pain knowledge and attitudes of nursing students: a literature review

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Pain Knowledge And Attitudes Of Nursing Students: A Literature Review

K.M. Chow, Joanne C.Y. Chan

PII: S0260-6917(14)00343-8DOI: doi: 10.1016/j.nedt.2014.10.019Reference: YNEDT 2817

To appear in: Nurse Education Today

Accepted date: 30 October 2014

Please cite this article as: Chow, K.M., Chan, Joanne C.Y., Pain Knowledge And At-titudes Of Nursing Students: A Literature Review, Nurse Education Today (2014), doi:10.1016/j.nedt.2014.10.019

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http://dx.doi.org/10.1016/j.nedt.2014.10.019

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PAIN KNOWLEDGE AND ATTITUDES OF NURSING STUDENTS: A LITERATURE REVIEW

K. M. Chow1

Joanne C. Y. Chan1

Affiliation: 1The Nethersole School of Nursing, The Chinese University of Hong Kong

Corresponding author: Dr Ka Ming Chow, Professional Consultant

Address: The Nethersole School of Nursing, Rm 628, Esther Lee Building, The Chinese University of Hong Kong, Shatin, The New Territories, Hong Kong SAR.

Day-time phone: 852-3943-4431

Fax number: 852-2603-5269

Email: [email protected]

Word count: 4,396

Acknowledgements: There are no acknowledgements.

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INTRODUCTION

Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” (International Association for the Study of Pain, 2014). It is the predominant reason for patients to seek health care (Oware-Gyekye, 2008). Thus, pain management is a high priority in patient care (Lui, So, & Fong, 2008). If patients‟ pain is not managed properly, the consequences can be detrimental. For instance, the inability to manage post-operative pain not only threatens the physical well-being of the patient but also their psychological well-being (McLean, Martin, Cousley, & Hoy, 2013).

As nurses have the most interaction with patients, providing quality nursing care to patients in pain is an important responsibility of nurses (Brown, 2013). A literature review on nurse-led care found that nurses assumed an important role in managing both acute and chronic pain (Courtenay & Carey, 2008). In particular, they were responsible for assessing pain, developing and implementing a treatment plan as well as educating patients (Brown, 2013). Though nurses play an increasingly important role in the pain assessment and management of patients, many nurses find it challenging (Ladak et al., 2013).

As nurse educators, it is our responsibility to prepare nursing students adequately for pain management before they become nurses. Nursing students must acquire comprehensive knowledge about pain and pain management before completion of their undergraduate education (Al-Khawaldeh, Al-Hussami, & Darawad, 2013). They must be able to fulfill responsibilities independently and communicate with other healthcare professionals as a team to provide the best quality of care to patients. Therefore, nurse educators need to understand the strengths and weaknesses in nursing students‟ pain knowledge and attitudes as well as the associating factors so as to identify facilitators and barriers in pain education. Such information is essential for preparing nursing students adequately for their roles in clinical placement and also as nurses in the future.

OBJECTIVES

The objective of this literature review is to identify, summarize and critically appraise current evidence on (i) pain knowledge and attitudes of nursing students, and (ii) pain education programs for nursing students.

LITERATURE SEARCH

Searches of MEDLINE, CINAHL, PsycINFO, British Nursing Index and GoogleScholar were conducted from 2004 to 2014. Keywords of „nursing student‟ and „pain‟ were used in combination to identify relevant articles. Two authors assessed all identified articles independently for inclusion into review. A total of 110 publications were identified. After removal of 11 duplicates or irrelevant studies, 99 full-text articles were retrieved for detailed evaluation. Inclusion criteria were: (i) nursing students in a pre-licensure study program, (ii) English in language, and (iii) related to pain management or pain education. Of the 99 articles, 11 articles met the inclusion criteria. The 11 studies can be further categorized into two sections for this review: (i) assessment of pain knowledge and attitudes (n=7) (see Table 1 for a summary of the studies), and (ii) an evaluation of pain education program for nursing students (n=4) (see Table 2 for a summary of the studies).

RESULTS

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Studies on assessment of pain knowledge and attitudes

Seven studies aimed at assessing pain knowledge and attitudes of nursing students in a pre-licensure program. All of these studies used descriptive cross-sectional survey.

Goodrich (2006) conducted a descriptive, cross-sectional and longitudinal study on a convenience sample of undergraduate nursing students at three year levels at a university in the United States of America by using the Pain Knowledge and Attitude Survey (McCaffery & Pasero, 1999). The sample size and characteristics of the participants were not specified. Data were collected twice a year for two years. The authors identified gaps in the nursing students‟ pain knowledge, such as the belief of their patients‟ self-report of pain, patients‟ experience of pain during sleep, and the use of meperidine. The results showed that students increased their pain knowledge and attitudes scores as they progressed through the curriculum.

Plaisance and Logan (2006) compared the pain knowledge and attitudes of nursing students from an associate program with students from a baccalaureate nursing program (n=313) in the United States of America. The Nurses‟ Knowledge and Attitudes Survey Regarding Pain (NKASRP) (Ferrell & McCaffery, 1998b) was used. The results showed that on average, all nursing students got 64% of the questions correct; only 3.8% of the students got more than 80% of questions correct and 88.8% of them got at least 50% correct. The items with the poorest performance were related to medications‟ actions, side effects, and administration. The baccalaureate nursing students‟ mean score was significantly higher than that of the associate degree nursing students‟ on the pharmacology items (p = .001).

Rahimi-Madiseh, Tavakol and Dennick (2010) assessed Iranian nursing students‟ pain knowledge and attitudes (n=146). The Knowledge and Attitudes Regarding Pain Tool (KARPT) (Ferrel & McGuire, 1998) was used. The tool was translated into Persian for administration. Data were collected from nursing students in two nursing schools. Overall, the students‟ pain knowledge and attitudes were poor. The mean of correct answers was 37%. None of the students answered more than 60% of the items correctly. Only 4.8% of students answered at least 50% correctly and more than 50% of the students were knowledgeable on only 10 items in the KARPT.

Shaw and Lee (2010) recruited undergraduate nursing students in New Zealand (n=430) to examine the misconceptions with regard to adults experiencing chronic non-malignant pain. Overall, the nursing students held misconceptions about adults with chronic non-malignant pain to a considerable degree: over 50% believed that psychological impairment was related to chronic pain; stress caused chronic pain; depression played a role in the experience of chronic pain; and patients taking opioids were likely to be addicted. These misconceptions were held to a lesser extent by the senior nursing students.

Al-Khawaldeh et al. (2013) conducted a study on baccalaureate nursing students in Jordan (n=240), besides using the revised Knowledge and Attitudes Survey Regarding Pain (KASRP) (Ferrell & McCaffery, 2008), they also asked students whether they read about pain, used pain assessment tools and clinical working experience as well as their perceived barriers of pain management. The students‟ mean score for the revised KASRP was 34.1%, which could be categorized as poor. Students who received pain management training had significantly higher scores in the revised KASRP than those who did not. In addition, students who reported that they used pain assessment tools more frequently had significantly higher scores than those who reported that they never or rarely used pain assessment tools. The top three

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barriers to performing pain management were “lack of knowledge and training regarding pain management,” “nurses working in clinical areas not using pain assessment tools and techniques,” and “unavailability of pain assessment tools in the clinical areas.”

Al Khalaileh and Al Qadire (2013) also did a survey on fourth-year undergraduate nursing students from three government universities in Jordan (n=144) using the Knowledge and Attitudes Survey (KAS) (Ferrell, McGuire, & Donovan, 1993). They replaced the American names of two drugs by local names they used in Jordan. The results showed that students had poor pain knowledge and attitudes, with an average of only 16 correct answers out of 40. In particular, students were weak in pain assessment and the pharmacological management of pain. Students also had negative attitudes regarding pain management, such as the use of opioids. More than half of them (52%) believed that patients should tolerate pain as much as possible before starting opioid treatment, and 48% suggested that the patients‟ pain could be managed with a placebo. There were no significant gender differences with regard to pain knowledge and attitudes. Whether students had received pain education prior to the study also made no difference to their pain knowledge and attitudes.

Duke, Haas, Yarbrough, and Northam (2013) evaluated the pain knowledge and attitudes of both nursing students and faculty members in the United States of America by using the KASRP. A total of 162 baccalaureate nursing students and 16 nursing faculty members at the same university participated. The results once again showed that both faculty members and students did not have adequate pain knowledge and appropriate pain management attitudes. The mean score of the KASRP was 22.41 out of 36 for the whole sample. There was a positive correlation between the level of education and the KASRP score. Significant differences were found between the junior and senior students, and between the junior students and faculty members. However, there was no significant difference in the scores between the senior students and faculty members, or between the first-semester and second-semester junior students. The first-semester senior students answered only 68% of the questions correctly in the KASRP, and this was well below the desired 80% that was considered as acceptable by the authors.

Studies on evaluation of pain education program for nursing students

Of the four included studies evaluating pain education programs for nursing students, various study designs were adopted. Two studies were quasi-experimental studies with pretest and posttest design, one was one group pretest and posttest study, and the remaining one was a randomized controlled trial. All the samples in the studies were nursing students in a pre-licensure program.

To explore the student nurses‟ knowledge of, attitudes towards, and self-efficacy in assessing and managing children‟s pain prior to and after the implementation of a pain education program, Chiang et al. (2006) developed a four-hour program focusing on the assessment and management of pain in children. The program targeted at the misconceptions about children‟s pain, different pain assessment tools, and pharmacological as well as non-pharmacological pain management for children. A total of 192 student nurses from a nursing school in Taiwan participated and assigned to receive the program. The delivery mode was didactic presentation and interactive discussion of case scenarios. Participants watched a 28-minute video which demonstrated various pain assessment tools and non-pharmacological pain management. The results showed that student nurses‟ knowledge of and attitudes towards children‟s pain management improved after the pain education program. Prior to the program, only 57% of the questions (20 out of 35 items) in a pain-related topics instrument, modified from the instruments by McCaffery and

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Ferrell (1997) and Manworren and Hayes (2000), were answered correctly, and the standard score of the total students‟ pain knowledge and attitudes was 55 out of 100. After the program, 91.4% of the questions (32 out of 35 items) were answered correctly, and the standard score increased to 74.1, which was significantly better than the pre-test score (p < .001). Before the pain education, the standard score for self-efficacy was 73.37 and it increased to 87.07 at post-test. The change was statistically significant (p < .001). Although the results of the study provided support for the effectiveness of the program, the use of students in one nursing school limited the generalizability of the results. In addition, no comparison group was included, and thus it could not be concluded that the results of the study were solely due to the program.

Owens et al. (2014) also conducted a pre- and post-interventional study to evaluate the impact of a structured pain education program on pre-registration nursing students‟ knowledge of and attitudes towards children‟s pain management in the United Kingdom. The program consisted of three three-hour workshops delivered by a pain nurse specialist, two workbooks on knowledge of physiology, pain assessment and pain management strategies for children, a half-day clinical placement with pain team, and reflection on learning. A total of 127 year-two nursing students participated. Sixty-four students were assigned to the intervention group and 63 students to the comparison group. Perception and attitudes towards managing pain in children were assessed by an instrument adapted from the Nurses‟ Knowledge and Attitudes Regarding Pain Survey questionnaire (Ferrell & McCaffery, 1995), which had 40 items. After the intervention, only 82 (65%) sets of questionnaires were returned, including 45 from the intervention group and 37 from the comparison group. The results showed that the intervention group had higher scores in the post-intervention questionnaire than the comparison group. At six months after completion of the program, both groups self-rated their knowledge of children‟s pain management as having improved, and there was an increase in the percentage of correct answers in both groups. However, there were still some items in the questionnaire answered correctly by less than half of the participants in the intervention group. The results were not satisfactory. Moreover, the low response rate of the returned questionnaires might not be an accurate reflection of the effects of the pain education program in the post-intervention assessment. Besides, interpretation of the results should take into account the fact that 50% of nursing training in the United Kingdom was clinical placement which might enhance nursing students‟ pain management. There was a possibility that improvement after the intervention was partly a result of clinical practice. There was no evidence that a differentiation was made between the impact of the program and the impact of clinical placement.

MacLaren et al. (2008) also designed a training program for children‟s pain management with a focus on cognitive-behavioral strategies in the United States of America. An evaluation of the effectiveness of the evidence-based cognitive-behavioral pain management training program on 58 baccalaureate nursing students‟ attitudes, knowledge and skill acquisition to implement the strategies was carried out. In the program, a 20-minute didactic information session on cognitive-behavioral techniques for pain control in children was delivered by the author with handouts provided for reference. Instructions to practice distraction and guided imagery were also given in the following week as a homework assignment. A total of 50 junior level nursing students were recruited, with 26 randomly assigned to the training group and 24 to the control group. Outcomes were measured by a self-developed instrument. The results showed that the training group was significantly more knowledgeable on non-pharmacological pain management at post-assessment than the control group (p < .025). However, there was no significant effect of training on attitudes towards cognitive-behavioral pain management. The training group also had

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a significantly better performance of cognitive-behavioral pain management strategies in clinical role-play than the control group. The limitation of the study was that the instrument used in the study had not undergone validation so there was no indication of its validity and reliability. Moreover, the small sample size might be not powerful enough to show the significant effects of the training program. There was also a potential of treatment diffusion as the students in the training group might have shared their experiences in implementing cognitive-behavioral strategies with those in the control group.

Apart from face-to-face interaction, e-learning resources have been used in pain education for nursing students in recent years. Keefe and Wharrad (2012) developed e-learning resources on pain management and measured their impact on pain knowledge and attitudes in undergraduate master nursing students in the United Kingdom. The e-learning resources included two modules: (i) pain assessment and (ii) treatment of pain. Articulate software was used to incorporate interactions, audio commentary and images. Teaching content was peer-reviewed at regular intervals by five pain specialists. A questionnaire adapted from Ferrell and McCaffery‟s (1998a), Nurses‟ Knowledge and Attitude Survey Regarding Pain (NKASRP), was used for evaluation. Forty-two master nursing student volunteers were randomly assigned to trial one module of the e-learning. A further 164 nursing students undertook the questionnaire and were assigned to the control group. The students in the intervention group took an average of 10 to 30 minutes to complete one module. For the control group, the mean response accuracy in the instrument was 53.8%, and no participants scored over 80%. For the intervention group, the mean response accuracy was higher, with a mean of 73.1%, and 21.4% of the participants scored over 80%. The more senior the year of study, the higher the scores for both assessment and treatment of pain. Participants who undertook the pain assessment e-learning scored higher on the assessment questions than the control group (p = .000). Participants who undertook the treatment of pain e-learning scored higher on the treatment questions than the control group (p = .000). The results of this study indicated that specific training on pain management topics using e-learning could improve related knowledge. However, the results should be interpreted with caution as participants in the intervention group were volunteers. This might induce a voluntary-response bias as participants in the control group were not volunteers. Besides, the number of participants undertaking the e-learning resources was relatively small (20%) compared to the whole population size. This might also lead to inadequate power demonstrated in the interventions.

Critical appraisal of the included studies

The quality of the included studies in the review was assessed by using the critical appraisal checklists of the Center for Evidence-Based Management (2014). All the seven descriptive cross-sectional studies adequately addressed the focused questions and the study design was appropriate for assessing pain knowledge and attitudes in nursing students. In addition, method of subject selection was clearly described in the studies. However, convenience sampling might introduce selection bias and sample size was not calculated according to power analysis. The response rate was satisfactory in two studies, and only three studies reported statistical significance of the results. After all, the findings from the studies could be applied to local organization.

The four interventional studies clearly addressed the focused question of pain education program effectiveness on nursing students. Three of them were appropriately designed for answering the research question as there were intervention and control groups for comparison. However, subject allocation was

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not random in two quasi-experimental studies which might introduce bias. Three studies adopted validated instruments to measure the outcome, but no studies reported effect size in the results.

Overall, the quality of the included studies was average. The strength of the evidence was acceptable. Critical appraisal of descriptive cross-sectional studies and interventional studies is illustrated in Tables 3 and 4.

DISCUSSION

All the studies on nursing students‟ pain knowledge and attitudes adopted a descriptive cross-sectional approach except that Goodrich (2006) also included a longitudinal component. Although a cross-sectional survey can reach a large number of nursing students and provide descriptive information about their pain knowledge and attitudes at the time of data collection, it falls short of tracking the growth of pain knowledge and the development of pain attitudes. The assessment of nursing students from one nursing school as observed in most of the studies, limits the generalizability of the results. Comparing nursing students from different nursing programs or different school years (Plaisance & Logan, 2006; Rahimi-Madiseh et al., 2010) added value to the outcomes. The inclusion of nursing students from multiple sites (Al Khalaileh & Al Qadire, 2013; Al-Khawaldeh et al., 2013) provided a more representative sample and enhanced the generalizability of the results. Moreover, none of the studies under investigation included a calculation of required sample size. One study did not even report the actual sample size (Goodrich, 2006). Future studies should include a calculation of sample size as under-recruitment of participants would both have impact on the power of the study.

A large proportion of the studies examined (Al Khalaileh & Al Qadire, 2013; Duke et al., 2013; Plaisance & Logan, 2006) used different versions of the Knowledge and Attitudes Survey Regarding Pain (KASRP) (Ferrell et al., 1993; Ferrell & McCaffery, 1998b; Ferrell & McCaffery, 2008). This is a practice to be encouraged as using the same instrument enable researchers to establish a dialogue to compare and contrast the results. However, all the studies on the assessment of pain knowledge and attitudes (Al Khalaileh & Al Qadire, 2013; Al-Khawaldeh et al., 2013; Duke et al., 2013; Goodrich, 2006; Plaisance & Logan, 2006; Rahimi-Madiseh et al., 2010; Shaw & Lee; 2010) did not include any other variables on top of pain knowledge and attitudes; there is, therefore, little understanding about the associating factors or the effect of the pain knowledge and attitudes of nursing students on their actual pain management in clinical settings.

The fact that researchers assessed the pain knowledge and attitudes of nursing students from different cultural backgrounds contributes to the bigger picture of the similarities and differences across cultures. However, the lack of discussion with reference to the respective cultural backgrounds hampers the interpretation of the results. For instance, do collectivism and individualism play a part in nursing students‟ pain knowledge and attitudes? Would students have discrepancies in their attitudes when facing patients from different ethnic groups? How was pain education traditionally taught in the respective curriculum and what are students‟ experiences of pain education? These questions remained unanswered.

Apart from the 11 included studies that demonstrated inadequate pain education and management, the problem is an international issue which has been well documented in review articles in the United Kingdom and USA (Motov & Khan, 2009; Taylor & Standbury, 2009). Those review articles targeted at nurses, but the papers we reviewed showed that nursing students were also not ready for pain

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management. This prompted the efforts on improving the basics, pain education in nursing students. Nurse educators need to better equip nursing students for pain management. For development and adoption of pain education program, nurse educators are encouraged to adopt an evidence-based approach.

Three included studies in the review were of a quasi-experimental design with or without a control group (Chiang et al., 2006; Keefe & Wharrad, 2012; Owens et al., 2014). The effects of the interventions on knowledge and attitudes were measured in the pre- and post-intervention period. However, different instruments were adopted in the studies, making comparison across studies difficult. In addition, most studies were not adequately powered to examine intervention effectiveness. The sample size ranged from 50 to 192, but the response rate was rather low and the number of participants in the intervention group was small. As a result, even though the evidence for the effectiveness of the pain education program was positive, it is premature to generalize the findings to all pain education programs or those specifically designed for children‟s pain management.

The design of the pain education programs was illustrated in the identified studies, but none of them was based on an established model or was theory-driven. Only the cognitive-behavioral training program in the study by MacLaren et al. (2008) was designed in accordance with the recommendations from the reviews of training literatures. Besides, three studies focused on children‟s pain management (Chiang et al., 2006; MacLaren et al., 2008; Owens et al., 2014) and one targeted e-learning resources. Therefore, the components of the programs varied across the included studies and thus the combination of results by meta-analysis was not appropriate.

To improve the validity of the interventions, the use of a theoretical framework to guide intervention design and a well-designed randomized control trial to evaluate intervention efficacy will improve the credibility of the results and strengthen the body of research. Testing the pain education programs with different nursing student populations and across different cultures can also increase the generalizability of the results.

Future research directions

Nurse educators and researchers are encouraged to take a step back to examine factors, such as psychosocial factors, which may influence the nursing students‟ pain knowledge and attitudes. More importantly, an examination of how pain knowledge and attitudes affect nursing students‟ clinical performance is crucial. As culture affects how pain is assessed and managed (Narayan, 2010), and cultural differences are dominant barriers for nurses‟ pain management (Strassels, Duke, Driver, Petty, & Torges, 2008), it is also important to study nursing students‟ pain knowledge and attitudes against different cultural backdrops. Nurse educators need to pursue evidence-based interventions to enhance the pain knowledge and attitudes of nursing students. The sustainability of improvement in pain knowledge and attitudes should also be a common goal for nurse educators. The evaluation of the effectiveness of these programs on students‟ actual pain management performance in the clinical setting is also essential but it is non-existent in the studies examined. The gap between knowledge and application must be addressed because, after all, the pain knowledge and attitudes of nursing students need to be translated into apt performance in pain management in real-life setting. Otherwise, nursing students are still not prepared to take up their responsibilities in pain management.

CONCLUSIONS

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A review of the literatures on pain knowledge and attitudes of nursing students worldwide has revealed that in general, their pain knowledge is inadequate and attitudes regarding pain management are inappropriate. Interventions that aim to enhance their pain knowledge and improve attitudes towards pain management have been shown to be effective. Limitations of the assessment of pain knowledge and attitudes studies as well as interventional studies were identified. Future research directions have also been identified. In particular, nurse educators and researchers are recommended to consider the other variables that might influence pain knowledge and attitudes, the impact of pain knowledge and attitudes on actual pain management in clinical practice, and the development of evidence-based intervention to improve nursing students‟ pain knowledge and attitudes.

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Owens, D., Smith, J., & Jonas, D. (2014). Evaluating students‟ knowledge of child pain and its management after attending a bespoke course. Nursing Children and Young People, 26(2), 34-40.

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Table 1. Descriptions of knowledge and attitudes regarding pain management among nursing

students

Author(s)

(year)

Sample Research design Instruments Findings

Goodrich (2006)

N=unspecified n=unspecified number of nursing students n=10 nursing faculty

A descriptive, cross-sectional and longitudinal study

Pain Knowledge and Attitude Survey (McCaffery & Pasero, 1999)

Overall, the performance of the students was suboptimal but there was no indication of exact mean scores. Students increased their pain knowledge and attitude scores as they progressed through the curriculum.

Plaisance & Logan (2006)

N = 313 nursing students from an associate program and a baccalaureate nursing program in Louisiana

A descriptive cross-sectional survey

The Nurses‟ Knowledge and Attitudes Survey Regarding Pain (NKASRP) (Ferrell & McCaffery, 1998b)

The mean score for all nursing students was 64% correct in the NKASRP. The items with the poorest responses were related to medications‟ actions, side effects, and administration. Baccalaureate nursing students had significantly better performance than associate degree nursing students on the pharmacology items.

Rahimi-Madiseh et al. (2010)

N= 146 nursing students in Iran


The Knowledge and Attitudes Regarding Pain Tool (KARPT) (Ferrell & McGuire, 1998)

The mean score was 37% in the 36-item KARPT. No students answered more than 60% of the items correctly. Only 4.8% of students answered at least 50% correctly and more than 50% of the students were

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knowledgeable on only 10 items in the KARPT.

Shaw & Lee (2010)

N = 430 undergraduate nursing students in Auckland


Self-designed instrument

Students had misconceptions about adults with chronic non-malignant pain. Over 50% of the students held the misconceptions that psychological impairment was related to chronic pain; stress was a contributory cause of chronic pain; depression played a role in the experience of chronic pain; and patients taking opioids were likely to be addicted. The misconceptions were held to a lesser extent by the senior nursing students.

Al-Khawaldeh et al. (2013)

N= 240 baccalaureate nursing students in Jordan


Questions on whether students read about pain, frequency of using objective pain assessment tools in clinical training, and work experience in hospital. Revised Knowledge and Attitudes Survey Regarding Pain (KASPR) (Ferrell & McCaffery, 2008) Self-developed

The students‟ mean score for the revised KASRP was 34.1%. Students who had received pain management training had significantly higher scores than those who had not. Students who used pain assessment tools more frequently had significantly higher scores than those who never or rarely used pain assessment tools. The most prominent barriers to pain assessment were lack of knowledge

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perceived barriers to pain management scale

and training regarding pain management,” “nurses working in clinical areas not using pain assessment tools and techniques,” and “unavailability of pain assessment tools in the clinical areas”.

Al Khalaileh & Al Qadire (2013)

N = 144 undergraduate nursing students in Jordan


The Knowledge and Attitudes Survey (KAS) Regarding Pain (Ferrell et al., 1993)

The mean score in the KAS was 16 out of 40 and there were no significant gender differences. Whether students had received pain education or not also had no impact on their performance.

Duke et al. (2013)

N = 162 students in a baccalaureate nursing program in Texas and n = 16 nursing faculty members at the same institution


The Knowledge and Attitudes Survey Regarding Pain (KASRP) (Ferrell & McCaffery, 2008)

The mean score of the KASRP was 22.41 out of 36 for the whole sample. There was a positive correlation between the level of education and the score of the KASRP. Significant differences occurred between the junior and senior students, and between the junior students and faculty members.

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Table 2: Evaluation of pain education program for nursing students

Author(s)

(year)

Sample Research design;

instruments

Education

program

Findings

Chiang et al. (2006)

N = 192 student nurses in a nursing school in Taiwan

One group, pretest and posttest design A pain-related topics instrument modified from McCaffery and Ferrell (1997), and Manworren and Hayes (2000)

A four-hour program focusing on children‟s pain including misconceptions, pain assessment tools, pharmacological and non-pharmacological pain management

Didactic presentation and interactive discussion of case scenarios

A 28-minute video was presented to demonstrate pain assessment tools and non-pharmacological pain management

Before the pain education, students answered only 57% of the questions correctly, and the total standard score of pain knowledge and attitudes was 55. After the program, 91.4% questions were answered correctly, and the standard score increased to 74.1 which were significantly higher than the pretest score. The standard score for self-efficacy had a significantly increase from 73.37 to 87.07 after the program.

Owens et al. (2014)

N = 127 pre-registration nursing students from the United Kingdom

A quasi-experimental study with pretest and posttest design An instrument adapted from the Nurses‟ Knowledge and Attitudes Regarding Pain

Structured pain management educational program

Three three-hour workshops delivered by a pain nurse specialist

Two workbooks on

Despite similar scores at baseline, the intervention group had higher scores after the intervention in pathophysiology, pharmacology and the management of pain, and perception/attitudes about children‟s cancer than the

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Survey questionnaire (Ferrell & McCaffery, 1995)

knowledge of physiology, pain assessment and pain management strategies for children

Half-day clinical placement with pain team

Reflection on learning

Content focused on essential skills, acute and continuing care of children and young people

control group. Six months after the intervention, both groups believed and demonstrated that they had better pain knowledge but for some items in the questionnaire, less than 50% of the intervention group were able to answer the questions accurately.

MacLaren et al. (2008)

N = 58 nursing students from a junior-level baccalaureate nursing program in the United States of America

A randomized controlled trial The Knowledge and Attitudes of Pain Management Questionnaire (KAPMQ) designed by the author

Cognitive-behavioral pain management training program

A 20-minute didactic information session on cognitive-behavioral techniques for pain control in children

Handouts of the training program were provided for reference

Instruction to practice implementation of distraction and

There was no significant effect of training on attitudes towards cognitive-behavioral pain management. The training group had significantly more knowledge on non-pharmacological pain management at post-assessment than the control group. The use of cognitive-behavioral strategies by the training group was higher in quality but not quantity than the control group.

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guided imagery as a homework assignment

Keefe & Wharrad (2012)

N = 206 undergraduate master nursing students from the United Kingdom

A quasi-experimental study with pretest and posttest design A questionnaire adapted from Ferrell and McCaffery‟s Nurses‟ Knowledge and Attitude Survey Regarding Pain (NKASRP) (Ferrell & McCaffery, 1998a)

E-learning resources development:

One module on pain assessment and one on treatment of pain

Articulate software was used to incorporate interactions, audio commentary and images

Average 10-30 minutes to complete one module

After the intervention, the intervention group had significantly better performance in the NKASRP with a mean response accuracy of 73.1% compared to 53.8% in the control group. The more senior the year of study, the higher the scores for both the assessment and treatment of pain.

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Table 3. Critical appraisal of descriptive cross-sectional studies

Appraisal questions Al Khalaileh & Al Qadire (2013)

Al-Khawaldeh et al. (2013)

Duke et al. (2013)

Goodrich (2006)

Plaisance & Logan (2006)

Rahimi-Madisch et al. (2010)

Shaw & Lee (2010)

1. Did the study address a clearly focused question / issue?

Yes Yes Yes Yes Yes Yes Yes

2. Is the research method (study design) appropriate for answering the research question?


3. Is the method of selection of the subjects (employees, teams, divisions, organizations) clearly described?


4. Could the way the sample was obtained introduce (selection) bias?


5. Was the sample of subjects representative with regard to the population to which the findings will be referred?


6. Was the sample size based on pre-study considerations of statistical power?

No No No No No No No

7. Was a satisfactory response rate achieved?

No No No Can‟t tell Can‟t tell Yes Yes

8. Are the measurements (questionnaires) likely to be valid and reliable?

Yes Yes Yes Yes Yes Yes No

9. Was the statistical significance assessed?

Yes No No No Yes No Yes

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10. Are confidence intervals given for the main results?


11. Could there be confounding factors that haven’t been accounted for?


12. Can the results be applied to your organization?

Yes Yes Yes Yes No No Yes

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Table 4. Critical appraisal of interventional studies

Appraisal questions Chiang et al. (2006)

Owens et al. (2014)

MacLaren et al. (2008)

Keefe & Wharrad (2012)

13. Did the study address a clearly focused question / issue?

Yes Yes Yes Yes

14. Is the research method (study design) appropriate for answering the research question?

No Yes Yes Yes

15. Were there enough subjects (employees, teams, divisions, organizations) in the study to establish that the findings did not occur by chance?

No No Yes No

16. Were subjects randomly allocated to the experimental and control group? If not, could this have introduced bias?

N/A No Yes No

17. Are objective inclusion / exclusion criteria used?

Yes Yes Yes Yes

18. Were both groups comparable at the start of the study?

N/A Yes Yes Yes

19. Were objective and unbiased outcome criteria used?

Yes Yes Yes Yes

20. Are objective and validated measurement methods used to measure the outcome? If not, was the outcome assessed by someone who was unaware of the group assignment (i.e. was the assessor blinded)?

Yes Yes No Yes

21. Is the size effect practically relevant?

No No No No

22. How precise is the estimate of the effect? Were confidence intervals given?

No No No No

23. Could there be confounding factors that haven’t been accounted for?

No No No No

24. Can the results applied to your organization?

No No No No

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Highlights

We identify, summarize and critically appraise current evidence on pain knowledge and attitudes of

nursing students.

We identify, summarize and critically appraise current evidence on pain education programs for

nursing students.

Nursing students worldwide had inadequate pain knowledge and inappropriate attitudes towards

pain management.

Pain education programs, in general, were found to be effective in improving nursing students’ pain

knowledge and attitudes.

pain knowledge and attitudes of nursing students: a literature review

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