistant D. Licensed Practicing Nurse E. A nursing student Years of Nursing Experience as an RN: _______ 5. Education completed Highest level of nursing education? A. Diploma B. Bachelor of Science in Nursing C. Associate Degree in Nursing D. Other. If so please state_____________ Do you currently work in a pain management clinic? A. Yes B. No

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50 Appendix C: Demographic Data Sheet (Continued) Have you had formal trai ning in pain management? A. Yes B. No

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51 Appendix D: Letter of Appr oval USF College of Nursing

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52 Appendix E: Letter of Approval USF Institutional Review Board

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53 Appendix E: Letter of Approval USF Institutional Review Board (Continued)


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Evaluating knowledge and attitudes of undergraduate nursing students regarding pain management
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ABSTRACT: ABSTRACT Unmanaged pain is a widespread problem that many cancer patients face on a daily basis. Cancer pain, which can either be caused by complications due to the disease process itself or from treatment measures used, has devastating effects on the quality of life for these patients and their caregivers. This study examined the knowledge and attitudes of undergraduate students regarding pain management. The sample in this study consisted of 41 undergraduate students at the University of South Florida College of Nursing. The students sampled were predominantly white, (n=30), female (n=37), seniors (n=41) taking Leadership and Management in Nursing. After volunteering to participate, students completed the demographic data form, the nurses' attitude survey and the Pain Management Principles Assessment Tool. The mean age of students was 22.46 years, with a range from 18 to 42 years. One student indicated that he or she had a bachelor's degree in another field with the majority of students being first time college students (n=31). The results of the study showed that a mean score of 19.4 (SD= 3.0) out of a possible 31(63%) was achieved on the knowledge of the students regarding pain management while, a mean score of 17.0 (SD=2.6) out of 25 (68%) was achieved on the Nurses' Attitude Survey. The data showed that nursing students demonstrated inadequate knowledge regarding pain management, and had mixed attitudes towards pain management. However, a weak to moderate relationship between knowledge and attitudes was found (r=0.33, p=0.038) due to the fact that students lacked the fundamental knowledge, and understanding as to why they were practicing certain pain management skills. Although the sample size was relatively small and not ethnically or demographically diverse, the response from the sample was sufficient in providing statistically meaningful data for this study. The results were seen to be consistent with previous studies that show poor management of pain. The findings of this study suggest the need for the development of specific strategies to effectively teach students about pain management, as well as integrate pain management as a major component of the undergraduate-nursing curriculum to improve patient outcomes.
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