This section examines literature review coverage on how nurses manage pain. Specifically, an attempt is made to find out how nursing knowledge and attitude toward pain management affect the process of pain management. Studies are briefly discussed to give a clear picture.
Pain management has received a considerable attention in the recent past (Salantera, 199; Zwakhalen, Hamers, Peijnenburg & Berger, 2007; Yu & Petrini, 2007; Lui, So & Fong, 2008; IASP, 2010). According to the International Association for the Study of Pain – IASP (2010) pain can be defined as emotional or sensory experience that is not pleasant to whoever is undergoing it. This feeling is often associated with damaging of body tissues.
Pain is commonly classified into two categories – acute and chronic. Acute pain has been described as pain that occurs rapidly and diminishes in the same manner upon treatment. Chronic pain is chronic in the sense that it lasts for longer time usually in terms of months. A third category has been added in the name “breakthrough pain” and is defined as pain felt in between the administration of the first and second dose (Lilley et al. 2011). Pain management entails the reduction of the unpleasant feeling felt by a patient to a level that can be tolerated (Berman et al., 2008). Pain management means is significantly through pharmacologic and non pharmacologic (Berman et al., 2008).
Pain management is an integral part of caring for patients. If pain is not managed well, it will significantly affect the standard of life that patients lead. Nurses closely interact with patients and spend much time with patients, and therefore are primary factors who determine how pain is managed. It is likely that nurses with good knowledge and positive attitude towards pain management will successfully manage pain in the patients they handle. Nurses play this significant role of managing pain by helping in the identification of patient undergoing pain, undertaking documentation and making follow ups. Nurses can also offer emotional support and help patients by referring them to the correct professionals unique to the nature of their pain (Birchenall & Adams, 2011). Therefore nurses form a very critical link between doctors and the patients in reference to managing pain. If this link is inefficient in any manner, for instance by way of communication, the success of pain management will be affected severely.
The knowledge and attitude that nurses have towards the management to pain will significantly affect the success of a pain management program. This is because the knowledge and attitude of a nurse toward pain will determine how she or he manages pain. Nurses attain their knowledge on managing pain in various ways. The common one is through clinical expertise whereby nurses undergo training on healthcare service provisions. Another factor that may affect the amount of knowledge in pain management that a nurse may wield includes her or his length of clinical experience. Keeping abreast with current evidence based practices by undertaking studies frequently will also sharpen the skills a nurse possesses on pain management (Burn & Grove, 2009). Knowledge enables nurses to make the best decision in regard to the management of pain.
The level of education acquired by a nurse has a direct implication on the kind of pain management that will be offered by a nurse. Various studies undertaken have shown that nurses have insufficient knowledge on how to manage pain. This was witnessed in a study undertaken by Zwakhalen et al. (2007) to find out the level of nursing staff knowledge and attitude about pain in a nursing home. In this study, the researchers sought to find out what nurses knew and believed concerning different features of pain in aged patients. The study also closely examined the correlation between educational level and clinical experience in regard to pain. In this study the respondents were (n=123) members of the staff from two nursing homes. The study findings revealed that nurses lacked sufficient knowledge on pain management. Their educational level was closely attributed to this ignorance. It was further revealed that the nurses were contented with their knowledge concerning pain management (Zwakhalen et al., 2007). This study revealed that educational level has a deep impact on the success of pain management.
In another study targeting (n=621) registered nurses, mixed feeling were obtained about the role of educational background and attending extra classes on pain management. The study was undertaken to figure how the knowledge of nurses on pain management. The nurses were from three hospitals and information was collected by use of questionnaires. The results of this study showed that the nurses surveyed lacked enough knowledge on pain management especially in aged patients. Surprisingly, it was found that there was no considerable difference made by nurses who had gone for extra classes on pain management. It was found that pain management improved by nurses improved with their age and clinical experience (Yu & Petrini, 2007).
Plaisance and Logan (2006) conducted a descriptive correlation research to find out the level of nursing student knowledge and attitude concerning pain management. A sizeable sample (n=313) of nursing students were picked from various nursing programs. More than half of those surveyed worked in a health care setting. It was found that the students did not posses updated information on pain management. This meant that they were not as effective as they were expected to be in relation to managing pain. One of the indicators that showed student inefficiency in pain management is that they made the assumption that their assessment on pain management was same as that of their patients (Plaisance and Logan, 2006).
In another study, oncology nurses were examined to assess their knowledge in the management of pain. The study also sought to identify the factors that point out to the knowledge of nurses in regard to their level of pain management. The nurses (n=287) surveyed were from different oncology wards. The findings showed that a staggering percent did not rate their patients’ pain accurately and hence it was clear that they could not management pain well. Furthermore, it was found that nurses could not make an accurate evaluation of their pain management knowledge and ability. Deficit of substantial knowledge and unfounded opinions affected the ability of the nurses to manage pain in a standard manner (Bernand et al., 2007).
Lui, So and Fong (2008) also carried out another study to find out the level of knowledge and attitude of nurses towards pain management. In this study, the nurses (n=143) surveyed were from medical units in Hong Kong. The research findings revealed the nurses as being insufficient in their knowledge and attitudes on pain management strategies. Furthermore, the study revealed existing conflicting attitudes among the nurses affected their efficiency in pain management. The study also confirmed other previous that the level of education does not have a considerable impact on the ability of a nurse to manage pain as expected (Lui, So & Fong, 2008).
In this study, it was revealed that 36 percent of the observed patients were undergoing pain great enough to affect their daily activities. It was further revealed that almost half of the patients who were suffering from metastatic disease were not treated in the standard manner as pertains to pain management in the cases of metastatic disease. Furthermore, it was found that up to 20 percent of the of cancer patients in ICU of some hospital setting felt unsatisfied with the pain management they were being undertaken through. In other instances, it was shown that nursing home cancer patients are undertreated for pain. 31 percent of the cancer patients released to from hospitals to nursing were reported to experience pain on a daily basis and out of this percentage, 26 percent were not treated for the pain experienced (Cleary, 2002).
Howel, Butler, Vincent Watt-Watson and Stearns (2000) undertook a study to assess the knowledge and attitude that nurses had pertaining to pain management. The study utilized a sample of nurses (n=101) obtained from in-patient units. The study utilized a tool that had 46 items meant to help in determining the knowledge of nurses on pain management. Of the nurses who underwent the study/inservice training, only slightly more than half completed the questionnaires issued. The findings of the educational inservice were based on the findings of those who completed the questionnaires (Howell et al., 2000).
The findings gathered from the educational in-service conducted by Howel et al. (2000) showed that nurses has a fair knowledge on pain management but the level of this knowledge significantly increased after the educational in service. Before the training, the following score were noted. There was a more than 70 percent correct score by nurses on questions seeking to identify the need for assessing pain on a continuous basis, use of narcotics in relieving chronic pain and how narcotics work on the CNS. A significant percent recognized the fact that patients may experience pain but not show it physically through signals. 43 percent felt that their patients should undergo some pain between their first and second doses. A huge percent (77) did not foresee the possibility of their patients becoming addicted to the medicine they were taking. Most of the nurses correctly identified tolerance as applicable in pain management. In all cases, the nurses believed that the patients were best placed to evaluate the pain that they experienced. On rating their pain management abilities, 44 percent viewed themselves as good at it while 32 percent felt they were very good at pain management. There was a general optimistic tone from the nurses that cancer could be controlled (Howell et al., 2000).
There was noted improvement in the scores. McNemara’s test was put into application to tests the statistical significance of the scores that had been obtained. Out of the 35 items in the questionnaire, 15 of them showed some improvement. The areas of pain management that showed improvement included how chronic and acute pain is managed and dangers associated with the administration of opioids. After a three-month interval, scores showed a reduction in the knowledge of the nurses that had been gained early through the educational in service. The study showed that nurses require continuous support in training to ensure that their pain management skills are updated and sharpened all through (Howell et al., 2000).
In yet another study, nurses (n=91) were examined to determine the influence of formal organizational pain management policy on pain management practices. The study duration was 72 hours. The setting of the study was a general medical inpatient units. The units were of a tertiary level located in an urban setting. The respondents were of two categories, RNs and LPNs. After collection of data and its analysis with the help of a t-test, it was found that there was no considerable difference between RNs and LPNs. Among the tools that were used in the analysis process were the Pearson’s product-moment correlation coefficient and Chronbach’s alpha. The study findings showed that being aware of a pain management policy which is place has an effect on the manner in which nurses manage pain (Alley, 2001).
Decision making by nurses in regard to pain management is significant to pain management effectiveness. Malek and Oliveri (1996) undertook a study to find out how nursing decisions affected management of pain. The research questions sought to identify the cues that nurses relied on in their diagnosis of pain, the clinical decisions nurses document in regard to pain management and how outcomes of pain management are documented. The study used a 25-item tool that the authors developed and referred to as Nurses’ Pain management Audit Tool (NPMAT). The study revealed five major findings. There was no adequate documentation being undertaken by the nurses in regard to patient pain assessment and as well as patient pain relief. It was found that pain was undertreated especially in the administration of PRN medication. It was also shown that documentation of cognitive and behavioral intervention was inadequate while that concerning physical intervention was not at all undertaken (Malek & Oliveri, 1996).
Pain management is a huge issue among nurses. Review of studies and empirical evidence has shown that pain management is not undertaken efficiently and thus many patients undergo unnecessary pain which needs not be the case. It has also been shown that in service training can improve the nursing knowledge on pain management but unfortunately only in the short run.