| | Education Changes Mexican Nurses' Knowledge and Attitudes Regarding Pediatric PainReceived 12 September 2008; received in revised form 29 July 2009; accepted 12 November 2009. published online 12 July 2010.
Corrected Proof Abstract This study explored the effectiveness of a pain education intervention on Mexican nurses' knowledge and attitudes toward pediatric pain. A convenience sample of 106 registered nurses from three hospitals in Mexico City was recruited. A Pediatric Pain Education Program (PPEP) was developed, implemented, and evaluated by a nurse researcher, clinical nurse specialist, and a child life specialist. The 4-hour program, which was translated into Spanish, consisted of pain assessment, physiology, and management, including pharmacology and nonpharmacology. The effects of PPEP were measured in a one-group pretest-posttest design using a translated Spanish version of the Pediatric Nurses' Knowledge and Attitudes Survey (PNKAS). A total of 79 nurses completed both tests. A paired t test indicated significant differences between pre- and posttest results (p < .0001) on the PNKAS. The hospital site and years of nursing experience were significantly related to nurses' pre- and post-PNKAS scores. One test item on children's ability to reliably report their pain had a significantly lower score after the intervention (p = .016). The intervention was effective in improving Mexican pediatric nurses' knowledge and attitudes. However, it is not known how long this effect was maintained. Health care professionals can share a common vision for pain management by increasing international collaborative efforts and by advancing pediatric pain knowledge. Pediatric pain management issues transcend continents and have no geographic boundaries (Broome & Huth, 2003). Worldwide, nurses continue to report a lack of knowledge concerning pain management techniques (Chui et al., 2003, Hamers et al., 1994, Salantera et al., 1999, Twycross, 2000, Van Hulle Vincent, 2005). However, research supports the idea that education can positively change attitudes and beliefs concerning pain management (de Rond et al., 2000, Huth et al., 2003, Tracey and Bramley, 2003). Knowledge through education can promote confidence and provide nurses with the ability and assertion to advocate on the patient's behalf and manage his or her pain effectively (Twycross, 2000). Because nurses are the largest group of universal health care providers (Dickenson-Hazard, 2004) they have a responsibility toward global health care which includes pain management. Nurses can share a common vision for pain management by increasing international collaborative efforts and by advancing pain management knowledge. In an effort to establish a collaborative and interdisciplinary education and research program, the Center for Professional Excellence at Cincinnati Children's Hospital Medical Center began the “Mexico City Project.” As part of this initiative we were invited to participate in a pain seminar. We took the opportunity to conduct an educational study. This study examined the effectiveness of a pain education intervention on Mexican pediatric nurses' knowledge and attitudes toward pediatric pain management. Literature Review  The effect of pain education on pediatric nurses' knowledge and attitude as well as their practice has been studied. Most recently, Johnston et al. (2007) used a clustered experimental randomized trial in six Canadian pediatric hospitals to determine whether coaching would change attitudes and knowledge about children's pain and improve pediatric pain practice. Out of 141 nurses who consented to participate, 90 completed the study and a total of 1,602 chart audits were performed. The experimental group received one-on-one coaching by leaders knowledgeable in pediatric pain with feedback for at least ten sessions after chart audits were completed on children for whom they provided care. The investigators found significant improvements in nurses' knowledge and documented pain assessments in the experimental group compared with the control group; however, there were significant differences between sites. Coaching did not increase the use of prescribed analgesics or the use of nonpharmacologic comfort strategies. They also found that the number of workshops that the nurses attended increased their knowledge scores. Furthermore, higher knowledge scores were more likely to result in nurses giving analgesics. A quasiexperimental design was used to evaluate patient and staff satisfaction with pediatric pain assessment guidelines and staff documentation (Treadwell, Franck, & Vichinsky, 2002). Eighty-five children or primary caregivers and 150 staff comprised the convenience sample conducted at two time points. The intervention consisted of multidisciplinary education and support to pediatric hematology/oncology staff (nurses, physicians, and psychosocial caregivers) on the implementation of a revised pain assessment. A questionnaire modified from the American Pain Society guidelines was used to interview children or their caregivers and staff. Respondents (i.e., children, family, and staff) reported increased staff pain assessment, staff responsiveness to the child's pain between time points, and greater satisfaction with the pain assessment tools. Chart audits also revealed an increase in the documentation of pain assessment and in the number of dimensions of pain that were assessed. A quality improvement project investigated the outcomes of a pediatric pain management program on nurses' practice (Knoblauch & Wilson, 1999). Fifty-two pediatric nurses who attended a 3-hour mandatory pain management program comprised the convenience sample for this study. Charts were audited over a 2-week period both before and after the educational program. Surprisingly, there was a reverse effect of increased lengths of time before the administration of the first dose of medication and between doses of medication after the educational program. The author's offered several possible explanations for the unexpected findings, e.g., the in-service program was not based on a needs assessment or individualized to the learner's needs, interactive teaching methods were not used, value clarification was not incorporated into the program, and the highest level of education was a baccalaureate degree. A multidisciplinary pediatric pain management program focused on learning behavioral pain management strategies (Solomon, Walco, Robinson, & Dampier, 1998). In this program, 43 attendees, 12 of whom were nurses, received 16 hours of content. Participants were evaluated on knowledge and skill acquisition. The tool used to measure knowledge was not presented, and skill acquisition was measured through the Pain Control Technique Checklist and participant videotapes. The investigators reported a significant difference in participants' knowledge from pre- to posttest and increased skill acquisition. Participants found that a variety of didactic and experiential experiences facilitated their learning. In Pederson's (1996) experimental design, 54 pediatric nurses were randomly assigned to either a treatment or control group. The treatment group attended a 2-hour educational program on five nonpharmacologic techniques that were appropriate for children. This program used a variety of teaching methods that included demonstration, discussion, and practice. Pediatric nurses reported significantly greater knowledge of and comfort with using nonpharmacologic pain techniques from pre- to posttesting. Also nurses' use of the five comfort strategies presented in the program increased from pre- to posttest. In the studies reviewed, a variety of methods, such as coaching, education, and support were used to educate nurses on pain management. Improvements were reported in knowledge, documented pain assessments, use of behavioral pain management strategies, staff responsiveness to a child's pain, and satisfaction with pain assessment tools. One study found that a pain management program did not increase the amount of analgesics given to children after surgery. Study limitations were low recruitment and high attrition rates, significant baseline differences between sites, combining children and caregiver reports, and the use of tools that lacked psychometric robustness. There is little published research that focuses on educating international nurses about pain management. To date, there is no literature that explores Mexican nurses' knowledge and attitudes regarding pain management in children. Two research questions guided this study. The first question was, “Do Mexican nurses who receive a pediatric pain education program (PPEP) have increased knowledge and attitude scores about pediatric pain management?” The second question was, “Are there differences in the Mexican nurses' knowledge and attitude scores based on age, education, years of nursing experience, site of employment, and current assessment of pain?” Methods Sample/Setting A convenience sample of 106 nurses who participated in the PPEP educational program comprised this nonrandomized pretest-posttest study. These nurses were employees of three hospitals in Mexico City: two pediatric public hospitals (n = 37) and one adult/pediatric private hospital (n = 69). The two pediatric hospitals were 313- and 350-bed facilities, and the adult/pediatric hospital was 220 beds, 20 of them pediatric beds. These three hospitals employed between 450 and 770 nurses. Further information on admitting diagnosis, acuity level, length of stay, staffing ratios, and the availability of analgesics were not made available to the investigators. Instrument The first instrument, Nurses' Knowledge and Attitudes Survey, was developed for nurses caring for adult patients (Ferrell & McCaffery, 1997) and was modified by Manworren (2000) for assessing pediatric nurses' knowledge and attitudes regarding pediatric pain. The Pediatric Nurses' Knowledge and Attitudes Survey (PNKAS) is a 40-item scale. The PNKAS was tested for content validity by a panel of five expert pediatric pain management nurses, and revisions were made. After the revisions the test-retest reliability after 8 weeks was 0.67 (Manworren, 2001). A Cronbach alpha of 0.72 and 0.77 for two samples of pediatric nurses demonstrates an acceptable level of internal consistency with this tool (Manworren, 2001). Spanish PNKAS Permission was obtained to use, modify, and translate the Pediatric Nurses' Knowledge and Attitudes Survey (PNKAS) into Spanish (Manworren, 2000). The original 42-item PNKAS was shortened to 30 questions and translated by the U.S. hospital's Spanish interpreter. Six of the omitted test questions were related to analgesic practices that were not used in Mexico City, such as the administration of Phenergan. The other six questions were omitted because they were not covered in the educational program. The resulting Spanish version of the PNKAS consisted of 19 true/false items, seven multiple-choice questions, and two patient case scenarios with two multiple-choice questions. This Spanish version of the PNKAS was not pilot tested before administration to Mexican nurses. In this study, there was no significant difference in terms of index of discrimination between the pre- and posttests. Using Kuder Richardson-20/Alpha, the reliability from this study was 0.65 (pretest) and 0.72 (post test), which is consistent with earlier results. The PNKAS has been used throughout the United States and translated into other languages, but it had not been translated to Spanish before this study. Procedure At the time this study was conducted, Mexico City's hospitals did not require a separate internal review process. The study was approved by the Internal Review Board in the U.S. Available nurses were invited to attend the presentation by each of their respective hospitals; the investigators did not contact any of the nurses before the presentations. Before each educational program, the participants were handed a packet by the researchers which contained a demographic sheet and a pre- and post-modified PNKAS. The participants were informed of the contents of the packet and the purpose of the study and that consent was implied by their voluntary completion of the packet. The participants were asked to individually complete the demographic sheet and pretest before the start of the presentations. Participants were allowed approximately 20 minutes to complete the demographics and pretest. More than one-half (n = 54) of the 106 participants answered all 30 questions, and the average number of answered questions was 28. This indicates that 20 minutes was an adequate amount of time to complete both the demographic sheet and pretest. The demographic sheet and pretest were collected before the PPEP and the posttest was collected at the end of the educational program at hospitals 1 and 2 by the researchers. Owing to the size of the audience at hospital 3, the pretest, posttest, and demographics were collected together after the educational intervention by the researchers. The program developers and presenters included two clinical experts (a clinical nurse specialist in pediatric pain management, and a child life specialist) and a docotoral nurse researcher specialized in pediatric pain management, all of whom were experts from the U.S. The curriculum was developed through a needs assessment which was obtained by a conference call with each Mexico City hospital to prepare for the PPEP presentations. The needs identified by all three hospitals included the skills and tools needed for pediatric pain assessment and the management of pain. The PPEP presentations were translated into Spanish by the U.S. hospital's interpreter. All of the presenters had interactions with a small group of Mexican nurses at our hospital before the presentation. Due to the time constraints, the Mexican nurses did not critique the PPEP content. The 4-hour presentations included a variety of styles, including lecture, question-and-answer format, case studies, props, and discussions. The educational program focused on basic principles of pain management in the pediatric patient and included content specific to pain processing pathways, pain assessment, and pharmacologic and nonpharmacologic strategies for treatment (Table 1). The program was similar in content for all three hospitals, although the delivery style varied. In the public hospitals, an interpreter translated the presentation after the speaker presented each slide (which had been translated into Spanish). However, the child life specialist was able to present portions of her presentation in Spanish. In the private hospital, the interpretation was performed simultaneously via headsets. Upon completion of the program, nurses from one hospital received a certificate signed by the investigators. The investigators have not provided any other follow-up education to these nurses.  | Pain Processing Pathways | | |  Nociceptive pain processing | | | Afferent fibers | | | Dorsal horn | | | Ascending tracts | | | Modulatory systems | | | Neuropathic pain processing | | | Centrally generated | | | Peripherally generated | | | Case study | | | Pain Assessment | | | Philosophy | | | Factors affecting pain | | | Signs of pain | | | Assessment | | | Initial | | | Reassessment | | | Pain scales | | | NIPS | | | CHEOPS | | | Oucher | | | VAS/NRS | | | Documentation | | | Evaluation | | | Pharmacologic Strategies | | | Analgesic steps | | | Nonsteroidal antiinflammatory drugs (NSAIDs) | | | Oral combinations with opioids | | | Opioids | | | Pain terminology | | | Tolerance | | | Physical dependence | | | Addiction | | | Placebos | | | Dosing guidelines | | | Onset and duration of intravenous opioids | | | Fentanyl | | | Morphine | | | Dilaudid | | | Demerol | | | Opioid side effects | | | Onset and duration of oral analgesics | | | Patient controlled analgesia | | | Eutectic mixture of local anesthetics | | | Effective dermal analgesia | | | Nonpharmacologic Strategies | | | Preparation | | | Role of parents | | | Environment | | | Developing a coping plan with child/family | | | Nonpharmacologic techniques | | | Alternative focus | | | Prayer | | | Breathing | | | Massage | | | Guided imagery | | | Play | | | Post procedural processing | | | Managing chronic pain | | | Appropriate use of humor | | | Care for the care giver | | | | |
Statistical Analysis Descriptive statistics were used to summarize the sample demographics and test scores. Analysis of variance (ANOVA) and exact tests were used to check the differences in demographic variables among the three hospitals. To analyze the research question on differences in knowledge and attitude before and after the intervention, a paired t test was conducted. Differences between each test item before and after the educational program was analyzed with McNemar test. To test the question that demographic variables related to knowledge and attitude differed among the three hospitals, repeated-measures ANOVA was performed for classified variables. Tukey pairwise comparisons were done as post hoc tests for significant variables. Pearson correlation coefficients were used to check for relationships between the test scores and the continuous variables of the nurse's demographics. All analyses were conducted by SAS 9.1. The two-sided significance level was set as .05. Results Description of the Sample A total of 130 questionnaire packets were distributed over all three hospitals. The final sample consisted of 106 nurses (Table 2). Four (3.8%) of the participants provided no demographic information, and some of the participants did not answer specific demographic questions. The mean age of all the participants was 34.1 ± 8.8 years and ranged from 19 to 60 years. The sample was composed of mainly women (91.3%) with technical education (62.9%). Educationally, the technical nurse in Mexico is similar to a licensed practical nurse. Slightly fewer than one-third of the nurses (31.9%) in this sample had a BS degree. The majority (76.2%) of nurses had ≤10 years of pediatric experience. In response to the question “do you assess pain,” 58.2% responded “yes” and 41.8% said “no.” This question was intended to determine whether pain assessment is a part of the nurse's role in pain management. | ∗ p < .05. †Analysis of variance. ‡Exact test. |
There were significant differences in the participant's age, years of nursing and pediatric nursing experience, and the assessment of children's pain among the three hospitals (Table 2). The nurses from hospital 1 were significantly older (p = .0302) and had more years of nursing experience than those in hospital 3. Hospital 2 also had nurses with more years of nursing experience than those in hospital 3. Hospitals 2 and 3 had significantly less pediatric nursing experience than those in hospital 1 and reported more use of pain assessment than did the nurses in hospital 3. The investigators are unaware of the amount of pediatric pain content nurses are given in their educational curriculums. Knowledge and Attitude A total of 79 nurses completed both pre- and posttests. The response rate for the pre- and posttest were 81.5% (106 out of 130) and 60.8% (79 out of 130), respectively. The range of possible scores on the Spanish PNKAS was 0-30. The mean score in the posttest was 16.7 ± 4.33, which was significantly higher than the pretest score of 13.1 ± 3.89 (95% confidence interval [CI] 2.75-4.49; p < .0001). The pre- and posttest scores were significantly correlated at r = .56 (p < .0001). Demographic Variables Related to Knowledge and Attitude No significant differences were found for nurses' age, current school enrollment, and pain assessment practices related to Mexican nurses' pre- and posttest PNKAS scores. The hospital site and years of nursing experience were significantly related to pre- and posttest PNKAS scores. In the pretest, nurses from hospital 1 scored higher than those from hospital 3 (p = .004; Fig. 1). Posttest results of nurses from hospital 2 were higher than those from hospital 3 (p = .01). Posttest scores from hospital 2 improved more than the scores from hospital 1 (p = .04). Figure 2 illustrates that nurses who had worked <5 years scored significantly lower on the pretest PNKAS than those who had worked >20 years (p = .04). However, after the PPEP, nurses working <5 years showed greater improvement than those working 6-10 years (p = .04). Additional Analysis Further analysis revealed that only one test item had a significantly lower score after PPEP (odds ratio .38, 95% CI .17-.86; p = .016). The question asked whether children <8 years old reliably report their pain. The level of item difficulty for this question was 54%, which means that slightly more than half of the nurses answered this question correctly. The discrimination index was 0.27. Item discrimination index refers to the correlation between each item with the overall test score (Ferketich, 1991). An item that scores less than 0.1 is considered to be a poor discriminator, and a correlation above 0.3 good. Four other questions that were most frequently missed are shown in Table 3, along with the items' correct answers and index of difficulty and discrimination. | ∗ Poor discrimination (<.1). |
Discussion In this study, pediatric nurses' pain knowledge and attitude scores significantly changed after a 4-hour educational program in three Mexican hospitals. This effect is similar to other findings in which pediatric pain educational programs report knowledge differences from pre- to postsurvey (Johnston et al., 2007, Pederson, 1996, Solomon et al., 1998). However, differences exist between the studies in the length of the educational programs (2-16 hours), instruments used to assess knowledge and attitudes, and the participants. Only one other study included six different Canadian hospitals (Johnston et al., 2007). Thus, comparisons among studies are challenging. The findings of the present study indicate that age and previous pain assessment practice were not significantly related to knowledge and attitude scores. Other studies that used the PNKAS and a modified PNKAS support our findings regarding age (Manworren, 2000, Rieman and Gordon, 2007). In contrast, Salenterä et al. (1999) found that age was significantly related to nurses' pain knowledge scores. Differences in results may be due to inconsistencies of programs, instruments, study design, and location of the studies (Finland vs. Mexico). No studies reported on nurses' pain assessment practice and its relationship to attitude and knowledge scores. Only one study supported our findings that the site in which the pediatric nurse practiced was associated with higher pain knowledge (Johnston et al., 2007). That study also used the PNKAS to test nurses' pain knowledge across six different hospitals. In the present study, changes in PNKAS scores were highest for nurses working <5 years. Other studies that measured attitude and knowledge scores in relation to work experience did not use an educational intervention; therefore, findings are difficult to compare. For example, Rieman and Gordon (2007) found that nurses who had worked 10-15 years scored higher than those who had worked ≤2 years. Manworren (2000) found no significant correlations between PNKAS scores and years of nursing experience. Margolis, Hudson, and Michel (1995) also found no significant correlation between years of nursing experience and beliefs and perceptions of pain. An additional analysis involved the test questions. One question had lower results after the teaching intervention. This question focused on children <8 years old being able to reliably report their pain. In contrast to the findings in the present study, both Manworren (2001) and Reiman and Gordon (2007) reported that 95%-98% of the nurses in their studies answered this question correctly. Differences in results between these studies may be due to translation issues. Limitations Limitations of this and similar studies include the lack of a control group and randomization. There was a lack of control regarding the dissemination and collection of the pretest in hospital 3. Because of limited time and the large audience, many tests were not collected until the break in the program. This may have allowed participants to complete the test during the lecture and/or discuss their responses with other participants. Also, the self-selection of the nurses from hospital 3 who chose to participate limits the generalizablity of the results. Those responding to the questionnaires may have been more positive and had higher knowledge scores than those that did not participate in the study; therefore, their attitudes and knowledge may not be representative of the participating group. Another limitation was that the posttest was given immediately after the educational intervention. Obtaining a measurement after a longer period of time would have assured durability over time. Additionally, these results do not indicate translation into clinical practice, because the measure was at one specific point in time in a test situation. Language was a major drawback of this international study. Two of the presenters were not bilingual and relied on translators. The Spanish-language PNKAS was not back-translated from Spanish to English to check for accuracy of the translations compared with the original. Recommendations Collaboration is an integral part of international educational programs/studies. Partnering with nurses in various countries to understand the cultural nuances is imperative when planning international programs. Before implementing this program, a needs assessment was obtained informally via long-distance telecommunication. A more formal assessment of the nurses' educational needs regarding pediatric pain management could also be considered before developing the program. This could be done through various methods such as observing patient rounds, questionnaires, chart reviews, and one-on-one or small group discussions with care providers. The internet, with its increase in availability, could be used to provide education and follow-up in a cost-effective manner. More international studies are needed to measure learning over a longer period of time, such as 6-12 months. Additionally, there is a gap in the literature regarding the influence of culture on Mexican nurses' pain management practice. Research indicates that nurse characteristics such as attitudes and personal beliefs, which can be affected by culture, influence their pain management practices (Broome & Huth, 2003). There is a need for further research that explores health care providers' assessment and treatment of pain in racial and ethnic minorities. Conclusions Changing pediatric nurses' knowledge and attitudes regarding pain management is a global collaborative effort. Continued education, clinical practicum, and partnerships with pain teams may help reinforce and sustain the change in attitudes toward pain. As clinicians and researchers, we benefit from recognizing and valuing the pain beliefs and attitudes of our international colleagues. Acknowledgments The authors acknowledge Catalina Fox and Lynn Sanner for their assistance and support of this research. They thank the participating hospitals in Mexico City. References Broome and Huth, 2003. 1.Broome ME, Huth MM. Nursing management of the child in pain. In: Schechter NL, Berde CB, Yaster M editor. Pain in infants, children, and adolescents. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2003;p. 417–433. Chui et al., 2003. 2.Chui LH, Trinca J, Lim LM, Tuazon JA. A study to evaluate the pain knowledge of two subpopulations of final year nursing students: Australia and Philippines. Journal of Advanced Nursing. 2003;41(1):99–108. MEDLINE |
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Van Hulle Vincent, 2005. 21.Van Hulle Vincent C. Nurses' knowledge, attitudes, and practices regarding children's pain. Maternal Child Nursing. 2005;30(3):177–183. ∗ Center for Professional Excellence-Research † Pediatric Pain Management ‡ Center for Professional Excellence-Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio  Address correspondence to Myra Martz Huth, PhD, RN, FAAN, Assistant Vice President, Center for Professional Excellence-Research, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 11016, Cincinnati, OH 45229-3039.
PII: S1524-9042(09)00132-5 doi:10.1016/j.pmn.2009.11.001 © 2010 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved. | |
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