Nurses' Knowledge of Pain: Benita Wilson

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ISSU ES I N CLINICA L NUR SIN G

Nurses’ knowledge of pain


Benita Wilson BSc, MSc, PGCE, RGN, DN
Tutor in Health Studies, Faculty of Health and Social Care, The University of Hull, Hull, UK

Submitted for publication: 12 September 2005


Accepted for publication: 18 March 2006

Correspondence: WILSON B (2007) Journal of Clinical Nursing 16, 1012–1020


Benita Wilson Nurses’ knowledge of pain
Tutor in Health Studies department Aim. The aim of this study was to establish if postregistration education and clinical
Faculty of Health and Social Care
experience influence nurses’ knowledge of pain.
The University of Hull
Background. Inadequacies in the pain management process may not be tied to myth
210 Nidd Building
Cottingham Road and bias originating from general attitudes and beliefs, but reflect inadequate pain
HULL HU6 7XR knowledge.
UK Design. A pain knowledge survey of 20 true/false statements was used to measure
Telephone: þ44 01482 464601 the knowledge base of two groups of nurses. This was incorporated in a self-
E-mail: [email protected] administered questionnaire that also addressed lifestyle factors of patients in pain,
inferences of physical pain, general attitudes and beliefs about pain management.
Method. One hundred questionnaires were distributed; 86 nurses returned the
questionnaire giving a response rate of 86%. Following selection of the sample, 72
nurses participated in the study: 35 hospice/oncology nurses (specialist) and 37
district nurses (general). Data were analysed using SPSS.
Results. The specialist nurses had a more comprehensive knowledge base than the
general nurses; however, their knowledge scores did not appear to be related to their
experience in terms of years within the nursing profession.
Conclusion. Whilst educational programmes contribute to an increase in know-
ledge, it would appear that the working environment has an influence on the
development and use of this knowledge. It is suggested that the clinical environment
in which the specialist nurse works can induce feelings of reduced self-efficacy and
low personal control. To ease tension, strategies are used that can result in nurses
refusing to endorse their knowledge, which can increase patients’ pain.
Relevance to clinical practice. Clinical supervision will serve to increase the nurses’
self-awareness; however, without power and autonomy to make decisions and affect
change, feelings of helplessness, reduced self-efficacy and cognitive dissonance can
increase. This may explain why, despite educational efforts to increase knowledge, a
concomitant change in practice has not occurred.

Key words: education, knowledge, nurses, pain, palliative care, practice

misconceptions about the pharmacological treatment of pain


Introduction
(Brockopp et al. 1998), exaggerated risks of opioid addiction
Previous studies document how practice is often led by myth and respiratory depression (Brockopp et al. 1998), patient
and bias rather than evidence-based knowledge. Myths include tolerance (Ferrell et al. 1993), misconceptions in relation to

1012  2007 Blackwell Publishing Ltd


doi: 10.1111/j.1365-2702.2006.01692.x
Issues in clinical nursing Nurses’ knowledge of pain

treatment of older patients (Closs 1996, Yorke et al. 2004) and had failed to prepare them adequately to care for patients in
children (Kart et al. 1997, McCaffery & Pasero 1999) and pain. Fothergill-Bourbonnais and Wilson-Barnett (1992)
disbelieving the patients’ pain reports (Walker 1994, Seers & concluded that it was the working environment and clinical
Friedli 1996, Bostrom et al. 2004). Reliance on such practice work undertaken within the specialist setting that was
and ritual often results in ineffective pain management and perceived by the nurses to be most influential in their
unnecessary suffering (Adriaansen et al. 2005). acquisition of knowledge about pain management. Further,
Hamilton and Edgar (1992) argue that most studies it was suggested that it was the hospice environment that was
concentrate on postoperative pain or malignant disease and perceived to have a greater influence in contributing to the
identify attitudes and beliefs as an explanation for ineffec- nurses’ knowledge base.
tive pain management, rather than lack of knowledge.
Consequently, Hamilton and Edgar (1992) adapted the pain
Effectiveness of pain education for nurses
knowledge and attitude survey by McCaffery (1989) to
examine nurses’ knowledge and understanding of the Adriaansen et al. (2005) describe the results of a study that
physiological/pharmacological aspects of pain assessment considered the effect of a postqualification course in palliative
and management, a direct contrast to isolating attitudes and care on the development of knowledge and self-efficacy for
beliefs of nurses. The results of the study indicated that two groups of nurses, Registered Nurses (RN) and Licensed
nursing staff had incorrect or incomplete knowledge regard- Practical Nurses (LPN). Pre- and post-course tests for
ing basic concepts and principles in the areas of: knowledge and self-efficacy using the self-efficacy instrument
• Differences between acute and chronic pain; for palliative care (SEP) were conducted. Because of the
• True risks of addiction; difficulty in approaching patients with poor prognosis,
• Duration of the action of analgesia; practice effectiveness was determined by measuring the
• Equivalent doses of analgesia. participants’ satisfaction and knowledge scores. The course
The authors concluded that inadequacies in the pain included regular reflective meetings with supervisors to
management process may not be tied to myth and bias discuss the practitioners’ own attitudes and progress in
originating from general attitudes and beliefs, but reflective of implementing change in the practice setting. The study used
inadequate pain knowledge. King (2004) identified how written assignments to demonstrate the nurses’ knowledge
nurses confirm that they have a limited understanding of and acquired competencies, as the authors suggested that
pharmacology and claim they are dissatisfied with the these evaluated the quality of palliative care given by the
educational experience, leading to feelings of anxiety follow- RNs. The focus of the reflective sessions centred on practical
ing qualification. The nurses acknowledged that they needed ways of improving care and involved discussion of the
pharmacological knowledge to underpin their practice of obstacles to care delivery. The RNs demonstrated an increase
patient assessment, nurse prescribing and drug administra- in knowledge, but the greater improvement was noted in their
tion. SEP score. The LPNs demonstrated a greater improvement in
Fothergill-Bourbonnais and Wilson-Barnett (1992) the knowledge and insight test; however, significant increases
conducted a comparative study involving hospice and Inten- in their SEP score did not occur as a result of the educational
sive Care Unit (ICU) nurses to identify and compare: input. It is of note that the LPN’s SEP score was higher than
• Perceived adequacy of knowledge base; that of the RN’s at the start of the course. The conclusion was
• The acquisition of knowledge pertaining to theoretical and that palliative care courses could make a significant contri-
pharmacological/non-pharmacological aspects of pain and bution to nurses’ knowledge and insight, as well as their self-
its management. efficacy in providing palliative care. This begs the question as
All the nurses were defined as expert as a consequence of to why there is a theory practice divide that results in patients
having more than three years postregistration experience in experiencing pain if the nurses feel that education and clinical
their respective specialist field. Both groups were seen as experience increase their knowledge base and self-efficacy.
specialist nurses managing pain in the critical or chronic
stage. The results indicated that, although the self-assessment
Effectiveness of pain education for patients
performance ratings of the hospice nurses were higher than
that of the ICU nurses, both groups demonstrated a reduced Wallace (1997) argues that only a few studies have con-
knowledge in specific content areas. The participants in centrated on evaluating the effectiveness of pain education,
general were not confident about their knowledge of with most focusing on practice in terms of assessment or
analgesia and suggested that their basic nurse education completion of documentation. Adriaansen et al. (2005)

 2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 1012–1020 1013
B Wilson

suggest that the impact of palliative care courses on pain The intention of this study was to compare two groups of
management is not well documented. Moreover, the evidence expert nurses. The hospice/oncology nurses are defined as
that does exist suggests that the effects on improving practice expert nurses because of their post-basic education and
are poor. clinical experience (Fothergill-Bourbonnais & Wilson-
Brown (2000) analysed the effects of a pain management Barnett 1992). However their focus and concentration on
project and identified that, whilst the pain knowledge scores pain management, identifies them as specialists within this
for staff were comparable with national averages, they did field (expert specialists). The second group was comprised of
not represent an acceptable level of knowledge and under- district nurses, primary care-based nurses who are often team
standing for optimal pain management. Following the intro- leaders and largely responsible for caseload management.
duction of the project, the nurses’ scores for the knowledge They are also defined as expert nurses because of post-basic
and attitude survey increased and the patients’ survey education and clinical experience (Fothergill-Bourbonnais &
identified high levels of satisfaction with care. However, the Wilson-Barnett 1992), but their focus and concentration on a
patients continued to report that they were experiencing wide range of nursing skills and clinical interventions makes
unrelieved pain of a moderate intensity. Brockopp et al. them generalists within the nursing profession (expert
(1998) suggest that, despite educational efforts to increase generalists), who engage in pain management. Selecting two
knowledge base, a concomitant change in practice has not groups of expert nurses, who have undergone postregistra-
occurred. tion education, allows a meaningful comparison in terms of
Similar results were identified by Innis et al. (2004), who clinical experience and level of education. The identifiable
examined the impact of pain education for practitioners on differences between the two groups should be the type of
patient satisfaction. Although the nurses’ pain knowledge clinical experience and focus of their knowledge base and
scores increased and their practice of documenting patients’ should afford the study the opportunity to identify if these
pain scores improved, the medical patients in the study did two factors influence knowledge levels.
not express lower levels of pain. This was despite expressing
an increased satisfaction with the service. Explanation for
Sample and method of data collection
this observation suggests that the results reflect inadequate,
ineffective pain control in the hospitals, with patients
Participants
believing that the staff are doing all that they can to relieve
their suffering. Bostrom et al. (2004) provide evidence to One hundred questionnaires were distributed and 86 nurses
support this explanation stating that, as interventions fail to responded giving an 86% response rate. The nurses were
address the problem, patients lose confidence in the practi- selected on their willingness to participate; representing an
tioners and cease to believe that pain relief is attainable. opportunity sample that was stratified to include equal
Bostrom et al. (2004) conclude that patients perceive that the numbers of:
critical factors in increasing pain levels are not having their • Hospice/Oncology nurses (specialist);
pain assessed and not being believed. • District nurses (general).
The hospice/oncology nurses were identified as one group
because they both deal with patients in pain on a daily basis
Overview of study
and all had attended postregistration pain and pain manage-
This study will part replicate the studies of McCaffery (1986) ment courses. It is acknowledged that one group nurse
and Hamilton and Edgar (1992). However, Hamilton and individuals with various life-threatening conditions in the
Edgar selected their sample of nurses from the general terminal stages, whereas the other group care for individuals
population, this did not lend itself to a comparative study as with a diagnosis of cancer, during all stages of their illness.
differences in clinical background could not be identified. Any participants with less than three years postregistration
Fothergill-Bourbonnais and Wilson-Barnett (1992) compared experience within their field of expertise were discounted
two groups of nurses from specialist clinical areas who were from the study (Fothergill-Bourbonnais & Wilson-Barnett
defined as specialists in pain management, making it difficult 1992). All of the specialist nurses had attended postregistra-
for comparisons to be drawn between the groups. The aim of tion pain or pain management courses/programmes. Any of
this study was to consider the responses of two groups of the general nurses identifying that they had completed
nurses from different clinical backgrounds to establish courses/programmes including modules relating to pain
whether there is a difference in the knowledge base because were discounted from the study in an attempt to ensure that
of clinical experience and postbasic education. their pain knowledge was limited to their preregistration

1014  2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 1012–1020
Issues in clinical nursing Nurses’ knowledge of pain

education. Of the 40 questionnaires returned by the specialist English equivalent. The participants were informed that the
nurses, five were discounted because the participants had intention of the questionnaire was to identify the knowledge
fewer than three years experience in their field of expertise. base and attitudes of nurses to pain management. The
Of the 46 questionnaires returned by the general nurses, six instructions stressed that they should answer the questions as
were discounted because the participants had fewer than truthfully as possible and refrain from referring back to
three years experience in their field of expertise and three previous questions or making use of additional information,
because they identified that they had attended specific e.g. books, Internet or each other to obtain a correct
courses/programmes on pain and pain management. The response. Details of the participants’ age, sex, nursing
titles given to the participant groups reflected the differences qualifications, nursing experience (defined in years) and
attributable to the focus of their practice and the completion completion of previous courses/programmes, including mod-
of specific pain and pain management courses, rather than an ules specifically relating to pain and pain management were
inference that the hospice/oncology nurses were expert in requested. Any participants with fewer than three years
dealing with pain. This sample allowed for a meaningful experience within their field of expertise were discontinued
comparison in terms of the level of clinical experience and from the study.
education, with identifiable differences in the type of clinical
experience and the focus of the knowledge base.
Procedure

The Local Research and Ethics Committee and the Research


Materials
Governance Committee for the local trust approved the
The self-administered questionnaire was a revised version questionnaire. Ethical approval was granted, as there was a
of the 20 true/false statements taken from a pain survey considered opinion that the participants were able to make
devised by McCaffery’s (1986) pain knowledge and attitude their own decision as to whether they wanted to complete the
survey and revised by Hamilton and Edgar (1992). This was questionnaire. The British Psychological Society Ethical
designed to measure nurses’ knowledge in relation to Guidelines were followed at all times (British Psychological
physiological/pharmacological aspects of pain assessment Society 1993). Face-to-face discussion with the relevant
and management. The participants are asked to circle a senior nurses from the clinical areas took place to explain
true/false response of their choosing for each of the the instructions for distribution and completion of the
statements. questionnaires. The written instructions on the front sheet
of the questionnaire emphasized that the responses would
remain anonymous and that the participants should complete
Design
the questionnaires individually, refraining from co-operating
The knowledge survey was one of four sections within a in their answers. Fifty questionnaires were allocated to the
questionnaire that considered knowledge, lifestyle factors of hospice/oncology nurses (specialist) and 50 to the district
patients in pain, inferences of physical pain, general attitudes nurses (general). The respective senior nurses explained the
and beliefs about pain management. It was piloted using six instructions to the prospective participants at their team
experienced nurse lecturers, representing the four different meeting and distributed the material by leaving the question-
branches of nursing (adult · 2, child · 2, learning disabil- naires in the staff room/general office. The participants were
ity · 1 and mental health · 1) because the scenarios/vignettes self-selecting, based on their willingness to participate and
included patients/clients of all ages, different ethnic back- completed the questionnaires alone, then posted their
grounds and with varying physical and psychological needs. responses in a sealed designated box in the staff room/general
They were asked to comment whether the questions reflected office. The questionnaires were collected two weeks later by
current research and published authorities’ attitudes, based the researcher.
on their knowledge of pain and pain management. Following
discussions with a panel of senior nurses the word ‘compar-
Scoring procedure
able stimuli’ in question 7 was replaced with the word ‘same
stimuli’ and in question 16 the word ‘potentiator’ was Eighty-six questionnaires were returned, 14 participants were
changed to ‘increases’. This was an attempt to render the discontinued from the study leaving 72 questionnaires to be
questions ‘reader friendly’ and avoid incorrect responses scored. Correct responses for the true/false choice was given a
because of misunderstanding of the question. The drug names score of one, incorrect responses zero, making the possible
were changed from the original Canadian terms to the maximum score of 20. The participants score was then

 2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 1012–1020 1015
B Wilson

divided by the maximum score and multiplied by 100 to give Table 4 Correlation of the pain knowledge scores and number of
an overall percentage rating. years in nursing for the general nurses and specialist nurses as one
group using Spearman’s rho

q p
Data analysis and results
0Æ412 0Æ01
Descriptive and inferential statistics were used to analyse the
data.
Table 1 demonstrates that the specialist nurses obtained a Table 5 Correlation of the pain knowledge scores and number of
higher mean score then the general nurses by identifying more years in nursing for the general nurses and specialist nurses as indi-
correct responses on the pain knowledge questionnaire. The vidual groups using Spearman’s rho

pain knowledge scores for the specialist nurses were com- n q p


pared with the general nurses’ pain knowledge scores using a
Specialist nurses 35 0Æ491 NS
Mann–Whitney U-test. A significant difference was found
General nurses 37 0Æ578 0Æ01
between the two groups of nurses’ knowledge scores
(Table 2).
Table 3 illustrates the nursing experience in years there is a corresponding increase in knowledge scores as the
expressed as a mean score for both the specialist and general nurses’ experience in years increases (Table 4).
nurses. The mean scores were compared using a t-test to The specialist and general nurses’ pain knowledge scores
establish if there was a difference in the experience between were correlated with their experience in nursing years as
the two groups. There was no significant difference in the separate groups using Spearman’s rho (Table 5). The results
nursing experience in terms of years for the specialist and established that there was no relationship between the
general nurses. specialist nurses’ pain knowledge scores and their nursing
Spearman’s rho, a test of rank correlation, was used to experience in years (Table 5). However, a positive correlation
establish whether there was a relationship between the was found for the general nurses, suggesting that as the
number of years in nursing and knowledge scores for the general nurses experience increases there is a corresponding
general nurses and specialist nurses as one group. The results increase in knowledge scores (Table 5). Table 6 offers details
indicated that a positive correlation exists between nursing of the gender status, age range and mean age of the
experience in years and pain knowledge scores, for the participants. A t-test was used to compare the mean ages of
specialist and general nurses as one group. This suggests that the specialist and general nurses in order to establish if there
was a difference between the two groups. No significant
Table 1 Pain knowledge scores for the specialist and general nurses difference was found suggesting that a cohort affect did not
expressed as a total mean score, mean score as percentage and appear to be influencing the findings. The gender status of the
standard deviation participants appeared to be very similar for both groups.
n Mean score Mean score (%) SD

Specialist 35 15Æ8286 79Æ42 1Æ8066 Discussion


General 37 12Æ7568 64Æ86 2Æ9193
The questionnaire considered the nurses’ knowledge of pain
using questions that embraced a broad knowledge base
Table 2 Comparison of the specialist and general nurses’ responses related to pharmacology, theories of pain and general pain
for the pain knowledge survey using a Mann–Whitney U-test management. The difference noted between the specialist
U Z p nurses and general nurses’ knowledge scores suggests that the
specialist nurses had a more comprehensive knowledge base
269 4Æ307 0Æ01
than the general nurses. This study used the same pain
knowledge test as Hamilton and Edgar (1992), which
Table 3 Nursing experience in years expressed as a mean score for identified that the mean score for both groups of nurses
both the specialist and general nurses and comparison by t-test was 63Æ9%. They cited lack of pain control knowledge as the
n Mean SD t d.f. p
main influencing factor in nurses’ managing pain ineffec-
tively. It was concluded that a score of 63Æ9% or lower
Specialist nurses 35 17Æ3429 8Æ3769 1Æ683 70 NS
constitutes a poor knowledge score, therefore, it is reasonable
General nurses 37 14Æ1892 5Æ5197
to propose that the general nurses demonstrated a poor

1016  2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 1012–1020
Issues in clinical nursing Nurses’ knowledge of pain

Table 6 Gender status, age range and mean age for the specialist and general nurses with a comparison of ages using a t-test

Age range Male Female Mean age SD t d.f. p

Specialist 25–49 2 33 35Æ2857 6Æ7560 0Æ460 70 NS


General 26–54 6 31 36Æ0810 8Æ1353

knowledge of pain management. Equally, it is argued that the Fothergill-Bourbonnais and Wilson-Barnett (1992) is found
specialist nurses mean score of 79Æ4% indicated a ‘good’ in the positive correlational relationship between the know-
knowledge of pain. The difference in knowledge scores ledge scores and experience when the nurses were considered
identified between the two groups was expected, because of as one group. However, when the nurses were considered as
the specialist nurses’ educational and clinical experiences. separate groups, it was noted that the relationship existed for
However, this observation begs the question as to whether it the general nurses’ experience and knowledge scores, rather
is the working environment or the educational experience of than the specialist nurses (Table 5). The educational and
the specialist nurse that determines their superior knowledge clinical experience should reinforce each other; with the
base. academic experience offering opportunity to increase a
On first inspection, it would appear that the difference nurse’s knowledge base and the clinical environment allow-
between the pain control knowledge scores is attributable to ing them to consolidate academic learning and establish the
the educational differences that exist between the two groups links between theory and practice. This could explain the
of nurses, rather than the clinical experiences. All of the correlation between the experience and knowledge score for
specialist nurses participating in the study had attended at the general nurses who may have received ‘ad-hoc’ education
least one postregistration course or study day devoted to the from various sources such as drug companies or peers.
subject of pain management. Whilst the specialist nurses However, there may be something within the specialist
had the advantage of postregistration education on pain, nurses’ clinical experience that disrupts this development,
the general nurses’ formal education appeared to be restric- thus offering explanation as to why a practice theory gap is
ted to their preregistration programme. Sofaer (1998) and evident in the management of pain. Evidence as to why a
Ferrell et al. (1993) argue that there is a lack of compre- theory practice divide exists is beyond the scope of the limited
hensive coverage of pain and pain management within findings of this small study. However, analysis of the results
the preregistration curriculum. Fothergill-Bourbonnais and in conjunction with previous research findings, may offer an
Wilson-Barnett (1992) and King (2004) identified how nurses explanation for the data obtained and allow an exploration
were not confident about their knowledge of analgesia of the proposed theory practice divide.
and suggested that their basic nurse education had not All attitudes have three dimensions: cognitive, affective
adequately prepared them to care for patients in pain. All the and behavioural (Secord & Blackman 1964). Although the
participants had a minimum of three years postregistration components are interrelated, they are not necessarily
experience within their field of expertise, hospice/oncology interdependent; i.e. the attitude expressed (cognitive) or felt
or district nursing, and no significant difference in the (affective) is not always congruent with the actions (beha-
participants’ nursing experience in terms of years was viour) that an individual displays. This proposal would in
established. This would lend support to the proposal that part explain the theory-practice divide identified by the
the knowledge scores are influenced by the nurses’ evidence that suggests educational efforts to increase
educational experience and strengthens the argument that knowledge have failed to demonstrate a concomitant change
education leads to an increase in knowledge scores. in practice (Brockopp et al. 1998, Adriaansen et al. 2005),
In contrast, Harrison (1991) argues that experienced resulting in unnecessary patient suffering and dismissal of
nurses are more accurate at pain assessment, an indication the pain experience (Brown 2000, Bostrom et al. 2004,
that training and work experience has made them more Innis et al. 2004). However, this explanation is too
skilful at interpreting the relevant cues that lead to effective simplistic as it falls short of offering an explanation as to
pain management. Fothergill-Bourbonnais and Wilson-Bar- the cause of the incongruence between the three compo-
nett (1992), proposals support this suggestion that the nents and fails to address the complex nature of the
working environment and clinical experience following problem.
qualification is the most influential factor in contributing to Bandura (1997) highlights that our sense of self-efficacy
pain care knowledge, with the hospice environment proving influences our sense of personal control. When estimating the
the most influential. Evidence to support Harrison (1991) and chances of success or failure of a particular behaviour,

 2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 1012–1020 1017
B Wilson

consideration is given to the evaluation of the effects of a 1957) that necessitates the nurse trying to ease the disequi-
given course of action for the individual and others. The librium by changing or adding an extra cognition. As a result,
decision to perform that behaviour is then dependent upon the nurse may deny their knowledge base or resort to the use
the evaluation that: of defence mechanisms such as reaction formation, denial,
• The action will lead to a favourable consequence; rationalization and intellectualization (Gross 1999), used to
• The individual can execute the action correctly. distance the nurse from the situation. The behaviours that
It is the evaluation of these two factors that then dictates arise from this process would serve to increase cognitive
the degree of self-efficacy an individual has and ultimately dissonance and may result in an increase in patients’ pain
will influence the decision to perform the behaviour. Those (Walker 1994, Wakefield 1995, Brockopp et al. 1998, Brown
with a strong sense of self-efficacy show less psychological 2000). Bostrom et al. (2004) argue that patients perceived
and physical strain, it follows that a high sense of self-efficacy that the critical factors in increasing pain levels were not
is the necessary perception for a nurse with responsibility for having their pain assessed and not being believed. This would
managing patients’ pain. However, goals that cannot be influence future evaluations of behavioural outcomes and
achieved or lie outside of the individuals control may contribute to the development of a self-perpetuating cycle
engender feelings of low self-efficacy. The consequence of that is instrumental in acculturating student nurses or nurses
this may be a sense of learned helplessness, leading to a new to the clinical setting. The outcome of this process is a
situation whereby the individual fails to exert control in reduction in the intention to perform effective pain manage-
situations where success is possible. It is prudent to highlight ment behaviours; unfortunately, this in turn will generate
that learned helplessness and low self-efficacy are not always situations that serve to increase the nurse’s perception of low
the inevitable outcome of being exposed to negative uncon- self-efficacy, learned helplessness and external locus of
trollable situations. It is the perception of the individual that control.
serves to define the sense of self-efficacy. This proposal could help explain the actions of the nurses
Nurses are likely to be confronted with demands that they in the study conducted by Adriaansen et al. (2005). They
cannot meet in the clinical environment. This may be because identified that the RNs began to feel more competent
of pain that is difficult to manage or as a result of lack of following the educational course, as indicated by their SEP
control over pain management decisions, in particular medi- score. However, it was noted that the non-completers,
cation (Field 1996, Brockopp et al. 1998). Nurses have the participants that withdrew from the course, felt more
knowledge that their patients are in pain, but are often competent than the completers did. It could be argued that
limited in their ability to manage the patient’s experience. the extra knowledge and reflective exercises served to
Evidence highlights that denial and mismanagement of highlight the obstacles confronting the RNs and increased
patients’ pain is a part of the nurse’s daily experience the feelings of learned helplessness and cognitive dissonance
(Walker 1994, Seers & Friedli 1996, Brockopp et al. 1998, that then led to the overall feelings of low self efficacy when
Brown 2000, Bostrom et al. 2004). This would suggest that compared with the non-completers. The LPNs identified that
members within the subculture of the clinical setting are they felt more competent than the RN’s at the start of the
likely to have expectations of others in relation to the course and failed to demonstrate a significant increase
acceptability or appropriateness of both the nurse and following educational intervention. The authors commented
patient’s behaviour (Davitz & Davitz 1985, Wakefield that this result might reflect the fact that they defined
1995, Salmon & Manyande 1996). This expectation and themselves as experienced practitioners and, therefore, were
transmission of cultural values and beliefs is reinforced via expected to be competent; this supports the proposal of
the process of Social Learning (Bandura 1986). This results in Bandura (1997) that it is the perception of the individual that
colleagues exerting social pressure to ignore and disbelieve serves to define the sense of self-efficacy. Although it could be
patients’ reports of pain and conveying this message in their argued that the LPNs were not directly responsible and
actions as ‘role models’ (Davitz & Davitz 1981). Conse- accountable for the patients’ pain experience and as such did
quently, the nurses’ appraisal of self-efficacy and sense of not experience the sense of learned helplessness and cognitive
control is likely to be low; even when there is every chance of dissonance, they also did not attend the reflective workshops.
a successful outcome.
Nurses may have a sound knowledge base but this can be
Implications for practice
challenged by a state of tension brought about by the
perception that they have no control over the situation. This The changing face of health care demands that all nurses are
then generates a state of cognitive dissonance (Festinger better educated and encouraged to be reflective, evidence-

1018  2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 1012–1020
Issues in clinical nursing Nurses’ knowledge of pain

based practitioners rather than handmaidens of care. Clinical


Limitations
supervision and the use of reflection to analyse practice may
all serve to increase the nurses’ awareness of practice and self It is important to note that the study sample was small and
(NHS Executive 1999). However, increasing the specialist limited to a specific group of nurses who were self-selecting. It
nurses’ awareness of pain management, may only serve to has to be acknowledged that the general nurses may have
increase the conflict felt by the nurse who is confronted with a received relevant educational input as part of a module
situation that they feel that they cannot deal with. Without within their district nursing/community nursing programmes.
power and autonomy to make decisions and affect change, Although it did not appear to affect their overall knowledge
feelings of helplessness, reduced self-efficacy and cognitive scores. Any of the general nurses identifying that they had
dissonance are likely to increase. In the past, nurses followed completed courses/programmes, including modules relating
the instructions of doctors in a task-orientated approach, to pain, were discounted from the study. It is difficult to
often without the underpinning knowledge or realization of control exposure to ‘ad-hoc’ education for the general nurses
responsibility and accountability. Educating nurses and from sources such as drug companies. However, it could be
highlighting accountability may not only cause conflict argued that this input tends to be restricted to the medicines,
between doctors and nurses (Brockopp et al. 1998), but also appliances and products that the district nurse can either
add to the feelings of helplessness that may ultimately lead to prescribe or are instrumental in recommending to the doctor
ineffective patient care (Walker 1994, Seers & Friedli 1996). for prescription. It usually does not extend to narcotics or
Adriaansen et al. (2005) argue that nurses have the ability to alternative drugs used in the management of pain. In
reflect on their own professional practice and are capable of addition, the discussion of the findings relies on previous
evaluating whether their attitudes and actions are congruent research findings to explain the absence of a correlational
with professional norms and patient needs. This is com- relationship between the specialist nurses’ knowledge scores
mendable, but only if the professional norms are congruent and nursing experience.
with the needs of the patient (Walker 1994, Seers &
Friedli 1996), if patients feel able to express their needs
Conclusion
(Brockopp et al. 1998, Bostrom et al. 2004) and if nurses
believe their accounts when they do (Walker 1994, Bostrom The limited findings of this small study, in conjunction with
et al. 2004). previous research findings suggests that the specialist nurses
Brockopp et al. (1998) warn that the barriers to effective would appear to have a more comprehensive knowledge
pain management are more complex than a lack of know- base in relation to physiological/pharmacology aspects of
ledge on the part of the health care providers, suggesting that pain and pain management than the general nurses within
education is not adequate when inappropriate behaviours are this study. Although it is clear that educational programmes
maintained by attitudes, social and structural problems. As have contributed to an increase in knowledge scores, it is
the nurses’ and doctors’ role become less defined and there is important to establish what affect the working environment
a transfer of responsibility and accountability, it is essential has had on the development of this knowledge base. The
that resources are made available to allow the nurse to high knowledge scores obtained by the specialist nurses did
address the problems. Only then will there be an improve- not appear to be related to their experience in terms of years
ment in patient care and an end to unnecessary suffering by within the nursing profession. The general nurses’ know-
both patients and nurses. Innis et al. (2004) advocate the need ledge scores were lower overall, but increased as they
for health practitioners to be held responsible for the became more experienced in nursing, despite the lack of
assessment and management of pain and call for a cultural formal education. An explanation for these findings is that
shift in the institutions to include a Multi disciplinary team the clinical environment in which the specialist nurse works
approach. Moreover, Brown (2000) argues that educational may induce feelings of reduced self-efficacy and low
approaches must be accompanied by interventions in care personal control, this then leads to feelings of learned
systems that directly influence the routine behaviours of helplessness and the development of an external locus of
clinicians, including the breaking down of barriers within the control. A state of cognitive dissonance may occur as a
multidisciplinary team, implementing comprehensive pain result of the conflict that arises from the nurses increased
management programmes that are evaluated and encouraging knowledge base and experience of having to deal with
trainers to act as ‘exemplars’. It is crucial that these ‘role patients’ unrelieved pain. To ease the tension, strategies are
models’ do not acculturate the nurses into a subculture that adopted to allow the nurse to survive within the system;
operates with actions that lead to ineffective care. these are only useful for defending and ignoring the stressor

 2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 1012–1020 1019
B Wilson

for a short time and are not effective ways of coping with Fothergill-Bourbonnais F & Wilson-Barnett B (1992) A comparative
the stressful situations. study of intensive therapy unit and hospice nurses’ knowledge on
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Gross RD (1999) Psychology the Science of Mind and Behaviour, 3rd
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Hamilton J & Edgar L (1992) A survey examining nurses’
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Harrison A (1991) Assessing patients’ pain: identifying reasons for
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