Nurses have numerous opportunities to interact with individuals experiencing pain and to institute pain relief measures. Despite this, the inadequate relief of pain has been well documented in the literature for over 20 years. A preliniinary step in unraveling the basis for the inadequate relief of patients' pain is the examination of curricular practices in associate degree and baccalaureate nursing programs related to pain and pain management.
Unrelieved pain is a significant problem. In one study, only one-third of patients experiencing pain (JV= 353) reported obtaining total relief at any one time (Donovan, Dillon, & McGuire, 1987). More recently, 70.6% of postsurgical patients diagnosed with cancer reported experiencing pain and only 38.2% recalled a nurse asking about pain (Paice, Mahon, & Faut-Callahan, 1991). Postoperative patients who engaged in activity had inadequate pain relief (Dodd, 1986). The accuracy of nurses' pain assessments has been demonstrated to be inconsistent (Choiniere, Melzack, Girard, Rondeau, & Paquin, 1990; latrati, 1986; Kroskosky & Reardon, 1989; Walkenstein, 1982; Zalon, 1993) and in one study, only 45% of nurses (JV= 53) regarded the patient's report of pain as the most influential factor in their assessment (Ferrell, Eberts, McCaffery, & Grant, 1991). Nurses have underestimated the analgesic needs of patients (Cohen, 1980; Marks & Sachar, 1973; Rankin & Snider, 1984). These clinical practice problems may be related to nurses' pain management education.
Nurses feel they are not prepared to manage the pain of their patients (Dalton, 1989; Fothergill-Bourbonnais & Wilson-Barnett, 1992; Fox, 1982). In a survey of 669 nurses from 23 countries, the majority believed they had received little or no educational preparation for the care of cancer patients and thought greater emphasis should be placed on cancer pain management (Pritchard, 1988).
Studies of nurses indicate that their knowledge of pain relief methods is limited. Watt- Watson (1987) reported that nurses with less than 10 years of experience and BSN students had a mean score of 52% (SD = 14) on a test of pain assessment and opioid administration. This study has serious implications for practice if novice and expert nurses have the same level of knowledge. Nurses (JV= 2,459) attending pain workshops were reported to lack basic knowledge about the pharmacological management of pain (McCaffery, Ferrell, O'Neil-Page, Lester, & Ferrell, 1990). Vortherms, Ryan, and Ward (1992), in surveying 790 nurses, reported a mean score of 56.4% on a test of pharmacological management of cancer pain and that nurses believed that 22% of patients overreport pain. Nurses have overestimated the likelihood of opioid addiction (Grier, Howard, & Cohen, 1979; McCaffery et al., 1990; Myers, 1985; Watt-Watson, 1987) and have been reported to be unfamiliar with equianalgesic doses of Opioids (Sheidler, McGuire, Grossman, & Gilbert, 1989). One study, focusing specifically on nonpharmacological pain management, found that nurses did not understand behavioral methods of pain relief (Sanders, Webster, & Framer, 1980). It isn't known whether these limitations in knowledge are related to lack of recall or basic education in nursing.
Graffam (1990), in a survey of pain content in 390 baccalaureate nursing programs, found that 81% included formal class content, which was integrated into several courses, and 57 reported no formal class content. The modal length of time devoted to pain and its management was 4 hours. Pain content included by over 80% of the respondents included assessment, drug therapy, and chronic and acute pain. Topics less often included were heat/cold, 69%; progressive muscle relaxation, 67%; pain theory, 64%, imagery, 63%; behavior modification, 60%; therapeutic touch, 54%; massage, 52%; and acupressure, 36%. She also reported that many respondents indicated that a number of topics were only mentioned and concluded that students may have inadequate knowledge and skills for dealing with patients in pain.
Diekmann and Wassem (1991) found that first and senior year baccalaureate students in Wisconsin (iV=938) had limited knowledge about the prevalence of cancer pain and its management. Senior students answered an average of 52% of the test items incorrectly. Only 29% of the students thought it was appropriate for patients to receive the maximum tolerated pain therapy when the prognosis was less than 2 years and only 28% correctly identified the oral route as the preferred route of pain medication. Sheehan, Webb, Bower, and Einsporn (1992) found that baccalaureate students (N =82) had certain beliefs and lacked specific knowledge which could lead to inappropriate cancer pain management. For example, students believed it was acceptable to delay maximum pain relief until the prognosis was less than 12 months and increased pain was related to tolerance rather than extension of cancer.
In a survey of faculty beliefs and curricula related to pain in 14 baccalaureate nursing programs, areas of limited faculty knowledge included content related to pain relief as a goal, clock watching, high-dose analgesics, pain-free state, opioid sites of action, chronic pain symptoms, and pharmacology (Ferrell, McGuire, & Donovan, 1993). Schools generally included content related to analgesics, anatomy and physiology of pain, etiology, assessments, and nonpharmacological interventions. The average time devoted to analgesics was 3.9 hours; nonpharmacological interventions, 3.5 hours; assessment, 3.2 hours; research, 2 hours; and beliefs and misconceptions, 1.4 hours. Interestingly, the area of worst outcome for faculty, pharmacology, received the most time. Faculty (N= 498) believed that their curriculum related to pain was moderately effective (M =5.7) and were moderately satisfied with their ability to supervise students in pain management (M = 6.26, 10-point scale).
Studies of nursing students indicate that lack of knowledge may contribute to long-standing problems in pain management such as underassessment of pain, inappropriate opioid use, and the prevalence of unrelieved pain. Understanding curricular practices would help educators in preparing nurses to manage pain. This study was designed to examine curricular practices related to pain by comparing associate degree (ADN) and baccalaureate (BSN) programs with respect to 1) time allocated to pain content, 2) theoretical content and clinical experiences related to pain management, and 3) faculty members' perceptions related to pain in the their curricula.
A random sample consisting of 200 ADN and 200 BSN programs was chosen from the National League for Nursing lists of accredited programs. This excluded new programs and those not meeting accreditation criteria. Baccalaureate programs only offering an RN-completion option were excluded in order to examine basic educational preparation in pain management. Usable surveys were returned by 177 associate degree and 174 generic baccalaureate programs yielding an 80% response rate. Surveys with less than two-thirds completed were considered unusable. Approximately two-thirds of the respondents completed the entire survey.
The survey was mailed to deans and directors of the programs asking them to have the faculty member with the primary responsibility for theoretical instruction in pain management to complete the survey. This was done to enhance the response rate by having a single individual responsible for its return. Some schools indicated the survey was circulated among their faculty. Questionnaires were coded to provide confidentiality and their completion signified consent. The Dillman (1978) method was used to enhance the response rate. This consisted of an introductory letter, the survey and accompanying letter, 1-week follow-up postcard, follow-up letter at 4 weeks, and a second follow-up letter at 7 weeks.
The survey instrument was designed to measure pain and pain management concepts taught in nursing programs. It consisted of 21 questions with multiple subparts so that the total number of items was 98. Respondents were asked to circle yes or no to indicate the inclusion of certain topics related to pain in the curriculum. Questions about assessment of pain were included because of problems identified in clinical practice. Fill-in items were used to assess the amount of instructional time devoted to pain. Three five-point Likert-type items were used to evaluate faculty members' perceptions about pain management content. The questionnaire was critiqued for face validity and clarity by four nurse educators, two nurses who conduct pain research, an oncology clinical nurse specialist, and a survey expert. Further revisions were incorporated after piloting with a small group of ADN and BSN program educators. Reliability has not been tested, and therefore, is a limitation of the study.
Figure. Pain assessment methodology.
Time Allocated to Pain Content
The results of this survey indicate a remarkable similarity between associate degree and baccalaureate nursing programs regarding the time allocated to pain and pain management in their curricula. ADN programs reported devoting an average of 8.4 hours and BSN programs an average of 9.6 hours to all aspects of pain management in the entire curriculum. However, when extreme outliers were deleted, the average hours of instruction for ADN (? = 148) programs dropped to 8.0 hours (SD = 6.6 hours) and 8.2 hours for BSN (? = 156) programs (SD = 6.2 hours). (Respondents most commonly did not complete the number of hours devoted to pain content and therefore, the results are reported for the number of respondents for each question). A t test indicated the means were not significantly different (t = - .42).
Pharmacological methods of pain management received an average of 4.7 hours (SD = 5.7 hours) of instruction in ADN (? = 149) programs and an average of 5.1 hours (SD = 5 hours) of instruction in BSN (? = 148) programs. A t test indicated the means of the two groups were not significantly different (¿ = - .61).
Nonpharmacological methods of pain management received an average of 2.9 hours (SD = 3.4 hours) and an average of 4.1 hours (SD = 8.6 hours) of instruction in ADN (n = 150) and BSN programs respectively. However, when extreme outliers were deleted from the analysis, the mean for BSN (n = 148) programs decreased to 3.5 hours and the standard deviation decreased to 3.5 hours. A t test indicated the means were not significantly different (t= -1.51).
Theoretical Content and Clinical Experiences Related to Pain Management
The survey focused on general theoretical content related to pain, pharmacological management, nonpharmacological methods, assessment of pain, and treatment modalities. The vast majority of respondents indicated that theoretical content about pain and pain management included definitions of pain (99%), theories about pain (93%), acute pain (99%), chronic pain (99%), cancer pain (96%), attitudes about pain management (97%), and psychological aspects of pain (99%). (Results are reported in percentages for the number of respondents for each item.)
Theoretical content related to the pharmacological management of pain included by the respondents' programs are guidelines for the use of analgesics (99%), opioid analgesics and side effects (100%), administration routes (100%), patient-controlled analgesia (96%), and adjuvant analgesics (89%). Equianalgesic doses are addressed by 83% of the programs.
Typically, the nonpharmacological methods taught in the classroom and observed or used in the clinical setting are the application of heat or cold, distraction, massage, relaxation, and TENS (transcutaneous electroneurostimulation). Theory related to therapeutic touch is taught in 78% of the programs, but observed by students in 49% of the programs, and used by students in 44% of the programs. Interestingly, some programs reported students using therapeutic touch without providing theoretical instruction. Additional methods taught, but not specifically included on the questionnaire were imagery and music therapy. A number of respondents reported that nonpharmacological methods are either just mentioned or discussed very briefly.
The vast majority of programs indicated that their students are taught to use a numerical rating and verbal descriptor scale in the classroom and clinical setting. A smaller percentage reported instruction in the use of a visual analogue scale (marking a line to indicate pain intensity) and the PQRST (pattern, quality, reaction, severity, treatments) method (Figure). Programs reported teaching the use of teacher-made tools or special tools, particularly with the pediatric population. The numerical rating scale is taught in the clinical setting by 76% of the ADN and 79% of the BSN respondents. Pain assessment for special populations, the elderly, children, laboring women, chronic pain patients, and cancer patients, is taught in the classroom and clinical setting for 91% to 99% of the programs. However, the special needs of substance abusers and recovering substance abusers are addressed by significantly fewer programs (Table 1). These questions were worded in order to ask about assessment, but it is possible that respondents answered whether there was a special content area in the curriculum devoted to the topic. Most students have the opportunity to have clinical experiences with acute (94%) and chronic (75%) pain patients.
Percentage of Programs Including Instruction in Pain Assessment for Special Groups
Faculty Perceptions of Pain Management in Their Curriculum
Faculty Perceptions About Pain Management in Their Curricula
The faculty of ADN and BSN who completed the survey are very similar in their perceptions about pain management in their curriculum. Faculty indicated that the amount of time allocated to pain and pain management in the curriculum was slightly less than adequate. Faculty believed that the theoretical preparation for pain management provided for their students by their program was adequate. They also believed that the preparation for pain management provided by the clinical instruction in their program was adequate (Table 2).
Although there may be considerable variation among individual programs, the results of this survey indicate that ADN and BSN programs are very similar with respect to the time allocated to pain and its management, specific theoretical content and clinical experiences, and faculty perceptions about the adequacy of pain management instruction. The results provide an explanation for the failure to find differences between ADN and BSN students in their response to patients in distress (Haggerty, 1987). Two possible explanations are offered. First, pain management is a essential skill for nursing practice, and therefore, graduates of both types of programs should be prepared with the same beginning competencies. It is quite possible that some ADN students receive more instruction in pain management than some BSN students and vice versa. Second, the time allocated to pain and pain management may be quite minimal for a significant number of programs, and therefore, differences between ADN and BSN programs may be indistinguishable. With the standard deviations approaching the mean, it seems likely that a significant number of programs devote a minimal amount of time to this essential nursing content. Graffam (1990) reported the modal time allocated to pain in BSN programs was 4 hours (N= 304) and Ferrell, McGuire, and Donovan (1993) reported an average of 14 hours (N= 14). The results of the present investigation fall in the middle, indicating the difficulty in determining exactly how much time is allocated to any particular content within a curriculum and the wide variation that exists among programs. However, without a minimum of theoretical knowledge, clinical experience, and conference time devoted to pain management, neophyte nurses may have difficulty with incorporating key concepts into their practice.
An ideal amount of time allocated to pain management is not known and may be different for different programs, depending on the conceptual framework and structure of the curriculum. For example, a program that has a strong conceptual foundation may have numerous points in the curriculum where learning about pain management is reinforced. If pain is only mentioned as a symptom of a disease and there are no subsequent points for reinforcement, faculty may need to re-examine their approaches to the treatment of pain content in the curriculum.
Most programs included a defined content area related to basic concepts about pain: definition, theories, types (acute, chronic, cancer), treatment, attitudes, and psychological aspects. This indicates most nursing students have at least a basic education regarding pain management. However, one limitation of the survey is that the yes/no checklist items may have resulted in the respondents tending to answer affirmatively. The inclusion of a topic in the curriculum does not reflect the depth of its coverage or the values fostered by the faculty about pain management.
Pharmacological methods of pain management receive over half of the theoretical content allocated to pain management for both ADN and BSN programs. Despite this finding, researchers have indicated that nurses have inadequate knowledge about the pharmacological management of pain (McCaffery, Ferrell, O'Neil-Page, Lester, & Ferrell, 1990; Sheidler, McGuire, Grossman, & Gilbert, 1992; Vortherms, Ryan, & Ward, 1992; Watt-Watson, 1987). The lower percentage of respondents reporting the inclusion of content related to adjuvant analgesics and equianalgesic doses indicates that these areas may be particularly problematic in clinical practice. These are newer topics and may not receive the emphasis they deserve possibly because of a lack of faculty expertise. In some instances, the incorporation of new concepts into the curriculum may only follow their adoption by practice settings (e.g., epidural analgesia), which may also vary geographically.
Nonpharmacological pain relief methods receive limited coverage. Although the survey asked about the inclusion of eight methods, the high percentages reported for their inclusion in the curriculum coupled with the average of 2.9 hours in ADN programs and 3.5 hours in BSN programs in instructional time indicates that a number of these topics could only be briefly described or mentioned. A number of respondents commented that this was the case in the present study as well as in Graffam's study (1990). It is possible that some of these methods are included under the general rubric of comfort, which was not specifically addressed in the survey. If these methods are only mentioned and students do not have the opportunity to develop proficiency in their use, then it is not surprising that nurses are unfamiliar with them as reported by Sanders, Webster, & Farmer (1980). This has serious implications for the use of research findings and the implementation of the acute pain clinical practice guidelines issued by the Agency on Health Care Policy and Research (1992). The lower percentage for therapeutic touch could be indicative of its lack of acceptance as a treatment modality or lack of faculty expertise with the method. The results indicate nonpharmacological methods and pain management in substance abusers and recovering substance abusers needs to be strengthened. Substance abuse education is an area that receives limited attention in basic nursing education (Hoffman & Heinemann, 1987; Long, Gelfand, & McGiIl, 1991). Therefore, it is not surprising that the needs of these populations with respect to pain management are not well addressed.
It is a very positive finding that 92% of the ADN and 96% of the BSN respondents indicated their students had classroom instruction on the use of a numerical rating scale for pain assessment. This is indicative of the potential for improvement in the pain assessments of practicing nurses as more graduates who have been taught this method enter the workforce. The lower percentage (76% ADN; 79% BSN) indicating the use of a numerical scale in the clinical setting may illustrate a lag in the clinical application of newer concepts.
Faculty satisfaction with the time devoted to pain management, and the theoretical and clinical preparation of their graduates for pain management are not surprising since faculty are reporting about their own programs and instructional practices. Less satisfaction with the time allocated to pain content may reflect negotiation with other faculty for competing interests as well as recognition of the importance of pain management in clinical practice. If faculty members were completely dissatisfied, it would perhaps indicate an inability to institute changes. The results are similar to that reported in a survey of critical care in BSN programs where faculty were satisfied with the critical care offerings, but less satisfied with the time allocated to critical care (Tanner, Hartshorn, & Rosenfeld, 1989). Similarly, Ferrell, McGuire, and Donovan (1993) reported that faculty believed their curriculum related to pain was moderately effective and that they were moderately satisfied with their ability to supervise students in pain management. A number of faculty commented that the survey prompted them to re-examine what was taught about pain.
The results of this survey indicate that nursing students receive basic education in pain management, specifically theoretical content, pharmacological management, nonpharmacological methods, and related clinical experiences, but there is considerable variation in the depth of the content as indicated by the time allocated to this essential nursing content. Faculty are somewhat satisfied with the time allocated in their curricula and their graduates' preparation for pain management, and as Ferrell, McGuire, and Donovan (1993) reported, have limited knowledge about pain management. With surveys indicating that nurses lack basic knowledge about pain and its management and patients are underassessed and undermedicated for pain, then the problem is not only lack of curricular time, but one of opportunities to enhance learning in the clinical setting through role modeling of clinical decision making by staff nurses and faculty knowledgeable in pain management. Consequently, faculty can play a significant role in changing the longstanding problems of inadequate pain relief in the clinical setting. Therefore, strategies directed toward the improvement of pain management should include enhancing faculty expertise and interest in pain management.
The educator's dilemma is how to include an evergrowing body of essential knowledge in the curriculum in a manner that is pedagogically sound. A multi-pronged approach to the improvement of the treatment of pain in nursing curricula is required to effect changes in clinical practice. The International Association for the Study of Pain (1993) has recently released a "Pain Curriculum for Basic Nursing Education," which can be used as a guide for curriculum development. The incorporation of the Agency of Health Care Policy and Research acute pain (Acute Pain Management Guideline Panel, 1992) and cancer pain (Jacox, Carr, Payne, et al., 1994) Guidelines into curricula would also help improve this area of practice. Theoretical knowledge needs to be integrated with values about pain management. Specific areas recommended for expansion include equianalgesic doses, adjuvant analgesics, and pain management in substance abusers. Greater emphasis on nonpharmacological methods of pain relief is warranted. These can readily be added to the traditional laboratories on the application of heat and cold in order to expand the repertoire of essential skills of novice nurses.
The survey largely measured empirical content related to pain. Additional research is needed to assess the knowledge and attitudes of senior nursing students or new graduates in pain management in order to more clearly delineate nursing education's influence on this area of clinical practice. Competency in pain management is not solely a function of content mastery. Therefore, education about pain management should include the critical analysis of issues and the development of values. Because it is the knowledge of students, their ability to critically analyze situations, and their values which ultimately influence their pain management strategies, further research is necessary to determine how analytic abilities and values related to pain management in students are developed.
- Acute Pain Management Guideline Panel. (1992). Acute pain: Operative procedures or medical procedures and trauma. Clinical practice guideline. AHCPR Publication No. 92-0032. Rockville, MD: Agency for Health Care Policy and Research.
- Choiniere, M., Melzack, R., Girard, N., Rondeau, J., & Paquin, M. (1990). Comparison between patients' and nurses' assessment of pain and medication efficacy in severe burn injuries. Pain, 40, 143-152.
- Cohen, F.L. (1980). Postsurgical pain relief: Patients' status and nurses' medication choices. Pain, 9, 265-274.
- Dalton, J.A. (1989). Nurses' perceptions of their pain assessment skills, pain management practices, and attitudes toward pain. Oncology Nursing Forum, 16(2), 225-231.
- Diekmann, J.M., & Wassern, R.A. (1991). A survey of nursing students' knowledge of cancer pain control. Cancer Nursing, 14(6), 314-320.
- Dillman, D.A. (1978). Mail and telephone surveys: The total design method. New York: Wiley.
- Dodd, J. (1986). Nursing evaluation of the efficacy of analgesic delivery in postoperative pain. Australian Clinical Review, 206-212.
- Donovan, M., Dillon, P., & McGuire, L. (1987). Incidence and characteristics of pain in a sample of medical -surgical inpatients. Pain, 30, 69-78.
- Ferrell, B.R., Eberts, M.T., McCaffery, M., & Grant, M. (1991). Clinical decision making and pain. Cancer Nursing, 14(6), 289-297.
- Ferrell, B.R., McGuire, D.B., & Donovan, M.I. (1993). Knowledge and beliefs regarding pain in a sample of nursing faculty. Journal of Professional Nursing, 9(2), 79-88.
- Fothergill-Bourbonnais, F, & Wilson-Barnett, J. (1992). A comparative study of intensive therapy unit and hospice nurses' knowledge on pain management. Journal of Advanced Nursing, 17, 363-372.
- Fox, L. (1982). Pain management in the terminally ill cancer patient: An investigation of nurses' attitudes, knowledge and clinical practice. Military Medicine, 147(6), 455-460.
- GrafFam, S. (1990). Pain content in the curriculum - A survey. Nurse Educator, 15(1), 20-23.
- Grier, M., Howard, M., & Cohen, F. (1979). Beliefs and values associated with administering narcotic analgesics to terminally ill patients. American Nurses Association Clinical and Scientific Sessions (pp. 211-222). Kansas City, MO: American Nurses Association.
- Haggerty, L. (1987). An analysis of senior nursing students' immediate responses to distressed patients. Journal of Advanced Nursing, 12, 451-461.
- Hoffman, A.L., & Heinemann, M.E. (1987). Substance abuse in education in schools of nursing: A national survey. Journal of Nursing Education, 26(7), 282-287.
- latrati, N.S. (1986). Pain on the burn unit: Patient vs. nurse perceptions. Journal of Burn Care and Rehabilitation, 7, 413-416.
- International Association for the Study of Pain. (1993). Pain curriculum for basic nursing education. IASP Newsletter, September-October, 4-6.
- Jacox, A., Can·, D.B., Payne, R., et al. (1994). Management of cancer pain. Clinical practice guideline #9. AHCPR Publication No. 94-0592. Rockville, MD: Agency for Health Care Policy and Research.
- Krokosky, N.J., & Reardon, R.C. (1989). The accuracy of nurses' and doctors' perceptions of patient pain. In S.G. Funk, E.M. Tornquist, M.T. Champagne, L. A. Copp, & RA. Wiese (Eds.), Key aspects of comfort: Management of pain, fatigue, and nausea (pp. 127-134). New York: Springer.
- Long, P., Gelfand, G., & McGiIl, D. (1991). Inclusion of alcoholism and drug abuse content in curricula of varied health care professions. Journal of the New York State Nurses Association, 22(1), 9-12.
- Marks, R.M., & Sachar, E.J. (1973). Undertreatment of medical in-patients with narcotic analgesics. Annals of Internal Medicine, 78, 173-181.
- McCaffery, M., Ferrell, B., OT-íeil-Page, E., Lester, M., & Ferrell, B. (1990). Nurses' knowledge of opioid analgesic drugs and psychological dependence. Cancer Nursing, 13(1), 21-27.
- Myers, JS. (1985). Cancer pain: Assessment of nurses' knowledge and attitudes. Oncology Nursing Forum, 12(4), 62-66.
- Paice, JA., Mahon, S.M., & Faut-Callahan, M. (1991). Factors associated with adequate pain control in hospitalized patients diagnosed with cancer. Cancer Nursing, 14(6), 298-305.
- Pritchard, A. P. (1988). Management of pain and nursing attitudes. Cancer Nursing, 11(3), 203-209.
- Rankin, M., & Snider, B. (1984). Nurses' perceptions of cancer patients' pain. Cancer Nursing, 7, 149-155.
- Sanders, S.H., Webster, JS., & Framer, E. (1980). Analysis of nurses' knowledge of behavioral methods applied to chronic and acute pain patients. Journal of Nursing Education, 29(4), 46-50.
- Sheehan, D.K., Webb, A., Bower, D., & Einsporn, R. (1992). Level of cancer pain knowledge among baccalaureate student nurses. Journal of Pain and Symptom Management, 7(8), 487-484.
- Sheidler, V., McGuire, D., Grossman, S.A., & Gilbert, M.R. (1992X Analgesic decision-making skills of nurses. Oncology Nursing Forum, 19(10), 1531-1534.
- Tanner, C, Hartshorn, J, & Rosenfeld, P. (1989). Critical care nursing in baccalaureate programs. Nursing and Health Care, 10(9), 483-488.
- Vortherms, R., Ryan, P., & Ward, S. (1992). Knowledge of, attitudes toward, and barriers to pharmacologic management of cancer pain in a statewide random sample of nurses. Research in Nursing and Health, 15(6), 459-466.
- Walkenstein, M. (1982). Comparison of burned patients' perceptions of pain with nurses' perception of patients' pain. Journal of Burn Care and Rehabilitation, 3, 233-236, 239.
- Watt-Watson, JH. (1987). Nurses' knowledge of pain issues: A survey. Journal of Pain and Symptom Management, 2(4\ 207-211.
- Zalon, M. L. (1993). Nurses' assessment of postoperative patients' pain. Pain, 54, 329-334.
Percentage of Programs Including Instruction in Pain Assessment for Special Groups
Faculty Perceptions of Pain Management in Their Curriculum