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Evaluating knowledge and attitudes of graduate nursing students regarding pain

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Title:
Evaluating knowledge and attitudes of graduate nursing students regarding pain
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English
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Jackson, Eric Bartholomew
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University of South Florida
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Evaluation
Graduate Students
Nursing Students
Pathophysiology
Dissertations, Academic -- Nursing -- Masters -- USF   ( lcsh )
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Summary:
ABSTRACT: ABSTRACT Insufficient pain management continues to be problematic for hospitalized patients throughout the country. It significantly interferes with a person's quality of life making it an issue of great concern to nurses in any setting. However, nurses do not do a good job of managing pain. The purpose of this evaluation was to assess graduate nursing students' knowledge and attitudes toward pain management. Forty (n=40) graduate nursing students were asked to participate in the evaluation. All students agreed and completed the Demographic Data Form, Nurses Attitude Survey and the Pain Management and Principles Assessment. Thirty-eight females and two males participated in this study. The mean age was 35 years old (SD=9.77) with a range between 24 and 62. The majority of the participants were Non-Hispanic white (70%), followed by African American (10%), Hispanic (10%), Asian and others. The mean years of nursing experience was 10 years with a standard deviation 7.31. The data showed that nursing students demonstrated inadequate knowledge regarding pain management. The mean score on the PMPAT was 66% (SD= 3.61). The mean score on the Nurse Attitude Survey was 77 (SD=5.8) on a survey with scores that could range from 25 to 100. The higher the score the more favorable that nurse is towards pain management. The scores ranged from 69 to 91. Knowledge and attitude scores had room for improvement, suggesting that the curriculum of the college could be improved. In addition, continuing education courses could be developed to support nurses' knowledge of pain management.
Thesis:
Thesis (M.S.)--University of South Florida, 2011.
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Includes bibliographical references.
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Mode of access: World Wide Web.
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by Eric Bartholomew Jackson.
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Document formatted into pages; contains 43 pages.

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ABSTRACT: ABSTRACT Insufficient pain management continues to be problematic for hospitalized patients throughout the country. It significantly interferes with a person's quality of life making it an issue of great concern to nurses in any setting. However, nurses do not do a good job of managing pain. The purpose of this evaluation was to assess graduate nursing students' knowledge and attitudes toward pain management. Forty (n=40) graduate nursing students were asked to participate in the evaluation. All students agreed and completed the Demographic Data Form, Nurses Attitude Survey and the Pain Management and Principles Assessment. Thirty-eight females and two males participated in this study. The mean age was 35 years old (SD=9.77) with a range between 24 and 62. The majority of the participants were Non-Hispanic white (70%), followed by African American (10%), Hispanic (10%), Asian and others. The mean years of nursing experience was 10 years with a standard deviation 7.31. The data showed that nursing students demonstrated inadequate knowledge regarding pain management. The mean score on the PMPAT was 66% (SD= 3.61). The mean score on the Nurse Attitude Survey was 77 (SD=5.8) on a survey with scores that could range from 25 to 100. The higher the score the more favorable that nurse is towards pain management. The scores ranged from 69 to 91. Knowledge and attitude scores had room for improvement, suggesting that the curriculum of the college could be improved. In addition, continuing education courses could be developed to support nurses' knowledge of pain management.
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Evaluating Knowledge and Attitudes of Gr aduate Nursing Students Regarding Pain Management by Eric B. Jackson A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science College of Nursing University of South Florida Major Professor: Susa n C. McMillan, Ph.D. Alice R. Boyington, Ph.D. Cindy Tofthagen, Ph.D. Date of Approval: April 11, 2011 Keywords: Evaluation, Nursing Students, Gr aduate Studies, Health Assessment, Pathophysiology Copyright 2011, Eric B. Jackson

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Acknowledgements I would like to express my sincere appreciation to Dr Susan McMillan and Dr. Cindy Tofthagen, who worked tirelessly with me on making this possible. You have both been wonderful mentors and I thank you for be ing patient with me throughout this whole process. I will always be grat eful for your assistance and support. A very special thanks also to Alice R. Boyington for being on my committee and giving me your expertise and insight on pain management. Special thanks to Dr. Linda Steele for allowing me to use her class time to conduct my study. Lastly, to Melissa Leggatt, thank you so very much for all your assistance with my statistics and formatting.

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i Table of Contents List of Tables ................................................................................................................ ...... ii Abstract ...................................................................................................................... ........ iii Chapter I – Introduction ...................................................................................................... .1 Statement of the Problem .........................................................................................2 Evaluation Question .................................................................................................3 Definition of the Terms ............................................................................................3 Significance of the Study .........................................................................................4 Chapter II – Review of the Literature ..................................................................................5 Knowledge ...............................................................................................................5 Attitudes ...................................................................................................................9 Summary of Literature ...........................................................................................10 Chapter III – Methods ........................................................................................................1 2 Sample....................................................................................................................12 Instruments .............................................................................................................12 Nurses Attitude Survey ..............................................................................13 Validity and Reliability ..............................................................................13 Pain Management and Principles Assessment Test ...............................................13 Demographic Data Form........................................................................................14 Procedures ..............................................................................................................14 Data Analysis .........................................................................................................14 Chapter IV – Results, Discussion, and Conclusion ...........................................................16 Results ....................................................................................................................16 Knowledge Test Scores..............................................................................17 Attitude Scores ...........................................................................................19 Discussion ..............................................................................................................20 Conclusion .............................................................................................................22 References .................................................................................................................... ......24 Appendices .................................................................................................................... .....28 Appendix A: Pain Management Pr inciples Assessment Test ................................29 Appendix B: Nurses Pain Mana gement Attitude Survey ......................................35 Appendix C: Demographic Data Sheet ..................................................................38

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ii List of Tables Table 1. Frequency and Percent of Students by Ethnicity and Gender.............................16 Table 2. Means and Standard Deviat ion for Students’ Age and Years of Experience in Nursing .........................................................................................17 Table 3. Frequency and Percent of Stude nts Passing Each Item of the PMPAT ..............17 Table 4. Mean and Standard Devi ation on Nurse Attitude Survey ...................................19

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iii Abstract Insufficient pain management continue s to be problematic for hospitalized patients throughout the country. It significantly interferes with a person’s quality of life making it an issue of great concern to nurses in any setting. Howe ver, nurses do not do a good job of managing pain. The purpose of th is evaluation was to assess graduate nursing students’ knowledge and attit udes toward pain management. Forty (n=40) graduate nursing students were asked to participate in the evaluation. All students agreed and completed the Demogr aphic Data Form, Nurses Attitude Survey and the Pain Management and Principles Assessment. Thirty-eight females and two males participated in this study. The mean age was 35 years old (SD=9.77) with a range between 24 and 62. The majority of the partic ipants were Non-Hispanic white (70%), followed by African American (10%), Hispanic (10%), Asian and others. The mean years of nursing experience was 10 years with a standard deviation 7.31. The data showed that nursing student s demonstrated inadequate knowledge regarding pain management. The mean score on the PMPAT was 66% (SD= 3.61). The mean score on the Nurse Attitude Survey was 77 (SD=5.8) on a survey with scores that could range from 25 to 100. The higher the sc ore the more favorable that nurse is towards pain management. The scores ranged from 69 to 91. Knowledge and attitude scores had room for improvement, suggesting that the curriculum of the college could be improved. In addition, continuing education courses could be developed to support nurses’ knowledge of pain management.

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1 Chapter I Introduction Insufficient pain management continue s to be problematic for hospitalized patients throughout the country. Pain is an unpleasant emotional or sensory experience associated with actual or potential damage to the tissues (International Association for the Study of Pain Subcommittee on Taxonomy, 1994,pp 209-213). Pain is the most common reason for physician consultation in the Un ited States (Turk 2004). It significantly interferes with a persons’ quality of life (Brevick 2008) ,making it an issue of great concern to nurses in any setting. Cancer pa in is believed to have five dimensions, including sensory (pain intensity), aff ective (unpleasantness) behavioral (pain behaviors), cognitive (pain beliefs), and physiologic (imp act on physical and social functioning) (Ahles, Blanchard & Ruckdesc hel, 1983).The incidence of pain in hospitalized patients with cancer is 38% to 73%. Incidences tend to be higher when reported directly from the patients. (McMil lan, Tittle, Hagan, Laugh lin, et al 2000).At any given time, one in two Americans are in pa in and one out of four has persistent or chronic pain. Leading causes of recurrent or persistent pain affecting Americans are headache pain, back pain, and neck pain. About four in 10 Americans say pain interferes with their mood, activities, sleep, ability to do work or enjoyment of life. Two-thirds report interference with any one of these ( Stewart, Ricci,Chee ,Morganstein and Lipton 2003).

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2 Statement of the Problem Pain is a significant problem in all patients and a special problem in cancer patients. However, nurses may not do a good job managing pain. This may be due to inadequate knowledge related to pain. Also, nurses may harbor attitudes that are not conducive to good pain management. Students enter nursing programs with preconceived misconceptions regarding pain management, and some practicing nurses continue to hold on to these notions rega rdless of training (Plaisance & Logan, 2006). The combined lack of nursing training and preconceived misconceptions regarding pain management seriously hinders nurses’ ability to properly manage pain (McCaffery and Ferrell 1996). Very few studi es regarding pain management focus on nurses who have had advanced training in the areas of pha rmacology and physical assessment (Plaisance & Logan, 2006). Therefore the purpose of th is evaluation was to examine the knowledge and attitudes of graduate nursing students who have had advanced courses in pharmacology and physical assessment that included pain assessment management content. Many nurses lack the education and training for effectively managing pain, resulting in longer hospital stays and reduci ng the quality of life of patients. This knowledge deficit is glaringly obvious in our educational programs and is also demonstrated by practicing nurses (Plaisance & Logan, 2006). Evaluation Question The following evaluation questions are addressed in this study: 1. What is the level of knowledge of pain management possessed by nursing students at the graduate level? 2. What are graduate nursing students’ attitudes towards pain management?

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3 Definitions of the Terms For purposes of this evaluation, the following terms are defined: 1. Pain: Pain is an unpleasant emotional or sensory experience associated actual or potential damage to the tissues (Internat ional Association for the Study of Pain Subcommittee on Taxonomy, 1994,pp 209-213). 2. Knowledge: Comprehension of facts, ideas, and information, gained through experience, instruction, and learning for a distinct use (Merriam-Webster Online Dictionary, 2009) 3. Pain Attitudes: A persisting set of beliefs and values that aff ect how one responds or reacts when pain is involved (McMilla n, Tittle, Hagan, Laughlin, & Tabler, 2000). 4. Pain Management: Pain Management encompasses all interventions used to understand and ease pain, and alle viate the origin of the pain according to the American Pain Society Quality of Care Task Force, (2005). Significance of the Study This evaluation may shed light on the attit udes of graduate nursing students in this college towards pain management. It is the hop e of the evaluator that all scores are very near 100, which would indicate an overall favor able response towards pain management. The examination gives researchers as well as faculty an actual baseline of graduate student’s knowledge of pain management. Again, researchers hope the mean will be a passing score of at least 80 pe rcent. Results may provide information about areas of strengths and weakness regard ing pain management knowledge. It may also help influence curriculum change and illuminate the need for pain management to be included in more conference presentations and contin uing education seminars. Results also may

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4 possibly inspire more research in this area th at could include more students and different schools. Evaluators hope to inspire students a nd faculty to seek further information in regards to pain management than what presented in the text.

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5 Chapter II Review of the Literature The purpose of this chapter is to present th e review of the rele vant literature. The literature identifies numerous impediments to effective pain management and, therefore demonstrates their impact on patient outco mes. Barriers analyzed include, knowledge deficits and negative attit udes of nurses possibly stemmi ng from preconceived notions regarding pain management. A study conducted by McCaffery, Ferrell and Rhiner (1992) surveyed fourteen major textbooks used as st andard references in medical-surgical and pharmacology courses. They found 1.6% of th e total textbook pages were devoted to pain content. Also, commonly used pain te rminology such as addiction, dependence, and tolerance were seldom mentioned in chapters on pain management. Knowledge It is well documented that pain assess ment and pain management are integral parts of the nursing care give n to patients. In a study by Rahimi-Madiseh, Tavakol and Dennick, (2010) investigators sought to qua ntify the current know ledge and attitudes toward pain of nursing students in Iran. Th ey conducted a cross-se ctional study using a well-validated questionnaire entitled the Knowledge and Attitudes Regarding Pain Tool The results showed severe knowledge deficit relating to pain and its management. It suggested a real need for improving the c ontent of pain and management in the undergraduate nursing edu cation curriculum. The presence of pain is one of the most common reasons people seek physicians for care, and it continues to be undertreated. Inadequate pain management is linked to

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6 nurse’s failure to assess pain and to interven e at the appropriate time. It has also been thought to result from a lack of attention paid to pain management in nursing curriculum. In a study conducted by Pliasa nce and Logan (2006) research ers investigated nursing student’s knowledge and attit udes about pain management. This descriptive study used the Knowledge and Attitudes Regarding Pain Tool They collected data from clinical nursing students (n= 313). The study incorpor ated students from the baccalaureate and from the associate degree nursing programs. The study revealed misconceptions about analgesics administration and duration, al ong with an exaggerated fear about the incidence of addiction among patients. The students did better in pharmacology items than non-pharmacology items. Most students re sponded appropriately to scenario based questions. However, when the situation required reassessment based on a patient’s response, the students’ chosen intervention wa s more often incorrect The students in the baccalaureate program scored a bit higher (6 5% correct) than those in the associate degree program (60.8% correct) (t [311] = 3.321, p = .001). Combined their scores were 64% indicating inadequate know ledge of pain management. The authors concluded that despite major initiatives by accrediting agencies, statewide Pain initiatives, and professional organizations, knowledge of pain management remain sub par. Nursing instructors and directors need to critically analyze their curriculum to determine whether students are being taught in-d epth and up-to-date pain ma nagement information that includes evidence based research an d current standards of care. Inadequate nursing education can be more readily seen in patients with cancer. These patients routinely require much more pa in medicine than other acutely ill patients thus further emphasizing the need for accura te and precise intervention from nurses. A

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7 study by Sheehan, Webb, Bower and Einsporn ( 1992) was conducted to identify the level of cancer pain knowledge among baccalaureate student nurses and to determine whether specific activities affect this level of know ledge. Two questionnaires were administered to 82 baccalaureate student nurses in the final semester of their program. Even though the students displayed a realistic pe rspective about the severity an d prevalence of cancer pain and psychological dependence, specific knowledge deficits and negative attitudes suggest the possibility of inadequate pain manageme nt. Some specifics in cluded were: students believed the maximal analgesic therapy shoul d be delayed until the prognosis was less than 12 months, the proportion of patients w hose pain can be cont rolled by appropriate therapy is less than is possibl e, increasing pain is related to tolerance rather than to progression of the diseases, the preferred rout e of administration is intravenous rather than oral, and the degree of respiratory de pression, rather than constipation does not decrease with repeated administration. Si gnificant positive correlations (p
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8 content. The researchers hoped to determine the baseline knowledge and attitudes of nursing students and faculty a bout the science of pain mana gement and to evaluate the content of pain management and the extent to which it is integrated into the curriculum. The results from the survey revealed ga ps in their understanding of the use of meperidine, pain experienced during sleep a nd believing patients se lf-reports of pain. Other areas in need of improvement were the incidence of respiratory depression, equianalgesic conversions and the use of placebos. Ultimately these investigators concluded student’s knowledge and attitudes improved as they progressed through the program, but there were many areas in which the minimal acceptable scores were not met. It is imperative that the faculty take a strategic approach to educa ting nursing students about pa in management and related issues. Nurses have a key role in effective pain management: The nurse’s accurate assessment, prompt intervention, and evaluation of pain relief measures are necessary for positive patient outcomes (Ersek & Poe, 2004). Inad equate pain relief has been attributed to many factors, including unwarranted pati ent fears and concerns about analgesia and clinicians’ inability to ade quately assess and manage pain (APS, 2003). The literature suggests that inadequate pain relief may also stem from nurses’ acknowledgment that a main source of pain management informa tion was nursing school (Clark et al. 1996). Although many nurses in those studies rate their knowledge as adequate, their mean scores on knowledge and attitude surveys did not reflect curren t knowledge of pain management practices.

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9 Two thirds of sample of nursing studen ts (n=32) were unable to complete a systematic pain assessment. Intensity of pain was the most frequently identified dimension, and approximately one half of the students re-evaluat ed the effect of suggesting pain-relief interventions. Mostly th e students were insufficient in the area of pain assessment (Lofmark, Gustavasson, a nd Wikblad 2003). Another study conducted in the United Kingdom involving entry level nursing students showed that they exhibited an unrealistic or exaggerated fear of patient’s risk of addiction when analgesia was prescribed for routine treatme nt (Allcock & Toft, 2003). A lack of knowledge of pharmacology was also noted in a study involving last year nursing students in Australia and Philip pines. A total of 150 students in three schools of nursing were surveyed to assess their knowledge of pain mechanisms and basic treatment principles. (Chui, Trin ca, Lim and Tuazon, 2003) They concluded students had insufficient knowledge about ba sic pain mechanisms, complex regional pain, and the management of chronic, noncan cerous pain. However, most students rated the undergraduate exposure to pain management as insufficient. Attitudes A study by McCaffery and Ferrell (1996) compared practicing nurses and nonnursing college student’s decisions about pain assessment and use of analgesia (n=85). They concluded that college students had several misconceptions about pain management. College students were less likel y to increase an analgesic dosage than practicing nurses when faced with a scenario involving a patient in pain. Students also reported greater concerns about the risk of a ddiction than practicing nurses. These finding were a complete surprise to the researcher s. They anticipated th at the students would

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10 have no strong beliefs towards pain mana gement. These findings support the argument that students enter schools of nursing with strong preconceived mi sconceptions towards pain management. A study conducted by McMi llan, Tittle, Hagan, and Small (2005) was designed to determine the cha nges in knowledge and attitude s of pain resource nurses (PRNs) as a result of an intensive pain ma nagement course. Researchers used a pain survey to assess attitudes of nurses towards patients in pain. Only after post-test instructions did the students s how impressive item gains on the instrument that measures attitudes towards patients in pain. The majority of the items show an increase in the number of PRNs who answered correctly or in a positive direction. Scores on the survey regarding general pain management attitude s were discouraging. The mean score was slightly lower for the PRNs on the pre-test (X=66.6) than for the staff nurses (X=71.8). Summary of the Literature Evidence from the past decade reveals nursi ng education itself has been a barrier to effective pain management (Goodric h, 2005). Nursing students have knowledge deficits related to cancer pain and were not prepared to develop holistic care plans for pain management (Sheehan,Webb, Bower, Ei nsporn, 1992). Resear ch indicates that healthcare providers, including nurses, may not be well prepared in pain management because of deficiencies in nursing and medical curriculum as well as some healthcare providers’ prevailing negative attitudes towards patients’ response to pain (Lasch, Greenhill, Wilkes, Carr, Lee, Blanchard 2002) Although pain management is important to delivering comprehensive patient care, nursing students do not have a sound knowledge base. A fundamental lack of knowledge at the unde rgraduate level may negatively influence continued learning about pain when nurses begin to practice. New

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11 graduates may not appreciate how complicated pain management is and may not realize they are ignorant about pain as a scie nce (Chiu, Trinca, Glim, Tauzon, 2003).Results from a survey questionnaire showed there wa s a severe deficit in knowledge related to pain and its management. It is argued that there is real n eed for improving the content of pain and its management in the undergra duate nursing education and curriculum (Rahimi-Madiseh, 2010). Despite major initia tives by accrediting agencies, management is still inadequate. Nursing faculty need to cr itically review their curriculum to determine whether students are being taught in depth and up to date in formation that incorporates evidence based research a nd current standards of car e (Plaisance & Logan 2006).

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12 Chapter III – Methods In this chapter the methods of the study are presented. This includes the characteristics of the sample such as the in clusion criteria for pa rticipation, variables under investigation and a descri ption of the instruments of measurement used to collect data. In addition, the procedures for data collection and the method of analysis also are discussed. Sample For the purpose of this evaluation, the targeted population is Masters nursing students having completed advanced courses in physical assessment or pharmacology. The sample consisted of 40 graduate nursi ng students. These students were currently pursuing Masters of Science degree at the University of South Florida. Oncology students who have had the required sympto m management courses were excluded. Instruments The instruments that were utilized in th is study were the Nurse’s Attitude Survey (NAS) (McMillan, Tittle, Hagan, Laughlin, a nd Small 2000) and the Pain Management Principles Assessment Tool (PMPAT)(McM illan, Tittle, Hagan, Laughlin, and Small 2000), in addition to a demographic data questio nnaire. Both tools were chosen as they clearly distinguish between knowledge defici ts and attitudinal barriers in pain management, which make them appropriate for the evaluation.

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13 Nurses Attitude Survey. The NAS, created by McMillan and colleagues (2000), is a 25-item instrument, which uses a four-point Likert -type format to assess attitudes toward pain management. Responses for the in strument can range fr om strongly disagree to strongly agree, with item scores varyi ng from 1 to 4 for each item. The higher the score, the more positive att itudes nurses have. The survey includes items on scheduling analgesics, use of opiates, pain assessment, goals of pain assessment, and misconceptions about pain management and non-phar macologic management of pain. Validity and reliability. Internal consistency was found using Cronbach’s alpha (r=0.70), which was adequate. Validity was al so demonstrated by a significant difference (p<. 01), from pre-test to post-test among nursing students. Pain Management and Princi ples Assessment Test The Pain Management and Principles Assessment Test(PMPAT) is a 31-item multiplechoice test with four response choices per question. The questionnaire was designed to test pain management knowledge regarding physiology, pharmacology, characteristics of pain management such as addiction, physical dependence, tolerance, and principles of assessment and management. Scores for the survey ranged from 0-31 or 0 to 100%, with higher scores meaning mo re questions were answered correctly (McMillan, Tittle, Hagan, Laughlin, & Small 2000). The PMPAT was designed based on a blue print from previous research studies attesting to its content va lidity (McMillan, Tittle, Ha gan, Laughlin, and Small 2000). Validity of the instrument was also test ed using a pre and posttest method among 28 nursing students before and after a three hour pain management course. Scores were found to be significantly improved from pr e to post test (t=6.76, p<0.01) supporting

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14 validity. Test-retest re liability was also discovered to be significantly high (r= 0.84, p=0.00). Demographic Data Form Each participant was also asked to comp lete a demographic data form. The form incorporates questions on age, gender, ethnicity, how many semesters had been completed in the MS program at USF, sp ecialty concentration, work experience and current work status a nd any additional traini ng in pain management. Procedures The students were approached during class a nd invited to participate. Prior to the administration of the questionnaires, the in structor was asked to leave the classroom, while the investigator remains in the room to supervise th e study, distribute the surveys as well as collect them. A brief explanation will be given regardi ng the evaluation, noting that there were no risks or benefits to part icipants for taking part in the study. Students were given the opportunity to ask relevant questions regarding the evaluation. Finally, students were asked to carefully read the instructions given and work individually on their questionnaires without the aid of textbooks or colleagues. The forms were returned to the investigator and the students’ pa rticipation in the study was finished. Data Analysis Demographic data were analyzed to desc ribe the sample. Analysis included means, standard deviations, fr equencies and percentages. Evaluation question one asks: “What is the level of knowledge of pain management possessed by nursing students at the graduate level?” To answer this question, means and standard devi ations were calculated.

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15 Evaluation question two asks: “What ar e graduate nursing students’ attitudes towards pain management?” To answer th is question, means and standard deviations were calculated.

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16 Chapter IV Results, Discussion and Conclusion The following chapter presents the findings of this evaluation. First the sample is described and then the evaluation question is addressed and the results are shown in a table format, and then discussed. Results Forty (n=40) graduate nursing students were asked to participate in the evaluation. All students agreed and completed the demogr aphic data form, Nurses Attitude Survey and the Pain Management and Principles Asse ssment Test. Thirty eight females and two males participated in this evaluation (N=40). The mean age was 35 years old (SD=9.77) with a range between 24 and 62. The majorit yof the participants were Non-Hispanic white (70%), followed by African American ( 10%), Hispanic (10%), Asian and others (Table 1). The mean age was 34.7 with a sta ndard deviation of 9.8. The mean years of nursing experience was 10 years with a st andard deviation of 7.31 (Table 2). Table 1 Frequency and Percent of Students by Ethnicity and Gender. Variable Frequency Percent Ethnicity Non-Hispanic White 28 70 African American 4 10 Hispanic 4 10 Asian 2 5 Other 2 5 Gender Female 38 95 Male 2 5

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17 Table 2 Means and Standard Deviations for Student’s Age and Years of Experience in Nursing Variable N Mean Standard Deviation Age 40 34.7 9.8 Years of Experience 40 10 7.31 Knowledge test scores. The average score on the PMPAT exam was 66% with a standard deviation of 3.61. Scores ranged from30-95%. Table 3 Frequency and Percent of Students Passing Each Item of the PMPAT Knowledge Item Frequency Percent Nursing action if the patient continu es to have pain after receiving the maximum ordered dose of analgesics 38 95 Helping patients who are afraid of opioids 36 90 The most accurate and reliable judge of the intensity of the cancer patient’s pain 35 87.5 Who should have the most control ov er the patient’s pain management regimen 35 87.5 Using distraction for pain management 35 87.5 Managing both cancer and non-cancer-related pain 35 87.5 Prostatic cancer has spread to a patient’s bones. In planning for his care, the primary factor to consider is quality of life. 35 87.5 Define tolerance 35 87.5 The percentage of cancer patients who suffer pain at some point during their illness 34 85 Differentiate the following: physical dependence, tolerance, decreases in level of analgesic in the blood, and addiction. 33 82.5 Primary benefit of providing steady state analgesia 32 80

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18Knowledge Item Frequency Percent Take into account which variables that affect the expression of pain 30 75 Symptoms of chronic pain 29 72.5 Giving appropriate doses: physic ians under-prescribe and nurses undermedicate 29 72.5 The action of naloxone 26 65 The preferred route of administration of narcotic analgesics for cancer patients 25 62.5 Principles underlying analgesic administration for persons with cancer pain 27 62.5 Characteristics of acute pain 24 60 Meperidine toxicity 24 60 Ninety percent of cancer patients suffer pain 23 57.5 All intensities of pain can be treated with cutaneous stimulation 23 57.5 Steady state analgesia methods 23 57.5 Duration of action of analgesic drugs 22 55 Mechanisms of action of analgesics 22 55 Physiology: Pain modulated by what? 19 47.5 Percent of patients receiving opiate analgesics around the clock who become addicted 19 47.5 When a patient having pain due to cancer is receiving analgesic medication on a PRN basis, level of discomfort when patient should request additional pain medication 17 42.5 Physiology: Nerve fibers -Dull and aching pain 15 37.5 Gate Control Theory 15 37.5 Pain management goals for patients 13 32.5 Basis for a nursing decision to administer pain medication 12 30

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19 Attitude scores. The mean score on the Nurse Attitude Survey was77 (SD=5.8) on a survey with scores that could range fr om 25 to 100. The higher the score the more favorable that nurse is towa rds pain management. The scor es ranged from 69 to 91(Table 4). Table 4 Means and Standard Deviations on Nurse Attitude Survey Attitude Item Mean Standard Deviation Continuous assessment of pain and medication effectiveness is necessary for good pain management. 3.7 .42 The level of discomfort when a patient should request additional pain medicationwhen having pain due to cancer and receiving analgesics PRN. 3.4 .64 Estimation of pain by a MD or RN is a more valid measure of pain than patient self report. 3.4 .64 Patients (and/or family members) may be hesitant to ask for pain medications due to their fears about the use of narcotics. 3.3 .56 Distraction and diversion of patie nt’s attention (use of music, relaxation) can decrease the perception of pain. 3.3 .48 A patient should experience discomfort prior to getting the next dose of pain medication. 3.3 .64 Giving narcotics on a regular schedule is preferred over a prn schedule for continuous pain. 3.2 .77 If a patient continues to have pa in after receiving pain relieving medication(s), the nurse should contact the physician. 3.2 .46 Lack of pain expression does not necessarily mean lack of pain. 3.2 .57 A constant level of analgesic should be maintained in the blood to control pain effectively. 3.1 .49 The nurse can make a more accurate assessment of the patient’s pain than the patient/family can. 3.1 .69 Patients receiving narcotics around the clock for cancer pain are likely to become addicted. 3.0 .61 Cancer pain can be relieved with appropriate treatment with anticancer drugs, radiation therapy and/or pain relieving drugs. 3.0 .55 Patients in pain can tolerate high doses of narcotics without sedation or respiratory depression. 2.9 .97

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20Attitude Item Mean Standard Deviation Patients can be maintained in a pain free state. 2.9 .61 Patients with chronic pain should receive pain meds at regular intervals with or without the presence of discomfort. 2.9 .69 Patients having severe chronic pain need higher dosages of pain meds compared to acute pain. 2.9 .87 Patients should be maintained in a pain-free state. 2.9 .73 Patients receiving narcotics on a PRN basis are more likely to develop clock-watching behaviors. 2.8 .81 Patients receiving around the clock narcotics are at risk for sedation and respiratory depression. 2.8 .82 Increasing analgesic requirements and physical symptoms are signs that the patient is becoming addicted to the narcotic. 2.8 .64 Cutaneous stimulation (e.g. heat, massage, ice) are only effective for mild pain. 2.8 .64 Patients (and/or family members) have a right to expect total pain relief as a goal of treatment. 2.75 .89 If a patient (and/or family member) reports pain relief and euphoria, the patient should be given a lower dose of the analgesic. 2.7 .76 The cancer patient and family should have more control over the schedule for analgesics than th e health professional. 2.7 .65 The most negative attitude s expressed by these gradua te nursing students involved whether the patient and family should have control over the pain management regimen, and whether pain relief and euphoria are undesira ble. Also low were if patients (and/or family members) have a right to expect total pain relief as a goal of treatment. Discussion The sample size of this evaluation is forty (n=40) with only two of the participants being male. This is one limita tion of the evaluation because males make up 20 percent of the nursing students in the USF nursing program. The average years of experience were ten years; this large nu mber of reported years of experience was

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21 important to the study. Evaluators sought to survey nurses with experience as well as nurses who had taken gradua te level nursing courses. The average score on the PMPAT was 66% with a standard deviation of 3.61. This is well below a failing average for gradua te nursing students. Some of the areas that were most frequently missed were knowledge based questions that should alert the USF nursing faculties to their shor tcomings in the curriculum. Questions like: The action of naloxone, Principles underlying analgesic ad ministration for persons with cancer pain, Steady state analgesia methods, and Meperidine toxicity had a less than 60 percent pass rate. Students did much better in physiology and planning; these were assessmentbased questions, which could be indicative of the high average of years of experience the group reported. But with an overall score of 66%, outcomes were much lower than expected which suggests a glaring weakness in the College of Nursing’s curriculum as far as pain management is concerned. Given the high mean of reported number of years of experience, these nurses should have had a w ealth of experience managing pain. These results suggest that some of th ese nurses were doing it badly. The mean score on the Nurse Attitude Survey was 77 (SD=5.8) on a survey with scores that could range from 25 to 100. The higher the sc ore the more favorable that nurse is towards pain management. The scores ranged from 69 to 91.This score represent a marginally favorable attitude towards pain management. Again these results were surprising based on the amount of years of experience thes e nurses reported.

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22 Conclusion This evaluation supports the importance of addressing pain management education and attitudes of those individuals that are directly responsible for pain management. Attitudes of nurses directly affect patient care and outcomes. Pain management education evaluation is a direct indication of how patient pain management will be managed. In this evaluation, participan ts indicated an overall favorable attitude towards pain management but failed miserabl y in the area of basic principles of pain management. This is one of the glaring reas ons why pain management continues to be problematic for patients in this country. The re sults of this survey support the conclusions of many other studies referen ced. For instance, Plaisance & Logan (2006) concluded that many nurses are deficient in pain management education and training therefore leading to longer hospital stays and poor patient outcomes. The participants in this study had an average of 10 years of nursing experience a nd three nurses had over thirty years. Every participant in this study had completed an undergraduate course in pharmacology and a graduate course in pharmacology. All were currently in the last phases of a graduate level health assessment course. Pharmacology wa s the area with most glaring weakness, whereas planning seemed to be the groups’ strongest knowledge base. In conclusion, it pleasing to know nurses have a overall favorable attitude to wards pain management but more emphasis but be placed on the understandi ng of the most fundamental concepts of pain management. Given that patients are having shorter hospi tal stays, it is unfortunate that nurses seemed to believe they should have more c ontrol over the pain management regimen than patients and families. Also, it is disturbing that nurses do not believe patients have the

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23 right to expect total pain reli ef as a goal of treatment. Cutaneous stimulation (e.g. heat, massage, ice) would possibly be utilized mo re if nurses believed it is effective for moderate to severe pain.

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24 References Ahles, T.A., Blanchard, E.B., & Ruckdesche l, J.C. (1983). The multidimensional nature of cancer-related pain. Pain, 17, 277-288. American Pain Society recommendations fo r improving the quality of acute and cancer pain management: American Pain Societ y Quality of Care Task Force. (2005). Archives of Internal Medicine, 165, 1574-1580. Bonica, J.J. (1978) Cancer Pain: A major National health problem. Cancer Nursing, 1, 313-316 Breivik H, Borchgrevink PC, Allen SM, Rosseland LA, Romundstad L, Hals EK, Kvarstein G, Stubhaug A. Assessment of pain. Br J Anaesth. 2008;101(1):17–24. Chuk, P. (2002) Determining the accuracy of pa in assessment of senior student nurses: A clinical vignette approach, Nurse Education Today22, 393-400. Clark, E. B., French, B., Bilodeau, M. L., Capasso, V. C., Edwards, A., & Empolito, J. (1996). Pain management knowledge, attit udes and clinical pr actice: The impact of nurses’ characteristics and education. Journal of Pain and Symptom Management, 11(1), 18-31 Cleeland, S., Gonin, R., Hatfie ld, J., Edmonson, R., Blum, R. Stewart. J., Pandya, K. (1994). Pain and Its Treatment in Ou tpatients with Metastatic Cancer. New England Journal of Medicine, 330: 592-596

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25 Erkes, E.B., Parker, V. G., Carr, R.L., & Ma yo, R. M. (2001). An examination of critical Care nurses knowledge and attitudes regard ing pain management in hospitalized patients. Pain Management Nursing, 2(2), 47-53 Ersk, M., &Poe, C.M. (2004). Pain. In S. Lewi s, M. Heitkemper, & S. R. Dirksen (Eds.), Medical-surgical nursingassessment and management of clinical problems (pp. 131-159). St Louis: Mosby Hamilton J & Edgar L. (1992) A survey examin ing nurses’ knowledge of pain control. Journal of Pain and symptoms Management 7, 18-26 Hirsh, A., Jensen, M., Robinson, M., (2010). Ev aluation of Nurses’ Self-Insight Into Their Pain Assessment and Treatment Decisions. The Journal of Pain, Vol 11, No 5 International Association for the Stud y of Pain Subcommittee on Taxonomy.(1986). Classification ofchronicpain:Descript ionsofchronic painsyndromesanddefinitions ofpainterms. Amsterdam:Elsevie Lasch, K., Greenhill, A., Wilkes, G., Carr, D., Lee, M., & Blanchard, R. (2002). Why study pain? A qualitative analysis of medical and nursing faculty and students knowledge of and attitudes to cancer pain management. Journal of Palliative Medicine, 5(1), 57-71. Lofmark, A., Gustavsson, C., & Wikblad, K. (2 003). Student nurses’ ability to perform Pain assessment. Nursing Education in Practice, 3(3), 133-143 McCaffery, M., & Ferrell, B. R. (1996) Correcting misconcep tions about pain Assessment and use of opiod analgesics: Education Strategies aimed at public concerns. Nursing Outlook, 44(4), 184-190

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26 McCaffery, M., & Ferrell, B. R. (1997). Nurses’ knowledge about cancer about cancer Pain assessment and management: Ho w much progress have we made? Journal of pain and Symptom management, 7, 478-484 McMillian, S., Tittle, M., Hagan, S., Laugh lin, J., Tabler, R. (2000). Knowledge and Attitudes of Nurses in Veterans Hospitals about Pain management in patients with Cancer : Oncology Nursing Forum, Vol 27, No 9 McMillian, S., Tittle, M., Hagan, S., Laughlin, J., (2000). Management of Pain and Pain Related symptoms in Hospitalized Veterans with Cancer: Cancer Nursing, Vol. 23, No.5 McMillan, S., Tittle, M., Hagan, S., Laugh lin, J., Small, B., (2005). Training Pain Resource Nurses: Changes in their knowledge and attitudes. Oncology Nursing Forum, Vol 32, No 4 Owens,K. (2000). Effects of nursing educat ion on students’ pain management Knowledge. Nurse Educator, 25(1), 33, 37. Pasero, C,. & McCaffery, M.( 2004). Comfort-function goals. American Journal of Nursing, 104(9), 77-78& 81 Plaisance, L., Logan, C. (2006) Nursing St udents’ Knowledge and Attitudes Regarding Pain: Pain Management Nursing, VOL, No 4, pp 167-175 Rahimi-Madiseh, M., Tavakol, M., Dennick, R. (2010) A quantitative study of Iranian nursing students’ knowledge and attitude s towards pain: Implication for education. International Journal of Nursing Practice, 16(5): 478-83 Sheehan DK, Webb A, Bower D, Einsporn R. Level of cancer pain knowledge among baccalaureate student nurses. J Pain Symptom Manage 1992;7:478-484.

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27 Stewart, W. F., Ricci, J. A., Chee, E., Morganstein, D., & Lipton, R. (2003). Lost productive time and cost due to common pain conditions in the US workforce. JAMA: The Journal of the American Medical Associati on, 290(18), 2443-2454. Ward, S., Gordon, D. (1996). Patient satisfaction and Pain Severity as Outcomes in Pain Management: A longitudinal view of one settings experience. Journal of Pain and Symptom Management, Vol 11 No. 4 Wilson, B. (2007). Nurses’ knowledge of pain: Journal of Clinical Nursing, 16, 10121020

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28 Appendices

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29 Appendix A: Pain Management Principles Assessment Test PAIN MANAGEMENT PRINCI PLES 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 suffers pain at some point during their illness? a. 10% b. 30% c. 60% d. 90% 2. What percentage of cancer patients 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 pain af ter 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 narcotics to the patient/family. c. Reassure the patient that the medication will work. d. Call the physician. 4. The preferred route of admini stration of narcotic analgesi cs 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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30 The most accurate and reliable judge of the inte nsity of the cancer pati ent’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 6. What percentage of patien ts receiving opiate analgesi cs around the clock become addicted? a. Less than 1% b. 5-10% c. 25% d. More than 25% 7. Which of the following statements accurately describe the mechanism of action of analgesics? a. Opiates act in the CNS to decrea se the transmission/perception of pain. b. Narcotics act at the periphery to decrease the transmission of pain. c. Non-narcotics act in the CNS to decrease the transmission/perception of pain. d. Narcotics work by the Gate Control mechanism. 8. Which kind of pain can be treate d with cutaneous stimulation? a. Mild pain only b. Moderate pain only c. Severe pain only d. Any intensity of pain 9. Which of the following statements accu rately reflects principles underlying analgesic administration for persons with pain due to advanced cancer? a. Prolonged administration lead s to tolerance which requires escalating amounts of analgesic to control pain. b. Prolonged administration often re sult in addiction, so drug amounts must be carefully limited in the early stages of the disease. c. Narcotics should be offered on an “as needed” basis to prevent drug dependence. d. Around the clock administration of narcotics (rather than PRN) results in clock-watching in patients and families.

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31 10. 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. Thrashing, grimacing, elevated he art rate, cold and clammy extremities. d. Groaning, elevated blood pre ssure, irritability, sweating 11. Which of the following drugs have the longest duration of action? a. Codeine b. Methadone c. Meperidine d. Morphine 12. Acute pain is frequently 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 temperature 13. Dull and aching pain sensations are the re sponsibility of which of the following? a. A-delta fibers b. C fibers c. Opiate receptors d. Small myelinated fibers 14. According to the Gate Control Theory, 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 15. Pain is modulated by which of the following: a. Opiate receptors mu, gamma, and kappa b. A-delta fibers c. C-fibers

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32 16. Mrs. Colton, a 160 pound female is 24 hours post-op following abdominal hysterectomy. She received a dose of morphi ne sulfate 8 mg IM at 4:00 pm. It is now 6:30 pm and she is complaining of pa in and requesting another injection. Her pain is most likely related to which of the following: 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 addic tion to the analgesic 17. 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 out c. To relieve her pain to a level that she can tolerate d. To provide her complete pain relief 18. 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 will b ecome addicted to narcotics c. His overall quality of life d. The wishes of his family regarding pain relief 19. In assessing the patient’s pain, the nurs e should take into a ccount which of the following variables which may a ffect the expression of pain: a. Environment and social conseque nces of expressions of pain b. Cultural diversity in the ways pa tients express their discomfort c. The observable measurable actions of the patient d. a and b e. a, b, c 20. The action of naloxone is: a. To enhance the effect of narcotic analgesics b. To act as a opiate antagonist c. To act as a narcotic agonist d. To act as a respiratory stimulant 21. Research suggests that: a. Physicians underprescribe and nurses undermedicate for pain b. Physicians prescribe appropria tely and nurses undermedicate c. Physicians underprescribe and nur ses give optimal doses based on those orders d. Physicians prescribe appropr iately and nurses medicate appropriately in the majority of cases

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33 22. One significant disadvantage of meperidine is: a. It is more expens ive 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 23. Which of the following methods of narcot ic administration pr ovides steady state analgesia? a. Patient controlled anal gesia using a pump b. Intravenous drip of opiates c. Intravenous bolus admini stration of narcotics d. Intramuscular injections every two hours 24. The primary benefit of providing steady state an algesia is which of the following? a. It is cost effective because it uses less nursing time b. The patient receives less narcotic overall c. Respiratory depression is less likely to occur d. The patient is more comfortable 25. A nursing decision to administer pain me dication 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 ac tion of narcotic analgesics 26. Who should have the most control over the patient’s pain management regimen? a. The patient b. The family c. The nurse d. The physician e. The pharmacist 27. DEFINITION: After repeated administration of an opiate, a given dose will begin to lose its effectivene ss, resulting in the need fo r larger and larger doses. This begins with decreased duration of analgesia and th en 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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34 28. Mrs. Easton has metastatic breast cancer w ith painful lesions in her spine. She is 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) 29. Another approach you might have tried w ith Mrs. Easton involves concentrating on a task such as needlepoint or a cr ossword puzzle or r eading a favorite book. This is an example of: a. Cutaneous stimulation b. Avoidance c. Distraction d. TLC (tender loving care) 30. Mrs. Sikes is a 72 year old woman with breast cancer which has metastasized to her pelvis. She also has moderately se vere arthritis. Which of the following statements about managing her pain are most likely true? a. Morphine is the drug of choice be cause 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 re lief because of the severity of her disease.

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35 Appendix B: Nurses Pain Ma nagement Attitude Survey NURSES PAIN MANAGEMENT ATTITUDE SURVEY Directions: Circle the response that best describes 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 narcotics on a regular schedule is preferred over a prn schedule for continuous pain. SD D A SA 2. A patient should experien ce 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 narcotics. SD D A SA 6. Patients receiving narcotics 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 narcotics without sedation or re spiratory 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 family member) reports pain relief and euphoria, the patient should be given a lower dose of the analgesic. SD D A SA 11. Patients with chronic pain should receive pain meds at regular intervals with or without the presence of discomfort. SD D A SA

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36 12. Patients receiving around th e clock narcotics are at risk for sedation and re spiratory depression. SD D A SA 13. Patients having severe ch ronic pain need higher dosages of pain meds compared 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 ha ve pain after receiving pain relieving medication(s), the nurse should contact the physician. SD D A SA 18. Patients receiving narcotics 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) can decrease the perception of pain. SD D A SA 20. A constant level of analgesi c 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 narcotic. 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 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

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37 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 discomfort would it first be appropriate for the patient to request additional 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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38 Appendix C: Demographic Data Sheet Demographic Data Form 1. Age range? a. 20-30 b. 31-40 c. 41-50 d. 51 or older 2. Gender? a. Male b. Female 3. Years of nursing experience? a. Less than 1 year b. 1 to 5 years c. 5 to 10 years d. 11 to 20 years e. 20 or more years 4. What is your ethnicity? a. Asian b. African-American c. Hispanic d. Non Hispanic White 5. Pain management training? a. Yes b. No