Nursing staff spend more time with patients with pain than any other health staff member. For this reason, the nurse must possess the basic knowledge to identify the presence of pain in patients, to measure its intensity and make the steps necessary for treatment. Therefore, a prospective, descriptive, analytical, and cross-sectional study was conducted to investigate the knowledge and attitudes regarding pediatric pain in two different populations. The questionnaire, Pediatric Nurses Knowledge and Attitudes Survey Regarding Pain (PKNAS), was applied to 111 hospital pediatric nurses and 300 university nursing students. The final scores for pediatric nurses and nursing students were 40.1 ± 7.9 and 40.3 ± 7.5, respectively. None of the sociodemographic variables predicted the scores obtained by the participants (
Pain is an individual, multifactorial experience influenced by culture, previous pain events, beliefs, moods, and ability to cope [
Today, pain in children is not adequately addressed, and yet there is a deficiency of knowledge in the treatment of pain in people of different areas of health, such as physicians, nurses, psychologists, and dentists [
A prospective, descriptive, analytical, and cross-sectional study was conducted to investigate the knowledge and attitudes regarding pediatric pain in two different populations: (a) pediatric nurses of a pediatric regional hospital (Mexico) and (b) nursing students of a Mexican university; this last institution is close to the pediatric hospital (these university students go to the pediatric hospital to perform their clinical practices).
Conduction of the study was done in two phases. In the first phase, a convenience sample of 111 pediatric nurses was evaluated in the pediatric hospital. These nurses were full-time employees at the hospital. In the second phase, a convenience sample of 300 nursing students was evaluated at the university. Students were attending the last six levels (semesters) of the undergraduate nursing. In the first phase, the researchers got to the hospital and asked the paediatric nurses of the different work shifts (morning, afternoon, night, and special shift) to fully complete the questionnaire (in one application). For the convenience sample of nurses, this was completed during several meetings at the hospital. Participants had 20 minutes to voluntarily complete the questionnaire. The same process was repeated with nursing students during their classes or academic activities in their school.
Permission was obtained to use, modify, and translate the PNKAS into Spanish (permission of the use of PNKAS was obtained directly from Betty R. Ferrell. City of Hope Pain Resource Center, 1500 East Duarte Road, Duarte, CA 91010, 626 256-HOPE Ext. 63829, Email:
The study protocol was approved by the Ethics and Investigation Committees of the Hospital del Niño DIF (Pachuca, Hidalgo, Mexico) and the study was carried out according to the guidelines delineated by the Declaration of Helsinki. Informed consents were obtained for completion of the questionnaires from all participants. Anonymity was assured and emphasized.
Data was entered into a computerized database. SPSS version 17 for Windows (SPSS Inc., Chicago, IL, USA) was used for descriptive and inferential statistical analyses. We performed exploratory analysis using the Pearson Chi-square test. Knowledge and attitudes about pain were analyzed with logistic regression analysis. Test scores were considered to be dependent variables, while nurses’ sociodemographics were potential predictors. For the multivariable analysis, we used stepwise logistic regression analysis. The
In the evaluation, 111 pediatric nurses volunteered to participate in the study. The mean age ± SD of these participants was 30.2 ± 7.4 years. One hundred and five participants were women (94.6%) and six (5.4%) were men. Table
Baseline characteristics of hospital pediatric nurses.
Time spent by the nurses with patients in pain (%) | |
0 to 50 | 37 (33.3%) |
51 to 75 | 20 (18.0%) |
76 to 100 | 54 (48.6%) |
Years of nursing experience | |
1 to 5 | 54 (48.6%) |
6 to 10 | 33 (29.7%) |
>10 | 24 (21.6%) |
Years of pediatric nursing experience | |
1 to 5 | 61 (55.0%) |
6 to 10 | 33 (29.7%) |
>10 | 17 (15.3%) |
Are you a member of an organization or association of nursing? | |
No | 108 (97.3%) |
Yes | 3 (2.7%) |
Are you a member of a committee of hospital nursing? | |
No | 111 (100%) |
Does your pediatric facility have a Pain Management Protocol? | |
No | 66 (59.5%) |
Unknown | 45 (40.5%) |
Does your pediatric facility have a Pain Management Critical Pathway? | |
No | 57 (51.4%) |
Unknown | 54 (48.6%) |
Does your pediatric facility have a Pain Management Committee? | |
No | 26 (23.4%) |
Unknown | 84 (75.7%) |
How many professional journals do you read monthly? | |
0 | 71 (64.0%) |
1 | 24 (21.6%) |
2 to 4 | 16 (14.4%) |
The five questions most often answered correctly by participants in the survey are presented in Table
Top 5 questions answered correctly by hospital nurses.
Item content (correct answer) | % correct |
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Analgesia for continuous pain should be given: (around the clock on a fixed schedule) | 92.8 |
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After the initial recommended dose of opioid analgesic, subsequent doses should be adjusted in accordance with the individual patient’s response. (True) | 86.5 |
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Analgesics for post-operative pain should initially be given: (around the clock on a fixed schedule) | 86.5 |
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Children who will require repeated painful procedures (i.e. daily wound care or blood draws), should receive maximum treatment for the pain and anxiety of the first procedure to minimize the development of anticipatory anxiety before subsequent procedures. (True) | 82.9 |
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Children with pain should be encouraged to endure as much pain as possible before resorting to a pain relief measure. (False) | 81.1 |
Top 5 questions answered incorrectly by hospital nurses.
Item content (correct answer) | % incorrect |
---|---|
The recommended route of administration of opioid analgesics to children with continuous or persistent pain is: (oral) | 98.2 |
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Patient A: Andres is 14 years old and this is his first day after abdominal surgery. As you enter his room, he smiles at you and continues talking and joking with his visitor. Your assessment reveals the following information: BP = 120/80; HR = 80; |
96.4 |
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Narcotic/opioid addiction is defined as psychological dependence accompanied by overwhelming concern with obtaining and using narcotics for psychic effect, not for medical reasons. It may occur with or without the physiological changes of tolerance to analgesia and physical dependence (withdrawal). Using this definition, how likely is it that opioid addiction will occur as a result if treating pain with opioid analgesics? (<1%) | 95.5 |
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Your assessment, above, is made 2 hours after he received morphine 2 mg IV. Half-hourly pain ratings after the injection ranged from 6 to 8, and he had no clinically significant respiratory depression, sedation, or other side effects. He has identified 2 as an acceptable level of pain relief. His physician’s order for analgesia is “morphine IV 1–3 mg q 1 h PRN pain relief”. Check the action you will take at this time: (Administer morphine 3 mg IV now). | 94.6 |
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Observable changes in vital signs must be relied upon to verify a patient’s statement that he has severe pain. (False) | 93.7 |
The knowledge about which of a series of drugs are or are not opioids or opiates is shown in Table
Knowledge of hospital nurses about which of the following drugs is or is not opioid or opiate.
Correct responses | ||
---|---|---|
|
% | |
Morphine | 94 | 84.7 |
Fentanyl | 72 | 64.9 |
Ibuprofen | 82 | 73.9 |
Ketorolac | 67 | 60.4 |
Metamizol | 70 | 63.1 |
Nalbuphine | 73 | 65.8 |
Naproxen | 81 | 73.0 |
Nimesulide | 81 | 73.0 |
Paracetamol | 86 | 77.5 |
Indomethacin | 45 | 40.5 |
Tramadol | 60 | 54.1 |
Aspirin | 83 | 74.8 |
In the second phase, the questionnaire was applied to 300 nursing students in their third to eighth semester. The mean age of this group of participants was 21.0 ± 1.7 years. Two hundred and sixty-eight participants were women (89.3%) and 32 (10.7%) participants were men. Table
Age and gender of the nursing students of different semesters.
Semester | Total | ||||||
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3rd | 4th | 5th | 6th | 7th | 8th | ||
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64 | 56 | 62 | 42 | 40 | 36 | 300 |
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Mean ± SEM | 19.4 ± 1.0 | 20.7 ± 1.6 | 21.2 ± 1.8 | 21.7 ± 1.4 | 21.3 ± 1.1 | 22.9 ± 1.1 | 21.0 ± 1.7 |
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4 (6.25) | 7 (12.5) | 6 (9.7) | 6 (14.3) | 6 (15.0) | 3 (7.5) | 32 (10.7) |
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60 (93.75) | 49 (87.5) | 56 (90.3) | 36 (85.7) | 34 (85.0) | 33 (82.5) | 268 (89.3) |
Top 5 questions answered correctly by nursing students.
Question (correct answer) | % correct |
---|---|
After the initial recommended dose of opioid analgesic, subsequent doses should be adjusted in accordance with the individual patient’s response. (True) | 92.0 |
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Children with pain should be encouraged to endure as much pain as possible before resorting to a pain relief measure. (False) | 84.3 |
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Analgesia for continuous pain should be given: (around the clock on a fixed schedule) | 77.7 |
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Comparable stimuli in different people produce the same intensity of pain. (False) | 76.0 |
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The most likely explanation for why a patient with pain would request increased doses of pain medication is: (The patient is experiencing increased pain). | 72.7 |
Top 5 questions answered incorrectly by nursing students.
Question (correct answer) | % incorrect |
---|---|
A child with continuous or persistent pain has been receiving daily opioid analgesics for 2 months. The doses increased during this time period. Yesterday the patient was receiving morphine 20 mg/h intravenously. Today he has been receiving 25 mg/h intravenously for 3 hours. The likelihood of the patient developing clinically significant respiratory depression is: (less than 1%) | 98.3 |
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Narcotic/opioid addiction is defined as psychological dependence accompanied by overwhelming concern with obtaining and using narcotics for psychic effect, not for medical reasons. It may occur with or without the physiological changes of tolerance to analgesia and physical dependence (withdrawal). Using this definition, how likely is it that opioid addiction will occur as a result if treating pain with opioid analgesics? (<1%) | 97.7 |
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Your assessment, above, is made 2 hours after he received morphine 2 mg IV. Half-hourly pain ratings after the injection ranged from 6 to 8, and he had no clinically significant respiratory depression, sedation, or other side effects. He has identified 2 as an acceptable level of pain relief. His physician’s order for analgesia is “morphine IV 1–3 mg q 1 h PRN pain relief”. Check the action you will take at this time: (Administer morphine 3 mg IV now). | 96.3 |
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The recommended route of administration of opioid analgesics to children with continuous or persistent pain is: (oral) | 91.3 |
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What do you think is the percentage of patients who over-report the amount of pain they have? Circle the correct answer: (0 to 10 %) | 91.0 |
There was a high correlation between the PKNAS scores of pediatric nurses and nursing students (Pearson coefficient = 0.86,
On a 12-item scale, an average score of correct responses of 5.96 ± 3.64 was obtained, with a minimum score of zero and a maximum score of 12 (Table
Nursing students knowledge about which of the following drugs are or are not opioid or opiate.
Correct responses | ||
---|---|---|
|
% | |
Morphine | 241 | 80.3 |
Fentanyl | 103 | 34.3 |
Ibuprofen | 134 | 44.7 |
Ketorolac | 166 | 55.3 |
Metamizol | 174 | 58.0 |
Nalbuphine | 137 | 45.7 |
Naproxen | 169 | 56.3 |
Nimesulide | 120 | 40.0 |
Paracetamol | 171 | 57.0 |
Indomethacin | 108 | 36.0 |
Tramadol | 93 | 31.0 |
Aspirin | 172 | 57.3 |
There was moderate correlation between the scores of knowledge about opioids of pediatric nurses and nursing students (Pearson coefficient
Nursing students were also analyzed separately (by semesters). There was no significant statistical difference between the PKNAS or opioids knowledge scores obtained by the six groups of students (data not shown) (
In this study, hospital nurses obtained an average score of correct answers of 16.0 ± 3.2 (on a 40-item scale) or 40.1 ± 7.9% (40 correct answers = 100%) on the PKNAS. This last mean score found in our study was slightly smaller than the preintervention score of 43.7 observed by Huth et al. [
Regarding the level of pain (intensity) in the two clinical cases of the questionnaire applied, the correct value of both questions was eight. It was noted that only four of 111 pediatric nurses (3.6%) correctly answered the evaluation of the patient who had a pain level of eight but that the patient was quiet and not complaining (Table
The choice of drugs and routes of administration are determined according to the type of patient (child, adult, women, etc.), the clinical condition (asthma, hypertension, trauma, postoperative, etc.), and the speed at which you want to initiate and maintain the pharmacological effect (angina pectoris, hypertensive emergency, severe pain, etc.). There is evidence that has shown that nurses have poor knowledge in pharmacotherapy [
In regard to the university curricula for health academic areas, such as medicine, nursing, or dentistry, these do not include a subject or “special unit” that focuses on the teaching of the physiopathology, assessment, diagnosis, and treatment of pain. The “pain” issue is only taught lightly in subjects such as physiology, nosology, pathology, surgery, and pharmacology. Nursing students’ low scores in studies that evaluated knowledge of pain management may be due to the scarce time that has been devoted to this topic in the nursing curricula. Graffam [
On the other hand, the nursing program of the university evaluated has only one course called “pharmacology.” It is almost impossible that, in 60 hours (two hours/week of theory and two hours/week of practice) of the course, nursing students can get or learn all the pharmacology of all systems, including the pharmacology of pain, such as NSAIDs, opioids, and anesthetics. This situation was observed in our evaluation, where four of the top five questions answered incorrectly by nursing students are associated with pain pharmacology (Table
One limitation of our study includes the lack of evaluation or quantification of the total hours of the university nursing curricula devoted to the assessment and management of pain. This data could help us to understand and/or justify the low scores found in the nursing students.
As the opportunities that students have to assess and manage children’s pain in their clinical practice along the years might vary, another limitation of our study was the recruitment and results analysis of students from six different levels.
We found that the level of knowledge about pain and its proper management is very poor, in both active pediatric nurses and nursing students. In this regard, the final score of the PKNAS in the pediatric nurses was not superior to or different from that of nursing students, so it follows that both groups have deficiencies. Due to these insufficiencies, pain in children remains inadequately and poorly managed, which leads to unnecessary suffering in the pediatric population. Therefore, it is necessary to increase the capacitation in this subject in both groups of participants. This capacitation must be continuous and include all aspects of the evaluation and treatment of pain in children.
The authors declare that Blanca Castro-Gamez is a pediatric nurse and she is a worker of the pediatric regional hospital where participant nurses were recruited for the study. The authors declare that there is no relationship between authors and the recruited nursing students.
The authors declare that there is no conflict of interests regarding the publication of this paper.
This work was supported by grant “Red Temática de Colaboración: Farmacología de la Reproducción” from REDES-PROMEP-SEP.