Pain Management: An Assessment of Surgical Nurses’ Knowledge
Patricia J. Puls-McColl
One of the most common problems that nurses address is pain management. Nurses are primarily responsible for providing pain relief in the health care arena. Pharmacologic management is the cornerstone of postoperative pain management, yet pain assessment and intervention often is not performed as recommended (Buck & Paice, 1994; Knoerl, Faut-Callahan, Paice, & Schott, 1999). This is a significant problem because pain relief not only correlates with patient satisfaction, but has legal ramifications as well (Clarke et al., 1996). For example, a court awarded a total of $14 million to the family of a nursing home resident who had bone cancer when the jury found that the man died in extreme pain because the nursing staff was alleged to have withheld, delayed, or substituted a placebo for morphine even though there was an order for morphine every 3 to 4 hours (Faison v. The Hillhaven Corp., 1990; Patterson, 1997). Thus, attention to proper pain management is clinically, ethically, and fiscally necessary.
Accurate nursing knowledge about pain assessment and intervention is critical to effective pain management and quality patient care (Loeb, 1999; McCaffery & Pasero, 1999; Young, 1999), but knowledge of pain assessment and research has shown that intervention varies greatly among nurses (Camp & O’Sullivan, 1987; Nash, Edwards, & Nebauer, 1993; Tanabe & Buschmann, 1999, 2000). The purpose of this exploratory pilot study was to assess registered nurse’s knowledge of pain assessment and intervention.
Background and Significance
Although pain management is a significant part of nursing care, many experts contend that formal nursing education fails to prepare nurses adequately to care for patients in pain (Clarke et al., 1996; Ferrell, McGuire, & Donovan, 1993). For example, 86% of nurses sampled said their basic nursing education did not prepare them to take care of patients with pain and 88% stated they needed increased know]edge and skills in the area of pain management (Fothergill-Bourbonnais & Wilson-Barnett, 1992). Educational deficits cited information regarding the fundamentals of pain pathophysiology and pharmacology (Dalton, 1989; Faries et al., 1991; Ferrell et al., 1993; Fothergill-Bourbonnais & Wilson-Barnett, 1992; Fox, 1982), proper analgesic dosing, dealing with issues such as preventing depression and other interventional consequences, and patients’ and providers’ fear of promoting addiction (Browne, 1996; Closs, 1996; Dalton et al., 1996; Hamilton & Edgar, 1992; Tanabe, 1995).
Pain assessment is the foundation for intervention and the key to effective pain management; however, it can be inadequate (Nash, Edwards, & Nebauer, 1993; Paice, Mahon, & Faut-Callahan, 1995). Numerous investigations have shown that patient self-report is the most reliable indicator of pain (Camp-Sorrell & O’Sullivan, 1991; Faries et al., 1991; Novy & Jagmin, 1997; Paice, Mahon, & Faut-Callahan, 1991; Tanabe, 1995). Given the subjective nature of pain, patient self-report is the optimal way to assess a patient’s need for pain medication. Unfortunately, many nurses do not use patient self-report of pain as an indicator of pain (Calvillo & Flaskerud, 1993; Camp-Sorrell & O’Sullivan, 1991). Further, pain assessment is inadequate. During a medical record audit, Fox (1982) found severe deficiencies in adequate pain assessment and lack of documentation of the effectiveness of analgesic interventions. It is unclear whether this is a matter simply of poor documentation, or whether the information was not collected (Camp & O’Sullivan, 1987). In this study, less than 50% of the information given to the investigators immediately following nurse assessment was found in the nursing documentation of the pain assessment.
A third area of knowledge deficit is pain intervention. The Agency for Health Care Policy and Research Acute Pain Management Guideline Panel (1992) stated that nonsteroidal anti-inflammatory analgesics should be scheduled around the clock for postoperative patients unless contraindicated. Also, opioid analgesics should be given on a scheduled basis with an intermittent order available to supplement the scheduled dosing for breakthrough pain. Around-the-clock dosing provides more stable plasma levels of analgesics allowing more continuous pain relief from the medication rather than the peaks and valleys of intermittent medication (Buck & Paice, 1994). Unfortunately, medicating with analgesics on an intermittent basis is the norm and not the exception, even when documentation indicates that the patient is experiencing severe pain (Fox, 1982; MacLellan, 1997). These identified gaps in the literature indicate a need for more detailed assessment of nurse knowledge of pain management in order to identify the precise nature of knowledge. Improved clarification these deficits will enable clinical nurse educators and faculty to develop more effective teaching and learning strategies. Ultimately, this will result in better patient management and satisfaction.
Loeser’s (1982) model of pain, modified by Paice et al. (1991; see Figure 1), was used as a conceptual framework for this study. In this model, the relationships between the physical aspects of pain, or nociception, the
subjective aspects of pain, referred to as the pain experience, and the objective aspects, or pain behaviors, are interrelated and lie within the field of system response. Paice and colleagues place Loeser’s model in the field of system response, implying that the patient’s personal pain experience and behaviors can be affected by external sources such as health care providers. System response refers to the environmental and health care system’s reaction to the patient who is exhibiting pain behaviors as a response to nociception and the subsequent pain experience. The multidisciplinary health care provider system response has a significant effect on the patient’s overall perceived pain. System response encompasses many variables, including nurses’ knowledge of pain, pain assessments, and interventions aimed at pain management (Paice et al., 1991). According to Slack and Faut-Callahan (1991), comprehending the interaction of these variables is a prerequisite for effective pain relief.
The following research questions were investigated:
1. What is the extent of nurses’ knowledge regarding pain assessment and intervention?
2. How is nurses’ level of education related to their knowledge of pain assessment and intervention?
Research design. A nonexperimental design was used to describe the sampled nurses’ knowledge of pain management. In collecting demographic data, initial nursing education was defined as the first formal nursing education program completed by subjects, and current nursing education referred to their highest level of formal nursing education completed. Cumulative experience was the number of years registered nurses had provided professional nursing services in any setting. The subjects were also asked to identify the number of years in specialized surgical orthopaedic nursing practice. Pain management was operationally defined as the nurses’ understanding and accurate utilization of the process of controlling pain. This incorporated their knowledge of pain assessment, including the role of multiple variables that may alter assessment such as interventions, reassessments, and care modification strategies (Slack & Faut-Callahan, 1991).
The convenience sample consisted of all available RNs (25) on an orthopaedic/surgical unit in a suburban community hospital who were willing to complete the instrument. Power analysis revealed that, for a one-tailed, 5% level of significance, power of 80%, a sample size of 25 would allow an effect size of 0.475 to be detected with the other variables remaining the same. Institutional review board approval and permission from the director of research, the nurse manager, and the quality assurance committee at the study hospital were obtained prior to data collection. At a monthly staff meeting, the investigator gave a brief explanation of the nature of the study to the unit nurses. Then, the nurses were asked to complete the instrument and return it to the researcher at that time. Data collection took place over a 2-week period.
Measurement. The instrument consisted of two parts. A short demographic data sheet to obtain educational background and length of practice was followed by administration of the RN’s Knowledge of Pain Assessment and Interventions Questionnaire (Tanabe, 1996). The questionnaire was adapted slightly by making the questions refer directly to orthopaedic rather than emergency department nurses and clinical situations. Questions are categorized into six areas or domains of pain management knowledge, which are: pain assessment; barriers to treatment; use of the terms addiction, tolerance, threshold, and dependence; actions and side effects of medications; treatment interventions; and the nurse’s role in pain management (Tanabe, 1996).
Reliability and validity. Tanabe (1996) evaluated the instrument for internal consistency, inter-item reliability, and test re-test reliability. Due to the multidimensionality of the instrument, the dichotomy of the questions, and the lack of item response variability for several questions in which nurses either knew the material or did not, the Kuder Richardson 20 score of 0.5 was low. In examining reliability reports, the fact that the distribution of answers was bimodal and not a normal distribution, it is questionable as to whether the Kuder Richardson 20 was the appropriate test. The reliability of nurses’ self-reports was supported by findings that were strongly correlated with chart documentation. As the instrument was successful in eliciting in-depth responses from emergency room nurses, the investigators decided that its use in an exploratory pilot study of orthopaedic/surgical nurses was appropriate. This decision was supported by the evidence of the instrument’s validity. The instrument’s validity was examined in several ways. The instrument was developed based on current literature and was reviewed for content validity by a panel of seven experts in pain management (Tanabe, 1996). The revised format was reviewed by a clinical nurse specialist in orthopaedic/surgical nursing.
Data analysis and results. Data from the demographic and pain questionnaires were analyzed using descriptive statistics. Initial nursing education, current nursing education, cumulative experience, and specialized surgical orthopaedic experience have been organized to show the percent and frequency at each interval of the four demographic variables. Pain questionnaire responses were analyzed using univariate analysis of variance.
All of the 25 orthopaedic/surgical nurses who participated were female, and thus stated that their initial nursing education was their only formal nursing education. Of the study nurses, 44% were diploma prepared, 24% earned associate degrees, and 32% had obtained baccalaureate degrees. The majority of nurses (68%) had either less than 6 years (36%) or greater than 20 years (32%) cumulative nursing experience (see Table 1). The majority of the nurses (64%) had less than 10 years of experience in orthopaedic nursing.
General Nursing Orthopaedic Nursing
Years n Percent n Percent
Less than 6 9 36 10 40
6 to 10 3 12 6 24
11 to 20 5 20 6 24
Greater than 20 8 32 3 12
Scores on the study instrument are calculated by summing the total of correct responses on the 39-item scale and calculating a percentage of correct answers. Thirteen additional items assessing nurses’ opinions regarding barriers to pain management are scored using a Likert scale and were analyzed separately. For the knowledge statements, scores ranged from 24 to 35, with a mean of 29.3 and a standard deviation of .83. Percentages of correct answers are categorized under their respective domains (see Table 2). Domain two (barriers to treatment) had an 88% correct rate. Sixty-three percent of the respondents answered items in domain three correctly (use of terminology), and 60% answered items in domain four correctly (actions and side effects of medications). Domain five (treatment interventions) had a score of 84%, and domain six (nurses’ role) had an 81% correct rate.
Percentage of Correct Answers by Domain
Domain 1 Domain 2 Domain 3 Medications, Domain 5
Pain Barriers to Use of Actions, and Treatment
Assessment Treatment Terminology Side Effects Interventions
Q % Q % Q % Q % Q %
1 100 7 92 3 72 4 64 45 84
8 100 13 68 9 40 6 40
31 100 17 88 14 52 10 100
34 100 35 92 38 60 12 52
40 100 36 100 41 64 15 56
39 88 52 88 16 40
47 88 32 56
Average Percent of Domain Questions Correct
100% 88% 63% 60% 84%
Average Percent of Domain Questions Correct
Note: Q – Question number; % = percent correct.
Scores on all of the items were examined to identify areas of specific knowledge deficits. On 13 items, less than two-thirds of the respondents gave correct answers.
The two items with the lowest correct response were questions 37 and 51. Question 37 asked, “When is the most appropriate time to re-medicate the patient?” Only 32% of the nurses answered that the patient should be medicated prior to the return of the pain. The majority replied that remedication should occur when the pain is mild. Question 51 addressed the effects of normeperadine, the metabolite of meperidine. Seventy-four percent of the nurses were unaware that normeperadine is associated with tremors and seizures.
Correlation of nurse variables and knowledge scores was calculated and analyzed. When comparing mean scores by educational level, the associate degree and diploma nurses had the same mean score (28.7 [+ or -] 2.7, mean [+ or -] SD). The score of the bachelor’s-prepared nurses, while higher (30.5 [+ or -] 2.4, mean [+ or -] SD) was not significantly or statistically different (F=l.09, p=NS). Therefore, for this sample, educational background did not appear to make a difference in knowledge scores. Nurses with cumulative nursing experience of 11 years or more had higher mean scores than the less-experienced nurses. Mean scores of nurses with 11 or more years of orthopaedic nursing experience also were higher than those with less orthopaedic experience. But, the differences on these variables were not significantly different statistically (experience [F=0.73, p=NS], experience in orthopaedic nursing [F=2.4, p=NS]). Based on these findings, neither education nor years of experience in nursing appear to make a difference in knowledge.
Nurses’ perceived barriers to the adequate treatment of pain was the topic of questions 18 through 30 (see Table 3). The greatest barrier named was nurses’ responsibility for caring for other acutely ill patients.
Nurses’ Reports of Barriers to Pain Management
Item Description Always Often
18 Responsibility of caring for other 16% 40%
19 Patient’s reluctance to report pain, 4% 24%
20 Patient’s reluctance to take opioids. 0 16%
21 Nursing staff reluctance to 4% 8%
22 Inadequate assessment of pain 8% 28%
and pain relief.
23 Inadequate staff knowledge of pain 8% 8%
24 Lack of time to adequately assess 8% 16%
and control pain.
25 Inability to medicate until 9% 4%
diagnosis is made.
26 Inability to determine history 4% 0
27 Use of alcohol or other 0 24%
28 Lack of intravenous access. 0 0
29 Cannot assess side effects because 0 4%
patient is off-unit.
30 Time to find narcotic keys. 0 0
Description Sometimes Rarely Never
Responsibility of caring for other 32% 8% 4%
Patient’s reluctance to report pain, 64% 8% 0
Patient’s reluctance to take opioids. 68% 16% 0
Nursing staff reluctance to 20% 40% 28%
Inadequate assessment of pain 40% 24% 0
and pain relief.
Inadequate staff knowledge of pain 60% 16% 8%
Lack of time to adequately assess 64% 8% 4%
and control pain.
Inability to medicate until 56% 32% 8%
diagnosis is made.
Inability to determine history 40% 40% 16%
Use of alcohol or other 28% 40% 8%
Lack of intravenous access. 44% 36% 20%
Cannot assess side effects because 40% 44% 12%
patient is off-unit.
Time to find narcotic keys. 0 28% 72%
Inadequate assessment, nurses’ lack of time to. adequately assess and control pain, and patients’ reluctance to report pain were the next most common-cited barriers. Nurses also identified factors that did not present barriers to pain management. Nurses claimed that finding narcotic drugs was never problematic, and nurses’ reluctance to administer opioids did not usually present a barrier. Aspects of medical treatment, such as intravenous access and recreational drug use, also rarely affected intervention.
This exploratory study aimed to identify nurses’ knowledge of pain management. Three main areas — education, assessment, and intervention — were identified as potential problem areas for nurses who must provide pain management for their clients. The findings of the present study provide information about each of these three areas.
To provide effective pain management, nurses must possess an adequate knowledge base. Numerous experts cite a lack of formal and informal education regarding pain management as a significant and serious problem (Ferrell et al., 1993; Fothergill-Bourbonnais & Wilson-Barnett, 1992). This study reinforces the idea that history, diagnosis, existing formal education, and experience are not necessarily strongly associated with nurses’ pain management. This suggests that pain management education is deficient regardless of nursing educational level or years of experience.
The results of this study identify specific areas of deficits throughout five of the six domains of knowledge. All of the nurses surveyed answered questions pertaining to pain assessment correctly. This is a surprising finding. In another investigation (Paice et al., 1991), nurses frequently made assumptions about patients’ pain, and 40% of the study patients said they had never been asked if they were experiencing pain. Clarke et al., (1996) found that nurses do not use patient self-report, the most effective way to evaluate a subjective feeling such as pain, as an indicator of pain. Taken together, previous research and these findings suggest that nurses know how to assess pain theoretically but are not doing it clinically.
It is important to note that although nurses answered all questions regarding pain assessment correctly, they exhibited knowledge deficits in areas that could hinder intervention efforts toward pain relief. Areas with the most room for improvement were knowledge of medication actions and side effects and on understanding of such concepts as pharmaceutical dependence, addiction, tolerance, and threshold. These findings are consistent with the literature (Browne, 1996; Closs, 1996; Dalton et al., 1996; Hamilton & Edgar, 1992; Tanabe, 1995) and are disturbing.
The nurses’ responses that caring for other patients often interferes with pain management is a complex and troubling issue. In this time of reorganization and downsizing in health care, nurses are feeling overworked and often feel there is not enough time to complete all their work. The response that due to other responsibilities, nurses lack the time to assess and treat pain is unacceptable and suggests that staffing is inadequate to maintain quality care. Since nurses can be held legally responsible for pain management, as held in the case of Faison vs. The Hillhaven Corporation, (1990), medical-surgical nursing units must be staffed to provide nurses with the ability to carry out their legal and ethical responsibilities. This barrier again supports the need for increased knowledge and application of that knowledge to improve patient care.
With respect to the modified version of Loeser’s model by Paice et al. (1991; see Figure 1), the findings of the present study fall within the background of the system response. Because nociception, pain experience, and pain behavior are all individual and patient specific, yet lie within the environmental field of system response, the quality of that environmental health care field of system response directly affects the patient that is experiencing pain. Adequate nursing knowledge is a part of system response. Without adequate nursing knowledge, the system response is unable to positively affect pain behaviors, pain experiences, and nociception. This study documents that nurses perceive that inadequate nursing staffing, due to health care organization problems, negatively affects patient care.
Several areas for improving nurses’ knowledge of pain management were identified, and the investigation raises numerous research questions. Future areas of study include the need to identify operational issues affecting nurses’ knowledge, as well as to define those issues that contribute to a lack of action even if the nurse’s knowledge of pain management is adequate. Such studies may provide answers that assist in strengthening the system response, which enables the patient to better manage pain.
There are several limitations to this study. The use of a small, self-selecting, convenience sample allows for potential unrecognized bias and limits direct application of the findings outside of the sample studied. The descriptive nature of the research does not allow implications or conclusions, only observation and description. Finally, the reliability of the tool used to collect the data is somewhat in doubt. Future studies using this instrument need to deal with these issues of reliability discussed previously. However, it is important to note that nurses identified and reported pain management barriers independent of the tool.
Knowledge deficits identified by this study support previous research and indicate that the anticipated diffusion of pain management guidelines, widely published since 1993, is far from complete. A continuing effort to bring the subject of pain management into heightened view is crucial to maintain awareness of the issue and, subsequently, to change practice. Continued efforts to implement practice guidelines and continuous improvement activities must be ongoing to improve basic and continuing nursing education and patient care. Encouraging continuing education for nurses by planning and executing employment-based education and promoting conference attendance and other educational opportunities may empower nurses to change practice. Organizations should solicit feedback from patients regarding their pain management through patient satisfaction surveys and followup interviews to evaluate care and provide direction for quality improvement initiatives.
Continuing education in the clinical setting is frequently mentioned in the literature as a vital method for increasing knowledge of pain management (Clarke et al., 1996; Dalton, 1989; Ferrell et al., 1993; Fothergill-Bourbonnais & Wilson-Barnett, 1992; Willson, 1992). Given recent cutbacks in funding staff education and development by health care organizations, there is concern that nursing knowledge deficits will not be corrected. However, unless nurses perceive knowledge deficits or lack of resources, interventions such as continuing education have little effect (Camp & O’Sullivan, 1987; Nash et al., 1993). The present study identifies areas of deficiency in pain management that can direct educational efforts and agrees with the need to emphasize completion and documentation of pain assessments (Camp & O’Sullivan, 1987). Further clinical research on pain assessment and management behavior is also needed (Nash et al., 1993). Exploring nurses’ awareness of the need for pain and knowledge management strategies in other populations (for example, surgical patients) is also needed (Ferrell, McCaffery, & Grant, 1991). Finally, basic nursing education programs also have a responsibility to improve their efforts with regard to pain management. Clearly, quality pain assessment and management are still unrealized ideals.
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Patricia J. Puls-McColl, MS, RN, is Education Specialist, Elmhurst Memorial Hospital, Elmhurst, IL.
Janean E. Holden, PhD, RN, is Assistant Professor of Medical-Surgical Nursing, College of Nursing, University of Illinois at Chicago, Chicago, IL.
MaryBeth Tank Buschmann, PhD, RN, C, is Professor of Medical-Surgical Nursing, College of Nursing, University of Illinois at Chicago, Chicago, IL.
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