Nurses' Knowledge of Pain: Benita Wilson
Nurses' Knowledge of Pain: Benita Wilson
Nurses' Knowledge of Pain: Benita Wilson
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
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
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
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-
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Issues in clinical nursing Nurses’ knowledge of pain
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
pain management. Journal of Advanced Nursing 17, 362–372.
Gross RD (1999) Psychology the Science of Mind and Behaviour, 3rd
Contributions edn. Hodder and Stoughton, London.
Hamilton J & Edgar L (1992) A survey examining nurses’
Study design: BW; data analysis: BW and manuscript knowledge of pain control. Journal of Pain and Symptom
preparation: BW. Management 7, 18–26.
Harrison A (1991) Assessing patients’ pain: identifying reasons for
error. Journal of Advanced Nursing 16, 1018–1025.
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