The Journal of Continuing Education in Nursing

Original Article 

Pediatric Nurse Practitioners' Knowledge and Attitudes Regarding Pain Management Study in Central China

Yun Hua, MM; Qin Zhang, BSN; Wang Ting, MM; Rong Qiu, MM; Wen-yan Yao, MM; Xiao-li Chen, PhD

Abstract

Background:

Nurses' level of knowledge about pain management directly determines the steps of implementation of clinical pain policies.

Method:

This study surveyed 2,882 pediatric nurse practitioners from six children's hospitals using demographics and pain management questionnaires, as well as the Chinese version questionnaire of the Pediatric Nurse Practitioners' Knowledge and Attitudes Survey Regarding Pain (PNKAS) via the WeChat application.

Results:

The total score on the PNKAS was 14.88 ± 3.58 for the pediatric nurse practitioners. Multiple regression results showed the main factors influencing the PNKAS score related to position, the frequency of receiving training pain-related knowledge, and working department, which could account for 35.1% of the total variance.

Conclusion:

Pediatric nurse practitioners from pediatric hospitals were not found to have sufficient knowledge or an appropriate attitude regarding pain management. A new standardized training project of pain management that is closely related to clinical practice for children should be conducted in the future. [J Contin Educ Nurs. 2019;50(6):275–281.]

Abstract

Background:

Nurses' level of knowledge about pain management directly determines the steps of implementation of clinical pain policies.

Method:

This study surveyed 2,882 pediatric nurse practitioners from six children's hospitals using demographics and pain management questionnaires, as well as the Chinese version questionnaire of the Pediatric Nurse Practitioners' Knowledge and Attitudes Survey Regarding Pain (PNKAS) via the WeChat application.

Results:

The total score on the PNKAS was 14.88 ± 3.58 for the pediatric nurse practitioners. Multiple regression results showed the main factors influencing the PNKAS score related to position, the frequency of receiving training pain-related knowledge, and working department, which could account for 35.1% of the total variance.

Conclusion:

Pediatric nurse practitioners from pediatric hospitals were not found to have sufficient knowledge or an appropriate attitude regarding pain management. A new standardized training project of pain management that is closely related to clinical practice for children should be conducted in the future. [J Contin Educ Nurs. 2019;50(6):275–281.]

Pain, widely defined by the International Association for the Study of Pain, is an unpleasant sensory and emotional experience associated with actual or potential tissue damage (Van Cleve, Bossert, & Savedra, 2002). As a symptom, it has acquired increasing attention and is considered—in the clinic—as the fifth vital sign, following body temperature, pulse, respiration, and blood pressure (Merboth & Barnason, 2000). Repeated painful stimulation in a child's early life stages—and these patients are considered as a special group—will lead to acute stress, permanent damage to the central nervous system, and emotional disturbance, as well as serious short-term or long-term consequences (Drendel, Kelly, & Ali, 2011). Currently, the main responsibility of pain management is shifting from anesthesiologists to nurses, which highlights the importance of the role of nurses in pain management (Song, Eaton, Gordon, Hoyle, & Doorenbos, 2015). Furthermore, the level of knowledge nurses have about pain management directly determines the steps of implementation of clinical pain policies. Therefore, the extent of mastery pediatric nurse practitioners have obtained related to pain management has a direct effect on a child's physical and psychological recovery, as well as his or her long-term quality of life. In this research, we accessed the pain management knowledge and attitudes of pediatric nurse practitioners in pediatric specialty hospitals by analyzing the main influencing factors through multicenter joint investigation. We further provided scientific evidence to help formulate standardized pain management training programs for pediatric nurse practitioners.

Study Design

The convenience sampling was used in this survey under the premise of sample representativeness. Before the interview started, our staff demonstrated to the participants the aim and meaning of this survey. All interviewees provided informed consent and agreed to be digitally recorded. In the surveys, 3,300 interviewees were recruited, with 550 individuals surveyed at each investigation site. Of the interviewees, 2,882 pediatric nurse practitioners from six tertiary-level pediatric specialist hospitals (Hubei Maternal and Child Health Hospital, Wuhan Children's Hospital, Human Children's Hospital of Hunan, Zhengzhou Children's Hospital, Jiangxi Provincial Children's Hospital, Anhui Provincial Children's Hospital) in central China that included the provinces of Hubei, Hunan, Henan, Jiangxi, and Anhui were selected to be the research objects from August to September 2015. The criteria for object selection were (a) pediatric nurse practitioners who were clinically engaged in nursing practice and (b) individuals' confirmation of their voluntary participation. Exclusion criteria included (a) nurses in advanced study and (b) nurse practitioners not clinically engaged in nursing practice were not considered in this study.

Method

Questionnaire Form Used in the Survey

Questions asked in the survey consisted of demographic information (e.g., age, department, professional title, position, education, and working hours) and existing status of pain management (e.g., whether to assess the child's pain frequency, patient's complaints, the frequency of receiving training on pain-related knowledge, or whether it is necessary to educate the patient regarding pain).

The Chinese Version of the Pediatric Nurse Practitioners' Knowledge and Attitudes Survey Regarding Pain (PNKAS)

This scale form (Manworren, 2001) has a Cronbach's alpha coefficient of .77 and was introduced and translated by Meng et al. (2006). A total of 42 entries were involved in the Chinese version of PNKAS, which included pain concept (11 items), pain assessment (8 items), drug analgesia (17 items), and analgesia methods (6 items). Among them, items 1 to 25 were true-or-false questions, 26 to 38 were single-choice questions, and 39 to 42 were case analysis questions. Each item accounted for 1 point; the total number of points possible was 42. Accuracy was determined by dividing the number of correct answers by the total number of entries multiplied by 100%. Fifty pediatric nurse practitioners were selected for the preliminary survey and the Cronbach's alpha coefficient was .72 after calculating, which indicated the form was suitable for this study.

Survey Method

The multicenter joint method was conducted to investigate the pediatric nurse practitioners' knowledge and attitudes using the WeChat application (Li, Han, Guo, & Sun, 2016). The individuals responsible for this survey who worked in these six tertiary-level children's specialist hospitals underwent training and informed the subjects of the purpose of the survey according to the principle of informed consent and voluntary participation. The individuals were able to log into the WeChat account and access the survey interface by selecting the “Agree” option once they understood the purpose of the survey. Subsequently, they were able to start to complete the questionnaire. The time used to complete the questionnaire was roughly 20 to 30 minutes. The individuals could submit immediately after finishing. If the time was exceeded or an individual completed the questionnaire multiple times, it was considered to be invalid.

Statistical Analysis

SPSS® 17.0 software was used for data entry and statistical analysis, which mainly described the general demographics and existing status of pain management, scores and accuracy of pain knowledge and attitudes according to frequency, composition ratio, mean, and standard deviation. Univariate analysis was performed using the t test, one-way analysis of variance, Mann-Whitney U test, and Kruskal-Wallis H test. Multivariate analysis was performed using multiple stepwise linear regression. In this study, p < .05 was considered statistically significant.

Results

The Existing Status of Pain Knowledge and Attitudes

When analyzing the information of 3,300 questionnaires, 2,896 questionnaires were recovered for the response rate of 87.8%; of those, 2,882 were valid for an effective recovery rate of 99.52%. The total PNKAS score was 14.88 ± 3.58 for the 2,882 pediatric nurse practitioners. The ranking of the accuracy of these four dimensions, from high to low, on the scale used on the form was pain concept, drug analgesia, pain assessment, and analgesia methods. Among them, 21 individuals had a total accuracy of 60% or above, accounting for only 7.3%.

Pain Management Tools Application and the Need for Pain Training

A total of 2,010 pediatric nurse practitioners applied pain assessment tools (69.7%). Furthermore, the most common pain assessment tool was the Wong-Baker FACES® Pain Rating Scale, with a utilization rate of 89.6%, which can be used with all patients age 3 years and older. A total of 2,237 (77.6%) pediatric nurse practitioners had undergone training related to pain, and 1,247 (43.3%) acquired knowledge by themselves. The pain training method with better selection of objects was a case study (82.6%), and the pain assessment procedures, techniques, and application of assessment tools were considered the most necessary information to acquire (90.5%).

Univariate Analysis for the Information of General Demographics and Existing Status of Pain Management

Univariate analysis was performed to describe the general demographics and existing status of pain management of objects (Table 1). The results suggested that the variances of age, education, whether to assess the pain of children regularly, whether to pay attention to the child's complaints, and whether it was necessary to learn the knowledge of pain were not significantly different. However, all other variables influenced the knowledge and attitudes of pain management.

Univariate Analysis for the Information of General Demographics and Existing Status of Pain Management (N = 2,882)Univariate Analysis for the Information of General Demographics and Existing Status of Pain Management (N = 2,882)

Table 1:

Univariate Analysis for the Information of General Demographics and Existing Status of Pain Management (N = 2,882)

Influencing Factors of Knowledge and Attitude of Pain Management for Pediatric Nurse Practitioners

We used the multivariate stepwise regression analysis; the dependent variable was the score of knowledge and attitude of pain management for pediatric nurse practitioners. The independent variables were variables that showed significant difference after univariate analysis tests. The assignment of independent variables was shown in Table 2, in which unordered multi-classification variables set dummy variables. If the variable arrived at level α = .05, those at level α = .10 were eliminated. The results of multivariate stepwise regression indicated that the variables included in the regression equation represented position, the frequency of receiving training pain-related knowledge, and the department, which explained 35.1% of the variance (Table 3).

Assignment of Independent Variables

Table 2:

Assignment of Independent Variables

Multiple Stepwise Regression Analysis of Pediatric Nurses' Pain Management Knowledge and Attitude Scores

Table 3:

Multiple Stepwise Regression Analysis of Pediatric Nurses' Pain Management Knowledge and Attitude Scores

Discussion

Pediatric Nurse Practitioners' Level of Knowledge and Attitude Toward Pain Management

The survey results meant that the total PNKAS score was (14.88 ± 3.58). Only 7.3% of individuals had a total accuracy of 60% or above. This result was consistent with other findings (Manworren, 2000) indicating that the level of knowledge and attitudes of pain management for pediatric nurse practitioners was low overall, which requires more attention.

In this study, the accuracy of the analgesia methods was the lowest, and three of the top five survey items of incorrect answers belonged to the dimension of analgesia methods, indicating that individuals lacked sufficient understanding of relevant knowledge. Reasons for this phenomenon include a late start of pain care, lack of clear provisions in the implementation of measures, and leading personnel in clinical practice. It may be have also resulted from an unestablished or unorganized management system (Cong et al., 2014).

In our study, 2,237 (77.6%) of the pediatric nurse practitioners received pain-related training; 2,654 (92.1%) of the pediatric nurse practitioners considered it necessary to learn the knowledge related to pain; and 1,247 (43.3%) of the pediatric nurse practitioners learned pain information by themselves. This indicated that the training about pain knowledge had been widely carried out in the clinic, and pediatric nurse practitioners have shown active responses and positive attitudes toward pain management. However, the mastery of pain knowledge level was still extremely low, which might be related to the immature and nonstandard training content, model, implementation plan, and evaluation methods of children's pain management in China. Although the pain training programs were offered by some hospitals in China, the contents and effectiveness of these programs were still worth exploring and considering due to the specificity of pain assessment of children and multidisciplinary management of pain.

Standardized and Normalized Training Projects of Pain Management for Children

The volume of knowledge related to pain, the skill level of pediatric nurse practitioners as instructors of pain assessment, measure implementation, and the development of pain management are of significantly important factors to improve the quality of pain. The principle reason leading to unsatisfactory practices of pain management are due to the lack of sufficient training, which was suggested and explained by other scholars (Huth, Gregg, & Lin, 2010). Through systematic training, the level of knowledge and attitude of pain management for pediatric nurse practitioners was improved significantly. In this survey, 2,237 (77.6%) of the pediatric nurse practitioners received pain-related training, but the results of the training were not impressive. At present, pain-related training as reported in China is predominantly is targeted at postoperative patients, those who suffer from cancer, and acute pain in adults; focus is not placed on pediatric patients, and pediatric pain training methods, content, and evaluation indicators still have not reached standardization and homogeneity. The pain assessment procedures, techniques, and application of assessment tools were the most necessary information that individuals were required to acquire (90.5%). Moreover, the most common pain assessment tool was the Wong-Baker FACES Pain Rating Scale, with a utilization rate of 89.6%. The grounds for revising optimal pain treatment programs was that after reaching the conditions, pediatric nurse practitioners used scientific and accurate pain assessment tools combined with the children's complaints when assessing behavior and vital signs (Thomas et al., 2015; Twycross, Finley, & Latimer, 2013). Children were relatively sensitive to pain, and they were often unable to describe the nature and extent of the pain accurately, which made the assessment difficult. In this study, 82.6% of pediatric nurse practitioners thought that the case analysis was the best pain-related training method. Therefore, case-based contextual training might be an effective way to improve the skill of pain assessment and capabilities of analysis and integration for nurses (Romero-Hall, 2015).

Analyzing the Influencing Factors of Knowledge and Attitude of Pain Management for Pediatric Nurse Practitioners in Pediatric Specialized Hospital

First, our research reported no statistically significant difference in scores of pain knowledge among pediatric nurse practitioners with different professional titles (p > .05), which was conflictive from the results of this study. The differences in pain-related training programs performed in various regions might be a convincing reason that explains this contradiction. This study also showed that the score pertaining to supervisors was higher than that of clinical pediatric nurse practitioners in the regression equation where the position was included (p < .01), which clarified that the level and skills of pain-related knowledge can be improved by increasing work experience, the promotion of position, and more comprehensive training resources. Second, there was a significant difference in pain scores among pediatric nurse practitioners (p < .01) with different frequency of receiving training pain-related knowledge. The more stable of training frequency, the more score obtained (Czarnecki, Salamon, Thompson, & Hainsworth, 2014; Twycross, 2013). Some research has clarified pediatric nurse practitioners' obstacles to pain management practice to include lack of relevant training and the organization's implementation of the guidance, which meant that the standardized and normalized training project of pain management for children was urgently needed to be constructed. Finally, the scores of pain knowledge between the pediatric nurse practitioners in intensive care units and other nursing units showed a significant difference (p < .05), which was similar to the findings concluded by Manworren (2000). The pediatric nurse practitioners in intensive care units, as a leading force without the escort (i.e., children in these units are not accompanied by their parents), could be more deeply concerned about and pay more attention to the pain of children. Another possibility was that additional nurses were placed in the intensive care unit, which resulted in each nurse having fewer patients and more time to complete an assessment, which may have resulted in this difference.

Conclusion

This survey covered six tertiary-level pediatric specialist hospitals in central China, reflecting the current level of pain knowledge of pediatric nurse practitioners needed to improve. Currently, the tools for assessing the pain knowledge level of pediatric nurse practitioners was PNKAS questionnaire in China; however, it is critical to explore further the construction of multidimensional evaluation criteria. This survey adopted the approach of the WeChat platform to receive the feedback, which maximized the efficiency of information acquisition. It is imperative to construct a standardized and normalized training project of pain management closely related to clinical practice for children.

References

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Univariate Analysis for the Information of General Demographics and Existing Status of Pain Management (N = 2,882)

ItemsNo. of Cases%Score (M ± SD)Statistical Quantityp Value
Age (years)4.606.203
  21–302,10072.914.84 ± 3.46
  31–4062121.514.86 ± 3.79
  41–50144515.56 ± 4.07
  > 50170.614.71 ± 6.02
Department2.445.014
  Intensive care unit67323.415.12 ± 3.33
  Other units2,20976.614.81 ± 3.66
Professional title24.660< .001
  Nurse1,28844.714.93 ± 3.58
  Nurse practitioner1,22242.414.61 ± 3.46
  Nurse-in-charge29910.415.28 ± 3.64
  Deputy director or chief nurse732.516.79 ± 4.55
Position3.617< .001
  Manager1926.715.95 ± 4.01
  Clinical nurse2,69093.314.80 ± 3.54
Initial education degree1.875.392
  Technical secondary67523.415.04 ± 3.77
  College degree1,5275314.76 ± 3.51
  Bachelor or above68023.614.99 ± 3.56
Highest education degree2.189.534
  Technical secondary351.215.17 ± 3.69
  Junior college degreea73725.614.91 ± 3.27
  Bachelor2,07972.114.85 ± 3.67
  Master's degree or above311.115.58 ± 4.46
Years of pediatric nursing experience26.908< .001
  0–51,51552.514.86 ± 3.45
  6–1079627.614.70 ± 3.66
  11–2039413.714.99 ± 3.73
  21–301645.715.91 ± 3.72
  > 30130.511.69 ± 5.14
Years of professional nursing experience16.927.002
  0–51,65157.314.81 ± 3.44
  6–1079927.714.90 ± 3.77
  11–2033011.514.96 ± 3.74
  21–30933.215.99 ± 3.62
  > 3090.312.00 ± 4.53
Do you routinely assess pain in children?0.352.725
  Yes2,02070.114.90 ± 3.58
  No86229.914.84 ± 3.60
Do you pay attention to the patient's chief complaint?0.252.801
  Yes2,70193.714.89 ± 3.60
  No1816.314.80 ± 3.34
The frequency of receiving training pain-related knowledge16.080.001
  Once per half year1846.415.07 ± 4.14
  Once per year1776.115.18 ± 3.20
  Irregular1,87665.115.02 ± 3.61
  Never64522.414.34 ± 3.40
Do you think it is necessary to learn the knowledge of pain?3.318.19
  Very necessary2,65492.114.92 ± 3.58
  Does not matter2127.314.52 ± 3.50
  Not necessary160.613.50 ± 4.12

Assignment of Independent Variables

Independent VariableAssignment Method
Department0 = Intensive care unit, 1 = Other units
Professional title0 = Nurse, 1 = Nurse practitioner, 2 = Nurse-in-charge, 3 = Deputy director or chief nurse
Position0 = Clinical nurse, 1 = Manager
Years of pediatric nursing experience0 = 0–5, 1 = 6–10, 2 = 11–20, 3 = 21–30, 4 = > 30
Years of professional nursing experience0 = 0–5, 1 = 6–10, 2 = 11–20, 3 = 21–30, 4 = > 30
The frequency of receiving training on pain-related knowledgeOnce per half year (Z1 = 1, Z2 = 0, Z3 = 0); Once per year (Z1 = 0, Z2 = 1, Z3 = 0); Irregularly (Z1 = 0, Z2 = 0, Z3 = 1); Never (Z1 = 0, Z2 = 0, Z3 = 0)

Multiple Stepwise Regression Analysis of Pediatric Nurses' Pain Management Knowledge and Attitude Scores

VariableRegression CoefficientSEStandardized Regression Coefficientt Valuep Value
Constant term17.0921.37211.292< .001
Position1.0760.3150.2262.735.006
Frequency of receiving training on pain-related knowledge2.1160.5220.2873.258.001
Department2.7520.2570.4364.128.004
Authors

Ms. Hua is Chief Superintendent Nurse, Outpatient Department, Ms. Zhang is Co-Chief Superintendent Nurse, Orthopedic Surgery Department, Ms. Ting is Nurse Practitioner, Nursing Department, Ms. Qiu is Supervisor Nurse, Delivery Room, Ms. Yao is Co-Chief Superintendent Nurse, Pediatric Intensive Care Unit, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, and Dr. Chen is Co-Chief Superintendent Nurse, School of Health Sciences, Wuhan University, Hubei, China.

Ms. Hua and Ms. Zhang contributed equally to this article and should be considered as equal first authors.

This work was sponsored by the Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Xiao-li Chen, PhD, Co-Chief Superintendent Nurse, School of Health Sciences, Wuhan University, No.115, Donghu Road, Wuhan 430071, Hubei, China; e-mail: 846730310@qq.com.

Received: September 05, 2018
Accepted: January 08, 2019

10.3928/00220124-20190516-08

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