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A comparative study of knowledge of pain management in certified and non-certified oncology nurses

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A comparative study of knowledge of pain management in certified and non-certified oncology nurses
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LaLande, Sherrie
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by Sherrie LaLande.
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A Comparative Study of Knowledge of Pain Management in Certified and Non Certified Oncology Nurse s b y Sherrie A. LaLande A thesis submitted in partial fulfillment o f the requirements for the degree of Master of Science College of Nursing University of South Florida Major Professor Cindy Tofthagen, Ph.D. A.R.N.P Susan C. McMillan, Ph.D. A.R.N.P. Laurie Stark M.S. R.N. Date of Approval: June 29, 2010 Key Words: opioids, cancer, education, palliative care Copyright 2010 She rrie LaLande

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i Table of Contents List of Tables ................................ ................................ ................................ ..................... ii Abstract ................................ ................................ ................................ .................... iii Chapter I Introduction ................................ ................................ ................................ ......... 1 Problem Statement ................................ ................................ ................................ ... 3 Research Questions ................................ ................................ ................................ .. 3 Definition of Terms ................................ ................................ ................................ .. 4 Significance of the Study ................................ ................................ ......................... 4 Chapter II Review of the Literature ................................ ................................ ..................... 6 Knowledge ................................ ................................ ................................ ............... 6 Education ................................ ................................ ................................ ................. 8 Effects of Certification ................................ ................................ ........................... 11 Conclusi on ................................ ................................ ................................ ............. 12 Chapter III Methods ................................ ................................ ................................ ........... 14 Sample ................................ ................................ ................................ .................... 14 Instrumentation ................................ ................................ ................................ ...... 14 Procedures ................................ ................................ ................................ .............. 15 Data Analysis ................................ ................................ ................................ ......... 15 Chapter IV Results ................................ ................................ ................................ ............. 17 Results ................................ ................................ ................................ .................... 17 Demographic Information ................................ ................................ .......... 17 Level of Knowledge ................................ ................................ ................... 19 Discussion ................................ ................................ ................................ .............. 21 Demographic Inform ation ................................ ................................ .......... 21 Level of Knowledge ................................ ................................ ................... 22 Implications for Nursing ................................ ................................ ........................ 24 Conclusion ................................ ................................ ................................ ............. 25 References ................................ ................................ ................................ .................... 27 Appendices ................................ ................................ ................................ .................... 29 Appendix A: Pain Manageme nt Principles Assessment Tool ............................... 30 Appe ndix B: Demographic Data Form ................................ ................................ .. 36 Appendix C: Letter of Appro val: Nature Coast Chap te r ONS .............................. 37 Appendix D: Letter of Approval: Greater Tampa Chapter ONS ........................... 3 8 Appendix E: Letter of Approval U SF Institutional Review Board ........................ 39

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ii List of Tables Table 1 Frequency and Percentage of Demographic Characteristics 18 Table 2 Independen t t in their Levels o f Pain Management Knowledge 19 Table 3 Independent t test Comparison of ASN/Diploma and BSN/MSN in their Levels of Pain Management Knowledge 20 Table 4 Frequencies and Percentages of Correct Answers on the PMPAT 21

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iii A Comparative Study of Knowledge of Pain Management in Certified and Non Certified Oncology Nurses Sherrie LaLande ABSTRACT Over 1.4 million people are diagnosed with cancer annually. Of t hose people, 70 90% experience some form of pain. Numerous efforts have been made to educate nurses in the management of pain, yet 30 50% of cancer patients repo rt that their pain is poorly managed It is not clear whether nurses who obtain certification in Oncology are better equipped to manage this patient populati on regarding their pain issues. This study compared the knowledge of Oncology Certified Nu rses (OCN) and Non Certified Oncology N urses (NCON) regarding pain management. The sample of 41 onc olo gy nurses included 19 who were c ertified in oncology and 22 who were not c ertified in o ncology from two Oncology Nursing Society Chapters in West Central Florida The nurses sampled were predominately Caucasian (n=35), females (n=38), with a mean age of 48.9 years all caring for patients in an oncology setting. The participants completed a brief demographic form and the Pain Management Principles Assessment Test (PMPAT) Results of the study showed that the Oncology Certified Nurses scored significant ly higher (mean = 71% ; SD = 2.9) on the PMPAT than did the Non Certified Oncology Nurses (mean = 62%; SD = 3.6) Although the sample size was small and limited in geographic location, the results are adequate in providing meaningful results

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iv ( p = .007) Findings suggest that there is benefit to oncology certification, allowing nurses to provide more comprehensive care for cancer patients in pain

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1 Chapter I Introduction The American Cancer Society (2009) estimates that approximately 1.4 million people a re diagnosed with cancer annually Throughout the course of their illness, it is estimated that 70% of those patients will experience severe pain. According to the National Pain Foundation, the numbers escalate for people with advanc ed cancer to between 75% and 90% (National Pain Foundation, 2010) Pain in ca ncer patients can be caused by e ffects of the tumor, via invasion of the bone, invasion of soft tissue, or nerve com pression. C omplications of treatment such as radiation, chemotherapy, or surgery c an be contributing factors as well Unfortunately, 30% 50% of patients receiving treatment for the disease report unrelieved pain (Ashley, 2008). Unrelieved pain has the potential to affect many aspects is directly related to fatigue, anxiety, emotional distress, mood disorders, depression, less social interaction, an result of these staggering statistics, pain has become one of the m ost feared aspects of cancer. In August of 2000, the American Cancer Society (ACS) developed a pain control plan after meeting with experts from various organizations devoted to pain control and palliative care (ACS 2001) In 2001, the Joint Commission on Accreditation of Healthcare Organization s (JCAHO) added pain assessment and

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2 management standards, naming pain the fifth vital sign in an effort to improve the standards of care The American Nurses Cre dentialing Center joined the American Society for Pain Management to offer the first nurse focused pain management certification in October 2005. This signified the need for a formal body of nurses with advanced knowledge and experience in pain management (American Nurses Association, 2005) In the summ er of 2006, nursing pain management experts and nurse leaders f Delegates meeting and passed Lucey MSN, RN, BC, PNP ( 2006) More recently the Oncology Nursing Society (ONS) he ONS Board of Directors in 1998 and last revised in 20 06 (ONS 2006) The point of this time line is to demonstrate that management of pain has bee n in the forefront for some time with many national organizations. However, pain continues to be untreated, undertreated, or improperly m anaged, despite these efforts. One barrier in the management of cancer pain is the lack of knowledge on the part of h ealthcare provider s, including staff nurses There are many contributors to the care of oncology patient s Nurses however, maintain a vital role when it comes to the management of pain in this population. The nurse is often the first to respond to a pat s readily available at the bedside to educate patients on how to actively participate in the management of their symptoms, includ ing pain. Finally when physicians prescribe less appropriate typ es, or doses of analgesics, nurses often play the role of advocate on behalf of the patient, providing assessment data to support appropriate management ( McMillan, Tittle, Haga n,

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3 Laughlin, and Tabler, 2000 ). The Agency for Health Care Policy and Research (AHCPR) guidelines suggest that 90% of cancer pain may be controlled through proper education of health care professionals ( 1994) Nursing certification is a process in which a non governmental agency validates the registered nu rses qualifications and expert kn owledge of practice in a specialized area of nursing. Oncology Certified N urses have met or exceeded requireme nts for practice in cancer care and have demons trated their knowledge by passing a standardized exam in oncology nursing, developed by t he Oncology Nursing Certification Corporation (ONCC). Nurses certified by ONCC are also expected to have completed education in oncology nursing and have demonstrated specific knowledge of symptom management including pain Oncology certified nurses have a tested knowledge of the specialty which is based on current professional pra ctice. Problem Statement Previous research has focused mainly on the knowledge and attitudes about pain management. Unfortunately, there is very little research focusi ng on whether oncology certification is beneficial in the management of pain in the oncology population. The purpo se of this study is to determine whether Onco logy Certified Nurses (OCN s) demonstrate a higher level of knowledge regarding pain management than the Non Certified Oncology N urses (NCON s ) when caring for the oncology population. Research Question s The following qu estions are addressed in this study: 1. What level of knowledge d have regarding pain management in the cancer population ?

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4 2. What level of knowledge do have regarding pain management in the cancer population ? 3. Do OCN s have a significantly higher level of knowledge regarding pain management of the oncology population, when compared to ? Definition of Terms The following terms are defined for the purpose of this study: Pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage ( National Pain Foundation 2010). Knowledge is the fact of knowing something with familiarity obtai ned by investigation, acquired study, or experience (Merriam Webster Online Dictionary, 2009) Significance of the Study For many years management of pain has been a priority for many national organizations which represent healthcare providers. Millio ns of dollars and countless hours have gone into creating models and making plans to eliminate this epidemic. Unfortunately, despite all of these efforts, many cancer patients still suffer with pain. Nurses are the primary care providers for the oncolo g y population. They are pivotal in most decision s relate d to patient care. If l ack of knowledge has been identified as the prima ry barrier to proper mana gement of pain, examining the level of knowledge nurses possess is an important step toward better pa in management for the oncology population The intent of this study is to provide insight into wh demonstrate a higher level of knowledge regarding pain management tha

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5 Results of this study may assis t schools of nursing and in service education departments, insuring the importance of effective pain management when planning nursing curriculum.

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6 Chapter II Review of the Literature The purpose of this chapter is to present a comprehensive review of relevant literatu re. M ost of the research available to date regarding knowledge of pain management almost always includes the correlation of nurses attitudes, as they are so closely intertwined. However, only the findings pertaining to nurses knowledge are reviewed h ere. K nowledge is gained through education. Therefo r e, it is important to include research on the methods to edu cate nurses i n the management of pain. Only one study was found to address the effect of certification in oncology nursing on pain management This overall lack of data supports the need for further research into this matter. Knowledge McMillan and colleagues (2000) sought knowledge and attitudes about pain management and patients in pain. Eighty five nurses both RNs and LPNs from seven med ical surgical units within two Veterans A dministration (VA) hos pitals participated in the study To he Pain Management Knowledge Test (PMKT) was used. The PMKT is a 31 item multiple choice test that cover s physiology and characteristics of pain, addiction, dependence, tolerance, and goals of pain managem ent. importance of asking patients about their pain and around the clock scheduling of opio id

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7 analgesics use of distraction and tolerance. However, there was a knowledge deficit when it came to the nurses understanding of the physiology of pain and the pharma cology of the analgesics. Rushton, Eggett, and Sutherland (2003) studied knowledge and attitudes about cancer pain management among oncology and non oncology nurses. The purpose was to obtain baseline data about the knowledge and attitudes of a group of Utah RNs regarding control of cancer pain Potential study participants were mailed a letter explaining the study, a demographic survey and the Nurses Knowledge and Attitudes Survey Regarding Pain, dev eloped by Ferrell. T h e tool contains 37 items based on standards of pain management from American Pain Society, World Health Organizatio n, and AHCPR (Rushton et al. 2003 ). Forty four oncology nurses and 303 non oncology nurses returned the surveys that were used in the data analys is. Findings suggested that the oncology n urses knowledge correlated more closely with the recommended princ iples of pain management in the cancer patient tha n did those of the non oncology n urses. As with the previous study by McMillan and colleagues ( 2000) the findings suggest oncology nurses have a lack of knowledge in regard to the pharmacology of medicati ons used in managing cancer pain. In yet another study pertaining to the assessment of nursing k nowledge, Wilson (2007) sought to determine whether there is a difference in the knowledge base between two groups of nurses with different backgrounds, and wh ether this was related to clinical experience or post basic edu cation. One hundred questionnaires were given to two (hospice/oncology and district). B oth groups were considered to be basic education and clinical experience. However,

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8 range of nursing skills and clinical inte rvent ions. Seventy two nurses participated by completing the revised Pain Survey devised b y McC affery The survey measure s knowledge of pain assessment and management. Findings suggest that the of pharmacology, theories of pain, and management. Interestingly the knowledge o f those nurses did not appear to be related to their years of experience. Clarke et al. (1996) wanted to assess the knowledge that RNs possess in regard to pain management and whether their educational preparation had any in fluence on that knowledge. Th e researchers administered the Pain Management: Nurses Knowledge and Attitude Survey to 120 RNs fro m two surgical ICUs, two orthop edic units, and two medical units including one medical oncology unit. Demographic information was also collected which inclu ded area of clinical practice, years of experience, general nursing degree, and other degrees or certification. Findings suggested that the level of nursing education positively correlated with mean scores on the Nurses Pain Knowledge and Attitude Survey. Also, n urses who worked on the medical oncology unit scored higher than nurses from the eight other non oncology units surveyed. Results showed that there are inconsistencies in the answers provided and an overall lack of knowledge regarding accepted st rategies for pain management. Overall, the findings were similar to previo us ly cited studies. Education Research suggests that other parts of the world are encountering the same issues A longitudinal

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9 study, conducted in European by Wells, Dryden Guild, Levack, Farrer and Mowat (2001) hypothesized that the hospital Palliative Care Team s advice and informal teaching encounters would improve the knowledge and attitudes of the nurses an d physician in regard to pain management One hundred thirty five doctors ( n= 32) and nurses ( n= 103) from an oncology surgical unit participated. Study participants were asked to complete the Knowle dge and Attitude scale devised by Elliott and colleagues (1995 ) The scale consiste d of 27 items pertaining to an and attitudes about pain and pain management. Participants also completed a demographic questionnaire about previous training, personal and professional details, and current priorities for training in palliative care. Baseline data was similar to the find ings in the previously cited studies, lack of knowledge and attitudes in management of pain. The initial data in this study was used primarily to target areas in ne ed of education by the institution s Palliative Care Team. The team was able to provide teaching sessions on a surgical unit where large number s of cancer patients are cared for and informal education opportunities that arose when patients on the unit wer e referred to the Palliative Care Tea m. At one year, 101 study participants completed the second set of questionnaires. Initial r esults indicated that having the personal interactions and education forums of the Palliative Care Team did improve the knowl edge and attitudes over the course of the ye ar. However only 19 staff members were able to attend the formal teaching sessions. Further a nalysis suggested that the staff members that attended the formal teaching sessions were no more likely to have impr ove d knowledge when compared to those who did not attend. Therefore, the findings were thought to be a result of the good working relationships that developed rather than through formal education.

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10 Wilkes, Lasch, Lee, Greenhill and Chiri (2003) hypothes ized that educational intervention such as Cancer Education Module for the Management of Pain (CEMMP) pain management The researchers also believed that the benefits o f early and reinforced exposure of such pain education would be maintained over time. CEMMP curriculum includes the pathophysiology of cancer pain, pharmacologic and non pharmacologic management, collaborative care, cultural diversity in pain expression and receptivity to treatment, and pain management under managed care. An oncology nurse specialist delivered seven, two to four hour seminars which covered the CEMMP curriculum at three participating graduate schools. Ninety two graduate nursing student s participated in the study. Students were asked to take a pretest before the seminar and a post test immediately after the class as well as a follow up test 6 and 24 month later Although 53% did not return the 6 month test and 77% did not return the 24 month test, the inves tigators were still able to demonstrate that the participants improved their knowledge of cancer pain management and also retained this knowledge at the follow up tests. De Rond, de Wit, van Dam, van Campen, den Hartog, and Klievink (2000) of the Netherlands implemented a Pain Monitoring Program (PMP) for the purpose of improving nurses knowledge about pain and pain treatment. They also intended to program consisting of formal lecture and open discussion. The focus was on the current trends in pain assessment and treatment. The program also included discussion about

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11 ana lgesics and use of non instructed on the importance of daily pain assessment using a Pain Intensity Scale (from 0 10). The study was conducted throughout three hospitals in the Netherlands. In total, 240 nurses worked in the nine wards from which participants would be gathered. The effects of the PMP were measured using a pre test and post test design before the start of the education program and again at 6 months, after implementation of the PMP. Par ticipants were asked to complete two questionnaires and a few socio demographic questions at both assessment points. The first questionnaire the participants completed me asured on a 5 point Likert type scale (strongly agree, agree, not agree, disagree, strongly disagree) to measure nurses knowledge of pain The second study measure was a newly created Pain Attitude Inventory (PAI). The PAI is a nine item questionnaire wh (DeRond et al. 2000). For analysis, data from 175 nurses at pre test and 144 nurses at post test were included. To estimate the amount of knowledge gained during the PMP, th e results of the pre test and the post t test. The results showed that nurses improved their knowledge of pain management after the PMP was implemented. Effect of Certification Coleman and colleagues (2009) co nducted a study in which they compared Oncology Certified N urses to non Oncology Certified N urses for knowledge related to symptom management of pain. They also measured patient satisfaction and nurse satisfaction. Patients were asked to complete the Pat ient Pain Questionnaire (PPQ) and

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12 the Press Ganey Inpatient Survey (INVR). Nurses completed the Nurses Knowledge and Attitude Survey Regarding Pain (NKASRP), Nurses Knowledge and Attitude Survey, a questionnaire on work satisfaction, and lastly, a general demographi c form. The Patient surveys were linked to the nurse who was providing care at that time. The results of the cancer patients surveys ( n= 270) showed overall high satisfaction with their care, and they believed that their pain was managed well. There was statistically no difference between certified nurses and noncertified nurses in this area. However, r esults showed that Oncology Certified N urses scored higher on the NKASRP than noncertified nurses. Attending more hours of continuing education and being members of the Oncology Nursing Society (ONS) were found to be contributing factors. Although, not relevant to this review of literature, job satisfact ion was high for all nurses who participated in t he study ( n= 93), with noncertified nurses scoring slightly higher. Conclusion Methods to treat pain ha ve been in existence for quite some time and it is estimated that 90% of cancer pain is treatable, yet effective pain management continues to elude man y patients. Nurses can assume a very important role in the assessment and management of pain However, research findings suggest that nurses are not prepared to handle this critical role due in part by their lack of knowledge and individ ual attitudes regarding pain, and p ain manageme nt. T here seems to be a reoccurring theme that implies a nurses preparati on and education about pain management is a contributing factor Results support the idea that pain education has been beneficial to n urses which in turn will overall benefit the patient. Certification is

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13 one way in which oncology nurses can demonstrate their advanced knowledge and continue to provide superio r pain management to the oncology population.

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14 Chapter III Me thods In this chapter, the methodology of the study is presented. This includes the characteristics of the sample, and a description of the instruments of measurement used to collect data. In addition, the procedures for data collection, and the methods of data analysis are discussed. Sample The target population included nurses from two Oncology Nursing Society (ONS) chapters in we st central Florida. Forty one nurses were recruited to participate in the s tudy. All of the nurses were c urrently prac ticing, and were caring for cancer patients in their primary nursing role. Nineteen of the nurses were OCN two were ld certification in pain management were excluded. Instrumentation Pain Management Principles A ssessmen t Test The Pain Management Principles Assessment Test (PMPAT) was administered. This instrument was chosen for use in this study, because it is a reliable and valid tool for measuring knowledge of pain management principles. The questionnaire contains 31 multiple choice items that cover pain, addiction, dependence, tolerance, goals of pain management, and principles of pain assessment and management (McMillan et al. 2000 ). A higher score indicate s a higher level of knowledge about the management of pai n. The

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15 fact that the test was built from a blueprint, basing items on a review of literature and that it was studied in a pre to post test fashion (t= 6.76, p <0.00) supports the validity of this instrument for use in this study. Test retest reliability with a one w eek delay supports the reliability of the instrument as well (r= 0.84, p<0.00) (McMillan et al. 2000) Demographic Data A demographic data form was cr eated for use in this study. The form contain s items such as age, gender, ethnicity/race, level of education, years of experience, and area of specialty. Procedures Approval was sought from the west central ONS chapters to approach their members for the purpose of participation in the study. Upon acceptan ce, approval was sought from the Univ ersity of South Flori da Institutional Review Board. Nurses were asked to participate at one of the monthly meetings between March and April of 2010. A cov er letter, explaining the study in its entirety was given to the members. The investigator was pre sent to answer a ny concerns or questions relate d to the study. Nurses agreeing to participate were given th e demographic sheet and the PMPAT Comple tion of the forms implied consent The instruments were gathered upon closure of t he meeting by the inves tigator and kept in confidenc e. No personal identifiers appear ed on the questionnaire Data Analysis Demographic data was analyzed using frequencies, percentages, means, and standard deviations Mean s and standard deviation s were used to answer research question 1; what level of knowledg have regarding pain management in the

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16 cancer population? Means and standard deviations were also used to answer research question 2; w hat level of knowledge have regarding pain management in the canc er populat ion? Independent t test was used to answer research question 3; d o OCNs have a higher level of knowledge regarding pain management of the oncology population, when compared t ?

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17 Chapter IV Results, Discussion and Conclusi on s This chapter presents the results of the Pain Ma nagement Principles Assessment T est, and This section discusses the strengths and weaknesses that surround the results It also discuss es what implications the findings hav e for nursing and future research Results Demographic Information The sample consisted of 41 nurses, 19 of whom were Oncology Certified Nurses. The mean age was 48.9 years, with a range of 28 65 years. Of the 41 nurses, 92.7% (n=38) were females, while 4.9% (n=2) were males One participant did not report age or gender The majority of nurses were Caucasian (85.4%, n=35), while 7.3% (n=3) were African American, 4.9% (n=2) were Asian, and 2.4% (n=1) were American Indian/Alaskan Nati ve. Most of the nurses were of Non Hispanic ethnicity (90.2%, n=37). Eighteen of the nurses reported having an Associate in Science of Nursing degree or Diploma and 18 reported having either a Bachelors in Science of Nursing or a Masters in Science of Nu rsing consisted of Licensed Practical Nurse s (n=3) and nurses with Masters in Health

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18 Administration (n=2). Fifty six p ercent (n=23) of the nurses had 20 or more years of experien ce (Table 1) Table 1. Frequency and Percentage of Demographic Characteristic s ________________________________________________________________________ Demographic Content Frequency Percent Gender Number of Females 38 92.7 Number of Males 2 4.9 E thnicity Hispanic or Latino 1 2.4 Not Hispanic or Latino 37 90.2 Unknown 3 7.3 Race American Indian/Alaskan Native 1 2.4 Asian 2 4.9 Black or African American 3 7.3 White or Caucasian 35 85.4 Experience 3 year s of experience 1 2.4 4 7 years of experience 6 14.6 8 11 years of experience 1 2.4 12 15 years of experience 7 17.1 16 19 years of experience 3 7.3 20 years of experience 23 56.1 Education Associate D egree 16 39.0 Dip loma 2 4.9 BSN 13 31.7 MSN 5 12.2 Other Degree 5 12.2 Practice Setting Inpatient 17 41.5 Outpatient 18 43.9 Home care 3 7.3 Other 3 7.3 ________________________________________________________________ ________

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19 Level of Knowledge The raw scores of the PMPAT in the OCN group were calculated and analyzed to address the first research question, the lev el of knowledge that the OCN possess regarding pain management in the cancer population. Raw knowle dge scores ranged from 16 (52%) t o 27 (87%), with a mean of 21.9 (71%) and a standard deviation of 2.9 (Table 2) The same process was repeated for the NCON group to answer the second research question, the level of kn owledge that the NCON possesses regar ding pain management in the cancer population. In this group, the raw knowledge scores ranged from 13 (41%) to 25 (81%), with a mean of 19.09 (62%) and a standard deviation of 3.6 In order to answer the final research question and explore differences in knowledge regarding pain management of the oncology population between the OCN and the NCON an i ndependent t test (p=.007). Table 2. Independent t test Comparison of Management Knowledge Group n M % M raw SD t p OCN 19 71 21.9 2.9 2.8 .007 NCON 22 62 19.1 3.6 When grouping the nurses with an Associate of Science in Nursing (ASN) and Diploma together, their mean score on the PMPAT was 19.7 with a standard deviation of 3.7. The nurses with a higher level of education, Bachelors of Science in Nursing (BSN) and Masters of Science in Nursing (MSN), had a mean score of 21.6 with a standard deviation of 3.2 (Table 3) The level of knowledge for the BSN/MSN group is not

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20 statistically different from the ASN/Diploma group (p= .120). Therefore, the level of education did not seem to influence the results of the study. Table 3 Independent t test Comparison of ASN/Diploma and BSN/MSN in their Levels of Pain Management Knowledge Group n M % M raw SD t p ASN/Diploma 18 64 19.7 3.7 1.6 .120 BSN/MSN 18 70 21.6 3.2 Areas in which the nurses knew the least on the PMPAT included physiology of p ain which included questions related to nerve fibers, gate control theory, and the effects of pain on the body (Table 4) The nurses also knew the least about pharmacology including when to administ a steady state of analgesia. P atient pain intensity judgment and goals of pain management were also areas of difficulty Areas in which 85% or more of the nurses answered in conjunction with narcotic to reliev e pain issues surrounding tolerance, benefits of maintaining a steady state of analgesia, patient control with pain management and that the patient is the most accurate and reliable judge of the intensity of their pain.

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21 Table 4. Frequencies a nd Percentages of Correct Answers on the PMPAT Answered Correctly ________________________ Content Frequency Percentage ________________________________________________________________________ Areas of Least Knowledge Physiolo gy Nerve fibers 3 7 Gate control theory 10 24 18 44 Pharmacology Administration of analgesics to achieve steady state 6 15 Best method of administration to achieve steady state 14 34 Goals of pain management 9 22 9 22 Prevalence of chronic cancer pain 17 42 Areas of Greatest Knowledge Steady state analgesia 35 85 Need for increased dose as a result of tolerance 35 85 Use of NSAIDS as an adjunct 36 88 Mechanism of action of analgesics 36 88 37 90 Physician contact when pain persists despite max dose 39 95 Patient is most accurate judge of pain 40 98 Use of distraction 41 100 Tolerance definition 41 100 ________________________________________________________________________ D iscussion Demographic Information When discussing demographic information obtained from a single sample one would exp ect to find some d ifferences from the larger population In this study, Caucasian females comprised the majority of the 41 participants (n=38). According to the 2004 National Sample Survey of Registered Nurses (NSSRN) there are 2,909,357

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22 licensed Regist ered Nurses in the United States. Approximately 5.8% are males, 4.2% are African American, 1.7% are Hispanic Latino, 3.1% are Asian, and 0.3% are American I ndian/Alaskan Native. Therefore, this sample is reflective of the population States. The average age of a nurse in the United States in 2008 was 47.0 years according to initial findings of the NSSRN. P articipants in this study were representative of the 2004 NSSRN for gender, ethnicity, race, and age However, because the data was collected in one geographic location and there was limited input from males, the various races, and ethnic backgrounds, results may not be generalized to include the entire population of nurses caring for oncology patients. For the purpose of this stu dy, oncology nurses were recruited from two local Oncology Nursing Society chapters in west central Florida. These nurses were chosen because of their known involvement with the care of patients with cancer A strength of this study is that the sample o f nurses represent different aspects of nursing care The Greater Tampa Chapter is composed of mostly oncology nurses caring fo r patients in a comprehensive cancer care setting at Moffitt Cancer Center T he Nature Coast Chapter is composed mostly of nurses caring for patients in the rural, private, and outpatient setting. A limitation of this study was the small sample size taken from one geographic region As with any study a larger sample size might have been more repre sentative. Level of Knowledge Oncology Certified Nurses scored significantly higher on the PMPAT than did the Non Certified Oncology Nurses. This finding is consistent with research conduct ed significantly higher on the pain manageme (2009). S tudies by Rushton and

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23 colleagues (2003), and Wil son (2005) have shown that nurse s caring for the oncology population score higher on various pain knowledge assessment tests as well It is thought that the oncology nurses caring for cancer patients with pain are more knowledgeable through their work experiences, and various educational offerings With the exception of the study by Coleman and colleagues, the other findings did not address certification as a potential influence upon the greate r knowledge of pain managemen t. There was a notable difference in the scores from the PMPAT when comparing educational background. The BSN/MSN group scored higher than the ASN/Diploma group. However, the difference was not statistically significant. This is unlike the findings of Clarke et al. (1996) that found a positive correlation between the level of nursing education with the mean scores on the Nurses Pain Knowledge and Attitude Survey. There are several fac tors that may have influenced the outcome of the current study The first is the small sample size. Another consideration is the number of years a nurse has been in practice. In this study, there were a large number of nurses (n=23) with 20 or more year s of experience. These nurses may hold an ASN or Diploma. However, because of their experience may have scored higher on the PMPAT. place of employment and amount of time providing direct patient care to the oncology population could have affect the outcome. Although the Oncology Certified Nurses and the BSN/MSN prepared nurse scored higher than their counterparts on the PMPAT, the mean for all groups was never higher than 71%. That is still considered a failing score by most stand ards. This only signifies the need for more education on pain management in current curriculums. Pathophysiology courses could include matters such as nerve fibers, gate control theory

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24 and pain modulators. Issues surrounding administration of opioids to achieve a steady state and best methods of administration would be best explained in a pharmacology course. Medical surgical courses could incorporate education on the prevalence of chronic pain and goals of pain management. Lastly, assessment courses c ould discuss the effects that pain can have on the body. Implication s for Nursing Obtaining specialty certification is b eneficial to oncology nursing In order t o be eligible for certification, the Registered Nurse must have been licensed for at least one year, completed a minimum of 1,000 hours of adult oncology nursing, and complete a minimum of 10 contact hours of continuing nursin g education in oncology nursing. The exam consists of 165 multiple choice items with 22% of the questions pertaining to symptom management, including alterations in comfort, rating scales, pharmacologic interventions and non pharmacologic interventions. Certification in oncology signifies that a nurse has experience and specialty knowledge beyond that of the general nurse As a result of an aging population and the increasing need for cancer care, the demand for knowledgeable nurses is on the rise. As our healthcare delivery system receives continued public scrutiny, e mployers look to distinguish themselves in the mark etplace. Certification of nursing staff can factor into accreditation by various agencies. According to the Oncolo gy Nursing Certification Corporation 8 out of 10 people in the general population are aware that nurses can carry certificatio n in a speci alty area. Having certified nurses, allows patients to feel confident about the care they are receiving Nurses also gain a sense of confidence and personal accomplishment from knowing that their knowledge in oncology nursing has been demonstrated

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25 Many go on to join national societies and local chapters catering to the oncology nurse, such as the Oncology Nursing Society (ONS) and the Hospice and Palliative Nurses Association (HPNA) Through these organizations, nurse s have access to a vast amoun t of education in the form of books, continuing education programs, journal articles, peer groups and annual conferences. All of these are designed to keep nurses updated on current trends in oncology nursing, including pain ma nage ment. This enables the ir cancer patient. Conclusion Management of pain, particularly in the oncology population has been a primary concern of patients, care givers and healthcare providers for countless years. However, 30 50% of patients continue to report unrelieved pain (Ashley, 2008). It is possible that arding pain management may contribute to poor pain relief in the oncology population. The results of this study identified that nurses whom obtain Certification in Oncology scored higher on their knowledge of pain management than their colleagues whom were not certified. scores for both groups were relatively low, indicat ing an overall deficit in knowledge regarding cancer pai n management. It is evident that there is a need for more education. in the area of pain management. Future different ethnic backgrounds and geographic locations. The sample should also include a proportionate number of males and females. I nclud ing a more accurate account of the

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26 ars of experience may be of benefit, as there may be a correlation between experience and level s of knowledge regarding pain management although that relationship was not demonstrated in this study Also, future studies should monitor ment practices to evaluate whether knowledge of pain management principles has a positive effect on pain severity or distress

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27 References Agency for Health Care Policy and Research(1994). Management of cancer pain: Clinical guideline number 9. Retrieved January 15, 2010 from: http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsarchive&part=A18803 American Cancer Society (2001). ACS drafts pain c ontrol measures Retrieved January 2, 2010 from: http://www.cancer.org/docroot/NWS/content/NWS_5_1x_ACS_Drafts_Pain_Con trol_ Measures.asp Americ an Cancer Society (2009). Cancer Facts and Figures 2009 Retrieved January 2, 2010 from: http://www.cancer.org/downloads/STT/500809web.pdf American Nurses Society (2005). ANCC annou nces n ew certification for pain managem ent nurses. Retrieved January 15, 2010 from: http://www.nursingworld.org/FunctionalMenuCategories/MediaResources/PressR e leases/ 2005/pr09208536.aspx Ashley, J.L. (2008). Pain Management: Nurses in Jeopardy. Oncology Nursing Forum 35(5), E70 E75. Clarke, E.B., French, B., Bilodeau, M.L., Capasso, V.C., Edwards, A., & Empoliti, J. (1996). Pain management knowledge, at titudes and clinical practice: the impact characteristics and education. Journal of Pain and Symptom Management, 11, 18 31. Coleman, E.A., Coon, S.K., Lockhart, K., Kennedy, R.L., Montgomery, R., Copeland, N., McNatt, P., Savell, S., & Stewa rt, C. (2009). Effect of certification in oncology nursing on nursing sensitive outcomes. Clinical Journal of Oncology Nursing 13(2), 165 172. deRond, M.E.J., deWit, R., vanDam, F.S.A.M., vanCampen,B.Th.M., denHartog, Y.M. & Klievink, R.M.A. (2000). A pain monitoring program for nurses: effects on nurses pain knowledge and attitudes. Journal of Pain and Symptom Management 19 (6), 457 467. Elliott, T.E., Murray, D.M., Elliott, B.A., Braun, B. Oken, M.M., Johnson, K.M., Post White, J. & Lichtblau, L. (1995). Physician knowledge and attitudes about cancer pain management: A survey from the Minnesota Cancer Pain Project. Journal of Pain and Symptom Management 10 (7), 494 504. Inside ANA (2006). Improving pain management: call to action Retriev ed January 15, 2010 from: http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ ANAPeriodicals/ AmericanNurseToday/Archive/2006/December/Issues.aspx

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28 Joint Commission on Accreditation of Healthcare Organiz ation (2001). Pain management standards. Retrieved January 2, 2010 from: http://www.jointcommission.org/J ointCommission/Templates/GeneralInformation .aspx ? NRMODE=Published&NRNODEGUID={A08FCD4F CB99 4B32 B309 1FF1F51CC6C6}&NRORIGINALURL=%2fNewsRoom%2fhealth_care_is sues.htm&N RCACHEHINT=Guest#9 knowledge. (2010). In Merriam Webster Online Dictionary Retrieve d January 19, 2010, from http://www.merriam webster.com/dictionary/knowledge McMillan, S.C., Tittle, M., Hagan, S., Laughlin, J., & Tabler, R.E. (2000). Knowledge and attitudes of nurses in veterans hospitals about pain management in patients with cancer. Oncology Nursing Forum 27(9), 1415 1423. National Pain Foundation (2010). Cancer Pain: What is it? Retrieved January 2, 2010 from: http://www.nationalpainfoundation.org/cat/8/cancer pain Rushton, P., Eggett, D., & Sutherland, C.W. (2003). Knowledge and attitudes about cancer pain management: a comparison of oncology and nononcology nurses. Oncology Nursing Forum 30(5), 849 855. Wells, M., Dryden, H., Guild, P., Levack, P., Farrer, K. & Mowat, P. (2001). The knowledge and attitudes of surgical staff towards the use of opioids in cancer pain management: can the hospital palliative care team make a differen ce? European Journal of Cancer Care 10, 101 211. Wilkes, G., Lasch, K.E., Lee, J.C., Greenhill, A. & Chiri,G. (2003). Evaluation of a cancer pain education module. Oncology Nursing Forum 30(6), 1037 1043. n. Journal of Clinical Nursing 16, 1012 1020.

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29 Appendices

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30 Appendix A: Pain Management Principles Assessment Test PAIN MANAGEMENT PRINCIPLES ASSESSMENT TEST Parallel Form DIRECTIONS: Circle the letter in front of the o ne best answer. You may write ON THE TEST. 1. What percentage of cancer patients suffer pain at some point during their illness? a. 10% b. 30% c. 60% d. 90% 2. What percentage of cancer patients suffer with pain for longer than one month? a. 20 30% b. 40 50% c. 70 80% d. 100% 3. I f the patient continues to have pain 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 that the medic ation will work. d. Call the physician. 4. The preferred administration route of opioid analgesics for cancer patients is which of the following? a. Intravenous b. Intramuscular c. Subcutaneous d. Oral e. Rectal 5. When a patient having pain due to cancer is receiving analgesic medication on a PRN basis, at what level of discomfort would it first be appropriate for the patient to request 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

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31 Appendix A: Pain Management Principles Assessment Test (Continued) 6. which of the following? a. The treating physician b. c. The patient d. The pharmacist e. 7. What percentage of patients receiving 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. Op ioids 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 treated with cutaneous stimulation? a. Mild pain only b. Moderate pain only c. Severe pain only d. Any intensity of pain 10. Which of the following statements accurately reflects principles underlying analgesic administration for persons with pain due to advanced cancer? a. Prolonged administration leads to tolerance which requires escalating amounts of analgesic to control pain. b. Prolonged administration often results in addiction, so drug amounts must be carefully limited in the early stages of t he disease. c. dependence. d. Around the clock administration of opioids (rather than PRN) results in clock watching in patients and families.

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32 Appendix A: Pain Management Principles Assessment Test (Continued) 11. Which group of symptoms are more 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. Th rashing, grimacing, elevated heart rate, cold and clammy extremities. d. Groaning, elevated blood pressure, irritability, sweating 12. Which of the following opioids have the longest duration of action? a. Codeine b. Methadone c. Meperidine d. Morphine 13. Acute pain is freque ntly accompanied by which of the following? a. Increased caloric requirements, increased temperature b. Increased oxygen requirements, decreased temperature c. Decreased caloric requirements, decreased temperature d. Increased caloric requirements, decreased temperatu re 14. Dull and aching pain sensations are the responsibility of which of the following? a. A delta fibers b. C fibers c. Opiate receptors d. Small myelinated fibers 15. According to the Gate Control Theory, the location in the nervous system that is 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 likely re lated to which of the following:

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33 Appendix A: Pain Manageme nt Principles Assessment Test (C ontinued) a. Physical dependence on the analgesic b. Tolerance to the prescribed 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 hysterectomy, your pain management goal for Mrs. Colton should be which of the following: a. Enough pain relief to allow her to cooperate in post op care b. To provide enough pain relief to keep Mrs. Colton from crying o ut 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 do ses later on b. The probability that he will become addicted to opioids c. His overall quality of life d. The wishes of his family regarding pain relief 20. following variables which may affect the expression of pain: a. Environment and social consequences of expressions of pain b. Cultural diversity in the ways patients express their discomfort c. The observable measurable 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 a opioid antagonist c. To act as a opioid agonist d. To act as a respiratory stimulant 22. Research suggests that: a. Physicians underprescribe and nurses undermedicate for pain b. Physicians presc ribe appropriately and nurses undermedicate c. Physicians underprescribe and nurses give optimal doses based on those orders d. Physicians prescribe appropriately and nurses medicate appropriately in the majority of cases 23. One significant disadvantage of meperid ine is:

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34 Appendix A: Pain Management Principles Assessment Test (Continued) a. It is more expensive than morphine b. It has more CNS toxicity than morphine c. It is more addicting than morphine d. It is more difficult to administer than morphine 24. Which of the follo wing methods of opioid administration 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 25. The primary benefit of provid ing steady state analgesia is which of the following? a. It is cost effective because it uses less nursing time b. The patient receives less opioid overall c. Respiratory depression is less likely to occur d. The patient is more comfortable 26. A nursing decision to admi nister pain medication should be based on all of the following EXCEPT: a. b. c. d. subjective report of the intensity of her/his pain e. 27. a. The patient b. The family c. The nurse d. The physician e. The pharmacist 28. DEFINI TION: After repeated 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

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35 Appendix A: Pain Management Principles Assessment Test (Continued) 29. Mrs. Easton has metastatic breast cancer with painful lesions in her spine. She i s reluctant to take her morphine 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) 30. Another a pproach you might have tried with Mrs. Easton involves concentrating on a task such as needlepoint 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 choice because it will treat pain from any source. b. Morphine and a non steroidal anti inflammatory drug together would get the best results with the least side effects. c. A non steroidal anti 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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36 Appendix B: Demographic Data Form Demographic Data Form 1. Age: __________ 2. Gender: __________ 3. Ethnicity: o Hispanic or Latino o Not Hispanic or Latino 4. Race o American Indian/Alask an Native o Asian o Native Hawaiian/Pacific Islander o Black or African American o White or Caucasian 5. Please select number of years practicing as a registered nurse. o 3 years or less o 4 7 years o 8 11 years o 12 15 years o 16 19 years o 20 years or > 6. Indicate highest lev el of nursing education that applies. o Associate Degree o BSN o MSN o PhD o Other _______________ 7. Indicate certifications that apply. o Oncology Certified Nurse o Advanced Oncology Certified Nurse Practitioner o Other (no abbreviations please)_______________________ 8. Pl ease indicate work/practice setting. o Inpatient o Outpatient o Home Care o Research o Consultation o Education o Nursing Home o Retired o Other: (Specify)____________________ 9. Do you provide care to oncology patients? o Yes o No If Yes, what percentage of your time is spent pr oviding direct patient care? _____

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37 Appendix C: Letter of Approval: Nature Coast Chapter ONS

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38 Appendix D: Letter of Approval: Greater Tampa Chapter ONS

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39 Appendix E: Letter of Approval USF Institutional Review Board

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