Original Article
Attitude and Intention
From the *Department of Acute Pain
Service, The Second Affiliated
Hospital of Zhejiang University,
School of Medicine, Hangzhou,
China; †Department of
Anesthesiology, The Second Affiliated
Hospital of Zhejiang University,
School of Medicine, Hangzhou,
China; ‡Department of Cardiology,
The Second Affiliated Hospital of
Zhejiang University, School of
Medicine, Hangzhou, China;
§
Department of Nursing, The Second
Affiliated Hospital of Zhejiang
University, School of Medicine,
Hangzhou, China.
Address correspondence to Jing-feng
Jin, RN, Department of Nursing, The
Second Affiliated Hospital of Zhejiang
University, School of Medicine, No. 88
Jiefang Road, Hangzhou 310009,
People’s Republic of China.
and Min Yan, MD, Department of
Anesthesiology, The Second Affiliated
Hospital of Zhejiang University,
School of Medicine, No.88 Jiefang
Road, Hangzhou 310009, People’s
Republic of China E-mail: zrjzkhl@
zju.edu.cn, zryanmin@zju.edu.cn
Received April 5, 2016;
Revised November 2, 2016;
Accepted January 12, 2017.
1524-9042/$36.00
Ó 2017 by the American Society for
Pain Management Nursing
http://dx.doi.org/10.1016/
j.pmn.2017.01.001
Regarding Pain
Management among
Chinese Nursing Students:
A Cross-Sectional
Questionnaire Survey
---Liang-yu Fang, RN,*,† Yin-chuan Xu, MD, PhD,‡
Dan-ni Lin, RN,§ Jing-feng Jin, RN,§ and Min Yan, MD†*
- ABSTRACT:
Optimal pain management is a priority in effective nursing care. Lack of
sufficient pain knowledge associated with inadequate pain management
has been proved. However, the intention, defined as the predictor of
behavior, regarding pain management remains unknown. Therefore, the
study was to determine the attitude and intention regarding pain man-
agement among Chinese nursing students and investigate the underlying
determinants and their interactions in terms of intention toward pain
management. The Pain Management Survey Questionnaire, comprising
the key determinants of the theory of planned behavior—that is, direct
attitude, belief-based intention, subjective norm, direct control, and in-
direct control—was used to collect data from 512 nursing students who
undertook clinical rotation in an affiliated hospital of a medical college
in China. Data were analyzed using descriptive statistics, independent
sample t test, Pearson correlation analysis, or structural equation
modeling analysis. Chinese nursing students reported negative attitudes
and behavioral intentions toward pain management. Direct control,
subjective norm, belief-based attitude, and indirect control
independently predicted nursing students’ intention to treat patients
with pain. Direct control was the strongest predictor. Structural equation
modeling analysis further revealed 39.84% of the variance associated
with intention that could be explained by determinants of the theory of
planned behavior. Additionally, educational school level and previous
pain management training had great effects on pain management
intention. Overall, this study identified intention as an important factor
in effective pain treatment. Chinese nursing students have negative atti-
tudes and insufficient intention to pain management. Therefore, hospi-
tals and universities in China should manage these factors to improve
nursing students’ practice regarding pain management.
Ó 2017 by the American Society for Pain Management Nursing
Pain Management Nursing, Vol -, No - (--), 2017: pp 1-10
2 Fang et al.
Pain, described as an unpleasant emotional sensation,
is the most common symptom experienced by a large
number of people. Pain could exert negative effects
both on patients’ physical activity and psychological
status. Therefore, relieving pain is a fundamental
requirement of patients (Chou et al., 2016; Ferrell,
2005). As part of the health system, nurses play an
indispensable role in effective pain management,
including providing accurate evaluation, appropriate
intervention, and sufficient pain education to
patients (Brown, 2013).
Carrying out these roles requires that nursing
students have gained adequate knowledge of pain
management in nursing schools and have been trained
for pain management during the early stage of their
career. Several studies conducted in Western countries
have highlighted the importance of pain knowledge in
effective nursing care (Al Khalaileh & Al Qadire, 2013;
Goodrich, 2006; Lui, So, & Fong, 2008; Plaisance &
Logan, 2006; Rahimi-Madiseh, Tavakol, & Dennick,
2010; Samuels & Leveille, 2010; Shaw & Lee, 2010),
providing the evidence that nursing students’
knowledge is essential for their roles in clinical
practice and their future roles as nurses.
Studies concerning knowledge about pain
management of nurses in China are few. The
knowledge and attitude survey regarding pain (KASRP)
scale was used by Wei, Run, Shuang, Hong, and
Xiuqiong (2014) to investigate the cognitive situation
of pain in 440 clinical nurses of hospitals in the Fujian
province of China. The average correct response rate
was 48.35%, far less than the data reported by similar
studies performed in Western countries (63.6% in the
United States, 73.8% in the United Kingdom, and
62.7% in Italy, respectively) (Keefe & Wharrad, 2012),
revealing that Chinese nurses had severe pain
knowledge deficits.
Therefore, nursing educators in China have
adopted targeted measures to solve problems of
inadequate knowledge in nursing pain management,
including the implementation of pain education
programs for nurses. However, the effective pain
management is still a big challenge for nursing care,
prompting us to identify other factors that might
influence the efficacy of pain treatment.
According to the theory of planned behavior
(TPB) developed by Edwards et al. (2001), intention
can predict an individual’s behavior, how hard the
person is willing to try, and how much effort they
are planning to expend to perform the behavior. We
should realize that only knowledge that is transformed
into prompt behavior could provide optimal pain
management, and intention is the major determinant
in the transformational process from knowledge to
behavior. Therefore, intention has been considered a
pivotal factor to affect pain management (Ajzen, 2011).
Several studies using the TPB indicate that
attitude, subjective norm, and perceived behavioral
control, the key determinants of TPB, could
influence one’s intention significantly (Aldrich, 2015;
Dumitrescu, Wagle, Dogaru, & Manolescu, 2011;
Guo, Wang, Liao, & Huang, 2016). Attitude is
determined by the person’s positive or negative
belief from an evaluation outcome of behavior.
Subjective norms indicate the person’s perceptions
after understanding other people’s expectations and
motivation according to others’ practice. Perceived
behavioral control is regarded as confidence and
belief in behavior performance (Dumitrescu et al.,
2011). Generally, the greater positive attitude,
subjective norms, and favorable behavioral control,
the stronger the behavior intention. Therefore, using
TPB is an optimal approach for understanding the
important role of intention in effective pain
management.
AIM AND RESEARCH QUESTIONS
To our knowledge, few studies have been conducted
to identify the intention and attitude of nursing
students regarding pain management in China. This
study aimed to determine the attitude and intention
regarding pain management among Chinese
nursing students and to investigate the underlying
determinants and their interaction in terms of
intention toward pain management. The following
four questions were asked:
1. What are the attitudes and intentions regarding pain
management among nursing students in China?
2. What are the determinants and their interactions in
terms of intention toward pain management among
Chinese nursing students?
3. What proportion of the variance in behavioral intention
could be explained by determinants of TPB?
4. Do characteristics of Chinese nursing students affect
their intention toward pain management?
METHODS
Design, Sample, and Setting
A descriptive, analytical and cross-sectional survey
design was used by distribution of a self-administered
questionnaire. The study was conducted at an affiliated
hospital of a medical college in Zhejiang province in
China over a period of 1 month in September 2015.
The sample inclusion criteria were nursing
students who were bachelor-degree candidates, had
 Pain Management among Chinese Nursing Students
undertaken clinical orientation in the aforementioned
hospital, and agreed to participate in the study. The
sample size was estimated using the software G* power
V.3.1 with two tails, an effect size of 0.5, a statistical
power of 0.95, and statistical significance of 0.05.
The estimated sample size was 210. However, a larger
sample size (N ¼ 512) was enrolled in the current
study. According to the principles and practice of
structural equation modeling analysis (SEMA), sample
size should be more than 200 because complex models
require a larger sample size (Rex, 2005), thus the
current sample size was sufficient.
Instruments and Measures
Self-administered questionnaires, consisting of two
sections, were used. The first section comprised
general information and asked participants for their
age, sex, educational school level, experience of
clinical orientation in hospitals, previous history of
pain management training, frequency of using
objective tools of pain assessment, and the way to
acquire pain knowledge.
The second section was the pain management
survey questionnaire (PMS), developed by Edwards
et al. (2001). The PMS is a 39-item, multiple-choice
test, measured on a Likert-scale, to evaluate the
attitude and intention related to pain management.
The PMS contains general attitude and six dimensions,
including direct attitude, belief-based attitude,
subjective norms, direct control, indirect control, and
behavioral intention. The detailed information of the
PMS and items for score calculation of general attitude
and the six dimensions are available in Supplemental
Tables 1 and 2, respectively.
The general attitude and direct attitude were
measured on a 5-point Likert scale, while the
remaining 5 dimensions were calculated on a 7-point
Likert scale. The 5-point Likert scale ranged from 1
(strongly agree) to 5 (strongly disagree), while the
7-point Likert scale was measured from þ3 (likely,
desirable) to –3 (unlikely, undesirable). The possible
range scores of the six dimensions were 9～45, 54
～54, 36～36, 9～9, 45～45, and 9～9,
respectively. The measured Cronbach’s alpha
coefficients were 0.78, 0.61, 0.67, 0.68, 0.68, and
0.79. All dimensions were scored consistently so that
higher scores indicated more positive attitude and
intention toward pain management.
General Attitude and Direct Attitude
Nineteen items in the PMS were developed to measure
the general attitude, and nine items were to address the
direct attitude toward pain management. They were
calculated on a 5-point Likert scale by the summation
3
of an individual’s score for the set of items in the
scale, reflecting willingness to administer pain-relief
medicine.
Belief-Based Attitude
Two groups of items, including three positive and
three negative consequences, were measured on a
7-point Likert scale, aiming to assess belief-based
attitude, that is, ‘‘When you administer pro re nata
(P.R.N) narcotic analgesic, how likely is it that the
following consequences will occur for the patient?’’
and ‘‘How desirable do you feel each of the following
consequences would be for a patient who has received
P.R.N narcotic analgesic?’’ The score for belief-based
attitude was achieved by multiplying each belief score
by the corresponding evaluation score and then
summing across the six products.
Subjective Norm
Two groups of items were developed to address
subjective norm, which refers to the unconscious
intention to deal with pain from the related person,
namely, ‘‘How likely is it that the following people
would think that you should administer P.R.N narcotic
analgesic to a patient with pain?’’ and ‘‘How likely are
you to go along with the wishes of the following
people?’’ Each group of items had four subordinate
effect factors, including the patient, the patient’s
family, nursing colleagues, and medical staff. A
subjective norm score was calculated by summing
the cross products of the corresponding scores on
the measures of effect factors.
Direct Control and Indirect Control
Direct control refers to the extent to which the
behavior is performed and is related to outside
opportunity. It was assessed by three items (e.g.,
‘‘How much do you agree that administering P.R.N
narcotic analgesic to a patient with pain is within
your control?’’ ‘‘How easy is it for you to administer
P.R.N narcotic analgesic to a patient with pain?’’ and
‘‘How much control would you have in administering
P.R.N narcotic analgesic to a patient?’’). The score of
direct control was calculated by the summation of an
individual’s score for the set of items in the scale.
Indirect control is associated with the nursing
ward expectations, the route of administration, type
of pain, patients’ medical or surgical condition, and
patients’ characteristics. Two groups of items (e.g.,
‘‘How much effect do ward expectations have on
whether you administer P.R.N opioid analgesia to a
patient with pain?’’ and ‘‘How often do you consider
ward expectations prior to administering P.R.N opioid
analgesia to a patient with pain?’’) were developed to
4 Fang et al.
evaluate the effect of these five aspects on nurses’
administration of P.R.N opioid analgesics. An indirect
control score was calculated by summing the cross
products of the corresponding scores on the measures
of the five aspects.
Behavior Intention
Behavioral intention is considered as the possibility of
performing effective pain management by participants.
The behavioral intention was assessed using the
7-point Likert scale. Three items were developed to
address behavioral intention: ‘‘How much do you agree
that you intend to administer P.R.N narcotic analgesic
when caring for a patient with pain?’’ ‘‘How likely are
you to give a narcotic analgesic prescribed on a P.R.N
(as needed) basis to a patient who has pain?’’ ‘‘How
likely are you to try to administer P.R.N narcotic anal-
gesic when caring for a patient with pain?’’ The score
of behavior intention was calculated by the summation
of individual’s score for the set of items in the scale.
Compared with the KASRP to assess the pain
knowledge of nursing staff, the PMS has the advantages
of analyzing the influence of behavioral intention on
pain management, especially the nursing staff’s ten-
dency to administer narcotic analgesic medication in
the process of pain care (Edwards et al., 2001). In
our study, we used PMS translated into Chinese.
Previous studies have provided evidence that language
translation does not affect the validity of the PMS (the
Cronbach’s alpha of the Chinese version of the PMS
was 0.73, and the Cronbach’s alpha of the six
dimensions were 0.73, 0.68, 0.67, 0.58, 0.80, and
0.56, respectively) (He & Tao, 2011; Hua, Yang, &
Linlin, 2014).
Ethical Considerations
The current study was approved by the research and
ethical committee of the Second Affiliated Hospital of
Zhejiang University, School of Medicine. Researchers
explained the purpose and procedures of the study
to the participants before having them answer the
questionnaire. The responses from nursing students
were kept confidential, and anonymity was ensured
throughout the whole study. Participation was
completely voluntary, and withdrawal at any stage of
the study was permitted.
Study Procedure
All the participants enrolled in this study were taking
part in their clinical rotation in an affiliated hospital
of a medical college in Zhejiang province in China.
After obtaining ethical approval from the ethics
committee of the hospital and receiving permission
to conduct the study from the Nursing Department,
blank questionnaires and information sheets were
sent to the clinical ward. The research team visited
the clinical unit, and the aims of the study were
explained to the participants. The participants were
then asked to complete the questionnaires, which
were returned to a designated box.
Data Collection and Analyses
Of the 542 distributed questionnaires, 512 completed
questionnaires were received, providing a response
rate of 94.5%. All completed questionnaires were inde-
pendently checked by two people. All uncompleted
forms were excluded from further analyses. Data
were entered into a computerized database, and IBM
SPSS software version 19 (SPSS 19.0, Inc., Chicago,
IL, USA) was used for statistical analyses. A p value
less than .05 was considered statistically significant.
The general characteristics of nursing students
regarding pain management were recorded using
descriptive statistics. Independent sample t test was
used to assess the difference in behavioral intention be-
tween subgroups as classified by students’ characteris-
tics. Pearson correlation analysis was performed to
evaluate the correlations between intention and the
PMS dimensions.
To further examine the relative contributions of
TPB determinants in predicting behavioral intention
toward pain management, variables were examined
in SEMA using AMOS 21.0 software (SPSS, Inc.). To
assess how well data fit structural equation models,
we calculated parameters including the comparative
fit index (CFI), goodness-of-fit index (GFI), Tucker-
Lewis Index (TLI), root mean square error of approxi-
mation, (RMSEA), and the standardized root mean
square residual (SRMR). The SEMA model as hypothe-
sized was accepted if the p value of the chi-square
test exceeded .05. The standard of well data fitting is
a CFI and TLI value ranging from 0.9-1.0, a GFI value
exceeding 0.9, an RMSEA value less than 0.05, and an
SRMR value less than 0.05.
RESULTS
The results are presented in four sections. The first sec-
tion comprises descriptive statistics of current attitude
and intention toward pain management. The second
section focuses on correlations between TPB
determinants and behavioral intension toward pain
management. The third section shows the relative
contributions of TPB determinants in predicting
behavioral intention toward pain management. The
last section includes the characteristics of nursing
students that could affect behavioral intention
regarding pain management.
 Pain Management among Chinese Nursing Students 5

Participants’ Characteristics
The mean age of nursing students was 22 years TABLE 1.
(standard deviation [SD] ¼ 1.25, range ¼ 19-25). The General Characteristics of the Sample (N ¼ 512)
majority of nursing students were women (89.6%,
Variables n %
n ¼ 459). One-third of nursing students were from
university-level nursing schools in large cities (31.3%, Age, years: Mean ¼ 21.91; SD ¼ 1.25
n ¼ 160), while others (68.7%, n ¼ 352) were from Sex
general nursing schools. All participants in this study Male 53 10.4
had attended clinical orientation in hospitals for at Female 459 89.6
Educational school level
least 6 months. Half of the students (51.2%) reported University-level nursing school in a large city 160 31.3
that they had ever received pain management training, General nursing school 352 68.7
and 38.5% reported that they always used objective Experienced clinical orientation in hospitals
tools for pain assessment. Additionally, 73.6% of the #6 mo 305 59.6
students gained their pain knowledge from an Acute 6-8 mo 166 32.4
>8 mo 41 8.0
Pain Service Department (APS) in hospitals, and Previous pain management training
52.2% from medical books or journals. The general Yes 262 51.2
characteristics of the participants are detailed in No 250 48.8
Table 1. Frequency of using objective tools for pain assessment
Never or rarely 115 22.4
Sometimes 200 39.1
Overall Attitude and Intention Regarding Pain Always 197 38.5
Management Require pain knowledge from APS in hospitals
The score of general attitude and behavioral intention Yes 377 73.6
No 135 26.4
was 51.13 (SD ¼ 5.84) and 0.06 (SD ¼ 3.31), Acquire pain knowledge from books or journals
respectively, indicating that the overall intention Yes 267 52.2
related to pain management is negative. Further No 245 47.8
calculation of scores of five dimensions, including
SD ¼ standard deviation; APS ¼ Acute Pain Service.
direct attitude, belief-based attitude, subjective norm,
indirect control, and direct control, were 22.32, 7.54,
samples: c2 ¼ 4.571 (d.f. ¼ 4, p ¼ .334), GFI ¼ .997,
3.78, 10.79, and 1.71, respectively. The mean score
CFI ¼ .998, TLI ¼ .992, RMSEA ¼ .017, and
for nursing students with relevant responses on each
SRMR ¼ .0185. Furthermore, the model revealed a sta-
dimension of the PMS is listed in Table 2.
tistically significant influence of direct control, subjec-
tive norm, and belief-based attitude, which together
Correlations between Behavioral and TPB explained 39.84% of the variance in intention to
Determinants improve pain management practice.
Intention correlated positively with direct control,
subjective norm, belief-based attitude, and indirect Characteristics of Nursing Students Affect
control. Direct control was the strongest correlator. Intention Regarding Pain Management
The percentage of nursing students with responses To identify other factors that might affect intention, we
on direct control of PMS and the correlations among compared the difference in behavioral intention
other dimensions of the model are shown in Tables 3
and 4, respectively.
TABLE 2.
Structural Equation Modeling Analysis Scores of PMS Dimensions
Structural equation modeling analysis was performed
using the AMOS technique to further assess the Items N Min Max Mean SD
contribution of determinants of TPB to predict
General attitude 512 19 75 51.13 5.84
behavioral intention toward pain management. The Direct attitude 512 9 43 22.32 4.69
initial behavior intention model included the paths Belief-based attitude 512 36 54 7.54 12.23
from TPB components, such as direct attitude, belief- Subjective norm 512 21 36 3.78 8.09
based attitude, subjective norm, direct control, and Indirect control 512 24 45 10.79 10.19
indirect control, and correlations among them (Fig. 1). Direct control 512 9 9 1.71 3.60
Behavioral intention 512 9 9 0.06 3.31
The final model (Fig. 2) was modified based on the
analysis of initial structure and fitted well with all PMS ¼ Pain Management Survey Questionnaire; SD ¼ standard deviation.
6 Fang et al.

TABLE 3.
Percentage of Nursing Students with Responses on Direct Control of PMS (N ¼ 512)

Items of Narcotic
No. Analgesic Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Score 7

Strongly agree Neutral Strongly

disagree
36b Administering PRN 15 (2.9%) 42 (8.2%) 45 (8.8%) 109 (21.3%) 68 (13.3%) 103 (20.1%) 130 (25.4%)
narcotic analgesic
to a patient with
pain is within my
control
Extremely easy Neutral Extremely
difficult
38 How easy would it be 20 (3.9%) 29 (5.7%) 67 (13.1%) 141 (27.5%) 130 (25.4%) 87 (17.0%) 38 (7.4%)
for you to
administer PRN
narcotic analgesic
to a patient with
pain?
Complete Neutral No control
control
39 How much control 18 (3.5%) 43 (8.4%) 68 (13.3%) 193 (37.7%) 74 (14.5%) 62 (12.1%) 54 (10.5%)
do you believe you
would have in
administering PRN
narcotic analgesic
to a patient?
PMS ¼ Pain Management Survey Questionnaire; PRN ¼ pro re nata.

between subgroups classified by students’ characteris-
tics. Analyses revealed that behavioral intention
consistently differed with educational school level
(t ¼ 3.56, p < .001) and previous pain management
training (t ¼ 3.47, p ¼ .001), but there was no
difference in other variables. Nursing students from
university-level nursing schools in large cities acquired
higher scores on intention than those from general
nursing schools, and nursing students’ intention was
more positive than those without experience of pain
training. The detailed information is described in
Table 5.
DISCUSSION
This study identified the intention of nursing students
as another important factor in effective pain treatment.
Nursing students in China have an overall negative
attitude and behavioral intention toward pain
management. Direct control, subjective norm, belief-
based attitude, and indirect control were found to
independently predict nursing students’ intention to
treat patients with pain. Direct control was the stron-
gest predictor. A total of 39.84% of the variance in
intention could be explained by determinants of TPB.
Additionally, educational school level and previous
pain training experience also had significant effects
on pain management intention.
Negative Attitude Affects Intention Toward Pain
Management
Many previous studies have used different versions of
the KASRP questionnaire to determine the role of
knowledge in optimal pain management (Chow &
Chan, 2015). Seven large, descriptive cross-sectional
studies conducted in Western countries revealed that
inadequate pain knowledge was by far the major
hindrance preventing nursing staff from achieving
effective pain treatment (Al Khalaileh & Al Qadire,
2013; Al Khawaldeh, Al Hussami, & Darawad, 2013;
Duke, Haas, Yarbrough, & Northam, 2013; Goodrich,
2006; Plaisance & Logan, 2006; Rahimi-Madiseh,
Yavakol, & Dennick, 2010; Shaw & Lee, 2010).
Furthermore, Alzghoul and Abdullah (2015) provide
evidence that knowledge of pain management has a
strong association (69% contributions) with pain man-
agement practice. The situation in China is similar.
Hence, targeted measures to solve problems of
inadequate knowledge, including various pain
education programs implementation, have been
adopted worldwide. Despite all of these efforts,
effective pain management is still a challenge for
 Pain Management among Chinese Nursing Students 7

TABLE 4.
Correlations* between Behavioral Intention and TPB Determinants

Correlation Coefficients*

Dimension GA DA BA SN DC IC BI

GA 1
DA 0.051 1
BA 0.046 0.046 1
SN 0.032 0.090† 0.221‡ 1
DC 0.069 0.067 0.124‡ 0.141‡ 1
IC 0.004 0.083 0.226‡ 0.282‡ 0.061 1
BI 0.056 0.085 0.211‡ 0.263‡ 0.559‡ 0.204‡ 1
TPB ¼ theory of planned behavior; GA ¼ general attitude; DA ¼ direct attitude; BA ¼ belief-based attitude; SN ¼ subjective norm; DC ¼ direct control;
IC ¼ indirect control; BI ¼ behavioral intention.
*Pearson’s correlation.
†
Correlation is significant at the .05 level (2-tailed).
‡
Correlation is significant at the .01 level (2-tailed).

nursing care, indicating that optimal pain management
is influenced by other factors in addition to knowledge.
Therefore, we aimed to investigate the role of
behavioral intention in pain management among
Chinese nursing students based on TPB, which is a
novelty of this study.
According to TPB, attitude had a strong effect on
intention, suggesting that the more positive a person’s
attitude, the more likely he or she is to intend to
improve his or her behavior. Of note, the scores of
attitude in our study were relatively low (direct
attitude: 22.32 vs. 31.70) compared with the finds of
Edwards et al. (2001), indicating a much more negative
attitude of nursing students in China regarding pain
management.
Worries about the side effects of analgesics,
including drug addiction and intelligence retardation, ac-
counted for the difference in nursing students’ attitude
between China and Western countries. Additionally,
traditional Chinese culture may be another major factor
Direct Attitude
Belief-based Attitude
Subjective Norm Behavioral Intention
Direct Control
Indirect Control
FIGURE 1. - Initial hypothesis to explain predicting factors
of behavioral intention regarding pain management.
contributing to the negative attitude of Chinese nursing
students toward pain relief medication. In China, people
who endure pain are considered brave, and this perspec-
tive is handed down from generation to generation and
is widely accepted by most nursing students.
Insufficient Behavioral Intention Toward Pain
Management
The score of behavioral intention in this study was
–0.06 versus 5.58 in Edwards et al. (2001), suggesting
the very low tendency of Chinese nursing students to
provide pain relief. Further analysis of correlations be-
tween intention and TPB determinants showed that
direct control was the strongest predictor to intention
regarding pain management, which was different from
other studies, which demonstrated that attitude ex-
erted the strongest effect on intention prediction.
The score of direct control in this study was –1.71,
far less than the data from studies conducted in West-
ern countries, indicating that nursing students in China
do not fully recognize their important role in effective
pain management. The general view in China that the
doctor is in charge of administering pain relief
medication is the major factor contributing to the
deficit of self-efficacy toward pain management among
Chinese nursing students.
The SEMA carried out in this study has advantages
for analyzing complex linkage between intention and
TPB determinants. It allows the modeling of the poten-
tial variables, which reduces the likelihood of
regression dilution (Dumitrescu et al., 2011). The
model revealed a statistically significant influence of
direct control, subjective norm, and belief-based
attitude, which together explained 39.84% of the
8 Fang et al.

34.09
**
1
E7 General Attitude
6.26
1.46 21.98
**
1 E1
E2 Direct Attitude -0.01

** 0.00
2.80 149.24
* 1 1
3.33 *
E3 Belief-based Attitude 0.02

1.19 ** **
21.81 65.32 ** Behavioral Intention
0.06
1
3.93
5.44
* E4 Subjective Norm
** 0.54
**
4.09
* 12.96

28.11
** 1
**
E5 Direct Control 0.02
23.19
103.54
**
2.24
1
E6 Indirect Control

Condition Number: 39.84

FIGURE 2. - Structural equations modeling analysis of intention regarding pain management within different dimensions.
Significance is indicated by an asterisk (**p < .001, *p < .05). Circles labeled E1-E7 indicate the measurement error of
corresponding observed variables. Single-headed arrows indicate the hypothesized direction of causality, and double-
headed arrows indicate nondirectional associations. Numbers adjacent to arrows represent the standardized direct effect.
Condition number is automatically calculated by software, indicating the proportion of the variance in behavioral intention
that could be explained by TPB determinants.

variance in intention to improve pain management
practice, reflecting the close relationship between
intention and TPB determinants.
In addition to TPB determinants, our study was
also able to identify other factors that might affect
behavioral intention. We found a statistical difference
in behavioral intention between subgroups classified
by educational school level and previous pain
management training, indicating that the higher level
of educational school and more previous training in
pain management result in more positive intention
regarding pain management. This result is consistent
with previous studies that reported that academic
background could influence the pain knowledge and
attitude of nursing students (Latchman, 2014). These
findings also highlight the importance of pain
education and training in cultivating nursing students
during the early stage of their nursing career.
Implications for Nursing Education, Practice,
and Research
This study has highlighted the important role of
behavioral intention in pain management and identi-
fied the factors that might affect the intention. To
improve the effectiveness of pain management,
nursing educators in China are recommended to

TABLE 5.
Differences in Behavioral Intention between Subgroups of Students’ Characteristics (N ¼ 512)

Variables N Mean ± SD t p

Educational school level

University-level nursing school in a large city 160 0.71  3.60 3.56 <.001
General nursing school 352 0.40  3.11
Previous pain management training
Yes 262 0.46  3.66 3.47 .001
No 250 0.55  2.86
SD ¼ standard deviation.
 Pain Management among Chinese Nursing Students
use our results to encourage nursing students to
enhance their self-efficacy toward pain management.
Furthermore, continuing educational programs and
seminars regarding pain management are essential for
nursing student training. In addition, our study has
demonstrated that TPB determinants explain about
40% of the variance with regard to the intention to
manage pain. It is recommended that further research
be undertaken to identify factors that contribute to the
remaining 60% of the variance in the intention, which
may provide more approaches for managing pain
effectively.
Limitations
Although our study provides information about
Chinese nursing students’ attitudes and intentions
regarding pain management, the following limitations
need to be considered. First, the design of our study
was cross-sectional and descriptive, which provides
linkages between study variables but not causality.
Second, the significant difference may not reflect the
whole status of pain attitude and intention among all
nursing students in China, since the population of
enrolled samples was limited to undergraduate
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SUPPLEMENTARY DATA
Supplementary data related to this article can be found
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