Running head: Nursing knowledge and attitude toward pain management in the critical care unit

Term paper about:

Nursing Knowledge and Attitude Toward Pain Management in The

Critical Care Unit

Prepared by:
Maysa’a Al-hilalat
Salsabeel Al-salameen

Supervisor :

Dr.Muwafaq Al-momani

Al-Hussein Bin Talal University

College: Princess Aisha Bint Al-Hussein College for Nursing and Health Sciences

Department: Master of Nursing

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Running head: Nursing knowledge and attitude toward pain management in the critical care unit

Abstracts

Background: Effective pain management is important to all patients suffering from pain whether
acute or chronic. Knowledge of pain combined with positive attitudes is the key to successful pain
management.

Aim: This study aims to evaluate nursing knowledge and attitude toward pain management in the
critical care unit.

Method: A comprehensive search was performed using electronic databases and bibliographies
to obtain relevant literature. Research articles and systemic reviews were gathered from Google
Scholar Database, PubMed, and Science direct. Key terms entered with all databases were: pain,
pain management, nurses' knowledge, nurses' attitudes, nurse, critical care units. Literature
published between 2010 and 2021 was reviewed for this research. Inclusion criteria were limited
to studies conducted among nurses as a target population, discussed nursing knowledge and
attitude toward pain management.

Result: Previous literature indicated that nurses have a lack of adequate knowledge and attitudes.
Ineffective pain management affects the lives of individuals. Inadequate pain management has
been shown to affect patient outcomes by potentially increasing hospital stay and delaying
recovery; thus, the management of pain has major nursing implications.

Conclusion: Nurses’ knowledge and attitude regarding pain management were poor. Compared
to other professionals in healthcare, nurses can manage pain effectively due to their close
relationship with patients.

Implication: Assessed nursing knowledge and attitude toward pain management in the critical
care unit in Jordan is very important to direct the health service. It's important for assessing
educational programs for nursing staff about providing patients with evidence-based pain
management.

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Running head: Nursing knowledge and attitude toward pain management in the critical care unit

List of Contents

page Title No

4 Introduction

4 Literature review 1

5 Pain 1.1

5 Pain management 2.1

6 Nurses’ role in pain management 3.1

8 Knowledge about Pain Management 4.1

10 Attitudes Toward Pain Management 5.1

13 Conclusion 2

13 Implication 3

14 Recommendation 4

14 References

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Running head: Nursing knowledge and attitude toward pain management in the critical care unit

Introduction

Pain is the major sign that leads people to attend hospitals, seeking relief and treatment.
Nurses play a vital role in pain assessment, relief, and evaluation. Patients in critical care units
suffer from moderate to severe acute pain, which can induce negative physiological and
psychological impacts if managed ineffectively. Optimum relief of pain is dependent on nurses'
knowledge and understanding of systematic assessment and sufficient pain documentation
(Francis and Fitzpatrick, 2013). Knowledge deficits and negative attitudes regarding pain
assessment and management, failure to assess the entity of pain, and miss communication between
the patient and the nurse, will contribute to suboptimal and insufficient pain management (Pasero,
2009). Many health care professionals have insufficient knowledge and attitude for effectively
managing pain, leaving many patients under a reduced quality of life (American Cancer Society,
2009).
It's important to understand nurse's level of knowledge and attitude towards pain management for
better recovery and outcomes. It's documented that nurses have a lower level of knowledge and a
negative attitude toward pain management. Data about nursing knowledge and attitude toward pain
management is lacking in Jordan. Having said that insufficient pain management will induce
patients' recovery and pain relief, which intern harms patient outcomes. Specifically, the
assessment of nursing knowledge and attitude toward pain management in the critical care unit is
not explored in Jordan. To understand this gap of knowledge, this paper intends to provide insight
into the knowledge and attitudes toward pain management among nurses in critical care units.

1.Literature review

The purpose of this section is to present a review of the Literature. The literature focuses
on pain management and demonstrates its impact on patient outcomes, in addition to the literature
that discussed the Impact of knowledge and attitudes of nurses towered Pain management.
This review starts with an overview of pain and pain management then the review contains a
discussion on studies that conducted to discuss pain management and nurses role in pain
management, then it showed studies that described the effect of knowledge and positive attitude
of nurses toward pain management for patients in the critical care unit. This review is very
important to the ministry of education and health care professionals to consider pain management

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Running head: Nursing knowledge and attitude toward pain management in the critical care unit

in continuous education and nursing undergraduate curricula and to implement educational

programs to improve nursing knowledge and attitudes toward pain management.

1.1Pain

Pain is considered as the major stressor that facing hospitalized patients and it's the most
common cause of seeking medical care (Ramira, Instone, Clark, 2016). Pain is considered a
physical symptom of illness or injury brought about by a simple stimulus-response mechanism
(Hossain, 2010). The international association of Pain defined pain as "unpleasant sensory and
emotional experience associated with actual or potential tissue damage or described in terms of
such damage" (Hossain, 2010).
Pain is classified into acute or chronic. Acute pain, such as postoperative pain that is recovered as
healing takes place, while chronic pain is persistent and is subdivided into pain related to cancer
and nonmalignant pain, such as arthritis, low-back pain, and peripheral neuropathy (Hossain,
2010). Mostly, pain could be as a result of, injury, surgery, illness, or nociceptive feelings which
allow patients to intend health-care services (Polomano et al., 2008).
Patients in the critical care units face intolerable pain which affects their physical, emotional, and
spiritual dimensions of their health (Eaton, et al. 2015; Pereira et al. 2016).
Pain control and management are important because unmanaged or untreated pain will have a
deleterious impact on the patient’s health and quality of life (Bartoszczyk and Gilbertson‑White,
2015).

2.1Pain management

Pain management is a major concern for patients. Receiving optimal pain management
guaranteed prompt and effective pain control and few adverse effects from pain or its treatment
(Prem et al., 2011). Adequate and effective pain relief and patient's overall satisfaction depends
on quick intervention delivery, engaging patients in their care, encouraging their communication
of pain, interacting with the healthcare provider, and establishing a trust-based relationship (Ramia
et al., 2017).
Governing organizations on pain and healthcare institutions affirm the patient's right of
involvement in all aspects of his pain management (American Society for Pain Management

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Running head: Nursing knowledge and attitude toward pain management in the critical care unit

Nursing (ASPMN), 2010). Based on the recommendations of the American Academy of Pain
Medicine, the American Pain Society, and the American Society of Anesthesiologists, healthcare
institutions have the responsibility to ensure the patients' right to optimal pain management (The
American Society of Anesthesiologists Task Force on Acute Pain Management, (2012).
A review of the literature revealed that there is relevance in pain control and management among
patients, nurses, and healthcare professionals. Various studies about perceptions of pain
management have shown that inadequate assessment, individual variability in the experience, poor
communication between the health care team and their patients are the most frequently cited factors
accounting for unacceptable pain treatment (Ramia et al. (2017; Prem et al., 2011 ).
Ramia et al. (2017) conducted a cross-sectional study to assess patients' descriptions of their acute
pain intensity; patients' attitudes towards their pain management during hospitalization in
Lebanon. A questionnaire was used to collect the data, and descriptive statistics were used to
calculate participants' responses. About 119 women on the maternity services and 177 patients on
the orthopedic services participated in the study. Results showed that 50% of obstetric and 37% of
orthopedic patients reported they have severe pain at its highest intensity. In maternity and
orthopedic patients, respectively, unfavorable practices included pain not being assessed before
pain medication administration (19.3% and 30.5%), having to wait for ≥30 minutes before getting
the pain medication (14.2% and 11.3%), and pain scores not being documented on the medical
chart (95% and 93.2%).

3.1Nurses’ role in pain management

Nurses spend a critical and significant role in pain management; they are greatly responsible
for pain evaluation, promotion of patient comfort, maintenance, and pain recovery (Voshall et al.,
2018; Prem et al., 2011). According to the American Nurses Association (ANA), nurses are
responsible for maintaining current knowledge in pain assessment and management (ANA, 2001).
Nurses have to be well-practiced and have much knowledge on pain assessment and management
techniques, where any mistakes or inability to manage pain can lead to inappropriate and
inadequate pain management practices (Kwon, 2014; Alqahtani and Jones, 2015).
Another study was conducted by Chatchumni (2015) to identify nurses' perceptions of patients in
pain and subsequent pain management. Eighteen registered nurses working in surgical wards.

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Running head: Nursing knowledge and attitude toward pain management in the critical care unit

Participants were condensed into four themes. Two themes revolved around their perceptions of
patient pain, uncomfortable patient, and restricted mobility, and changed mood. The other two
themes comprised intolerable pain would be managed, and managing pain through our own
experience seems to be of importance in their professional assumption that evidence-based practice
is inadequate for patients' postoperative care. It reported that nurses work to an organized pain
assessment guideline and pain management models according to cultural contexts, which is
developed within an understanding of the nurse-patient relationship, and specifically holistic
nursing models of care can play an important role in bridging the connection between training and
practice.
A study was conducted by Chatchumni (2015) to identify nurses' perceptions of patients in pain
and subsequent pain management. Eighteen registered nurses working in surgical wards.
Participants were condensed into four themes. Two themes revolved around their perceptions of
patient pain, uncomfortable patient, and restricted mobility, and changed mood. The other two
themes comprised intolerable pain would be managed, and managing pain through our own
experience seems to be of importance in their professional assumption that evidence-based practice
is inadequate for patients' postoperative care. It reported that nurses work to an organized pain
assessment guideline and pain management models according to cultural contexts, which is
developed within an understanding of the nurse-patient relationship, and specifically holistic
nursing models of care can play an important role in bridging the connection between training and
practice. In addition, Chatchumni (2020) conducted a study to identify the importance of nurses'
role in postoperative pain management, to apply knowledge about pain management to be able to
use in the care of patients after surgery to reduce pain. Findings revealed that most of the available
research paints a negative picture of pain assessment and management in the surgical ward. There
is evidence of positive developments in clinical practice that have the potential to improve the
patient's experience in postoperative pain management. The study recommended the nurses' role
in pain management in response to the discomfort and pain of patients by focusing on patient-
centered care. Alzghoul and Abdullah (2020) conducted a study to examine pain management
practices by nurses. A transverse, correlational design study was assessed that involving 266
registered nurses. The nurses were requested to provide information on pain management via three
instruments: attitude to, knowledge of, and self-efficacy of pain management. Results showed that
nurses displayed an essential relationship between self-efficacy and attitude towards pain

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Running head: Nursing knowledge and attitude toward pain management in the critical care unit

management. In addition, results showed a substantial connection between the nurses' familiarity
to pain management and their ability to manage it in patients' pain (p < 0.001). It concluded from
the previous studies that nurses play a significant role in pain management and relief.

4.1Knowledge about Pain Management

Insufficient and inadequate knowledge by nurses has emerged as the most significant
aspect of effective pain management (Chiu et al., 2003). Insufficient knowledge is evident in many
works of literature. According to the previous studies, it is concluded that nurses had inadequate
knowledge and negative attitude towards non-pharmacological pain management which indeed
affects effects on the patient's physical, emotional and spiritual wellbeing, the quality of life,
increase the incidence and severity of complications, and consequently increase health care cost
(Karabulut, Gürçayır, and Aktaş, 2016). In addition, data indicated that most nurses had
insufficient knowledge about the World Health Organization pain ladder, and were not aware that
a combination of drugs could be used synergistically to alleviate pain safely, without patients
developing respiratory depression (Bernardi et al., 2007).
Accordingly, several works of literature have studied the effectiveness of pain management, and
the knowledge of nurses towards patients' pain management. A descriptive study implemented by
McNamara, Harmon, and Saunders (2012) to assess the effectiveness of an acute pain educational
program in improving nurses' knowledge, skills, and attitudes regarding postoperative pain
management. A convenience sample of 59 nurses attending an educational program on acute pain
management participated. Validated questionnaires were used and completed by the participants,
immediately after and six weeks after the educational program to assess nurses' knowledge and
attitudes towards acute pain management. Nurses were also asked to rate their views on 18
statements on acute pain management. The results showed that the acute pain educational program
intervention improved nurses’ knowledge and attitudes towards pain assessment and management.
Effective pain management was most successful immediately after the pain education program.
A cross‑sectional survey was conducted by Samarkandi (2018) to assess Saudi nurses’ knowledge
and attitudes toward pain management. Nurses were recruited from high acuity care units,
including nurses from the medical and surgical wards. Their knowledge on the degree of pain was
measured using the survey for “Knowledge and Attitudes Survey Regarding Pain.”. Results

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Running head: Nursing knowledge and attitude toward pain management in the critical care unit

indicated that about 123 nurses took part in the survey. The total mean score of correct answers
for the 39 questions asked was 17.4 ± 4.2, which is considered to be less than the pass mark of
19.5. There were no statistically significant differences between the nurses' total average score and
demographic characteristics, except for their initial level of education. Results concluded that
nurses have limited knowledge and negative attitudes toward pain management, where half of the
nurses reported that they don't take any previous pain education in the last 5 years. Another cross-
sectional quantitative study implemented by Kahsay and Pitkäjärvi (2019) investigate the
emergency nurses´ knowledge, attitude, and perceived barriers regarding pain management.
Results showed a poor knowledge level and attitude of the emergency nurses. About 49.5% of the
participant nurses with Bachelor's Degree had significantly higher knowledge and attitude level
compared to the nurses at the Diploma and Certificate level of professional preparation Nurses
who had previous training regarding pain scored significantly higher knowledge level compared
to those without training. The highest perceived barriers to adequate pain management in
emergency departments were measured to be overcrowding of the emergency department, lack of
protocols for pain assessment, nursing workload, and lack of pain assessment tools. There was no
significant difference in perceived barriers among nurses with different demographic
characteristics.
Jira et al. (2020) assessed the knowledge and attitude towards non-pharmacological pain
management and its associated factors among nurses among Ethiopian nurses. The survey was
conducted on 209 professional nurses, with a 96.7% response rate. Findings indicated that 51.2%
of nurses had adequate knowledge and 47% of nurses had a favorable attitude towards non-
pharmacological pain management. Nurse-to-patient ratio, training, and knowledge of non-
pharmacological pain management were significantly associated with nurses' attitudes to non-
pharmacological pain management. In addition, they found that factors significantly associated
with knowledge; are level of qualification, taking educational courses, nurse to patient ratio, and
work experience. Kizza (2012) conducted a descriptive cross-sectional study of 170 nurses in
critical care units, results reported that about 96% of the nurses who care for seriously ill patients
do not use the pain assessment tools, and also almost half of them do not have adequate knowledge
on the key assessment principles of pain. In addition, Abdul-Jaleel and Rajha (2020) applied a
quasi-experimental design to investigate the effect of nursing educational program nurse's
knowledge about postoperative pain management for postoperative patients. Fifty nurses were

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Running head: Nursing knowledge and attitude toward pain management in the critical care unit

survived to evaluate the effectiveness of an educational program on nurse’s knowledge about the
management of patients with postoperative pain in AL-Najaf AL-Ashraf city at Al-Sadder medical
city. The results of the study show there is a highly significant effect of the educational program
regarding nurses’ knowledge toward postoperative pain management. It was concluded that the
majority of nurses in the surgical ward had a knowledge deficit concerning the management of a
patient with postoperative pain.

From the previous studies it's concluded that the majority of nurses had a knowledge deficit
concerning pain management of patients. this implies that nurses should improve their knowledge
by educational sessions to keep them up to date toward postoperative pain management.

5.1Attitudes Toward Pain Management

Negative attitudes by healthcare professionals are considered a barrier to effective pain

management. Factors that evaluated positive attitudes for effective pain management was
inadequate nursing education since nursing faculty themselves were insufficiently knowledgeable
on the principles of pain management regarding the pharmacology of medications and physiology
of pain (Latchman, 2010).
Negative attitudes by nurses and healthcare professionals are another barrier to effective pain
management that is studied in the literature. In another study conducted by Basak et al. (2010) to
assess pain management during the post-operative period, the study showed that nurses had
insufficient knowledge and negative attitudes. Latchman (2010) examined the knowledge and
attitudes of undergraduate students regarding pain management. A sample of 41 undergraduate
students at the University of South Florida College of Nursing participated. The students sampled
were predominantly white, (n=30), female (n=37), seniors (n=41) taking Leadership and
Management in Nursing. Students completed the demographic data form, the nurses' attitude
survey, and the Pain Management Principles Assessment Tool. Results showed that 31(63%) was
achieved on the knowledge of the students regarding pain management while, out of 25 (68%) was
achieved on the Nurses' Attitude Survey. The data showed that nursing students demonstrated
inadequate knowledge regarding pain management, and had mixed attitudes towards pain
management. A weak to moderate relationship between knowledge and attitudes was found

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Running head: Nursing knowledge and attitude toward pain management in the critical care unit

because students lacked the fundamental knowledge, and understanding as to why they were
practicing certain pain management skills.
In addition, Yava et al. (2013) assessed nurses’ level of knowledge and attitudes toward pain
management. A total of 246 nurses were included in the study. Results indicated that 48.8% were
working at a surgical unit and 77.2% were staff nurses. Only 11.8% had taken a pain management
course and 31.7% had read a book or journal on pain. Regarding the questionnaire, the rate of
correct responses to the NKASRP scale was 39.65% while the mean number of correct answers to
all questions was 15.86±7.33 with a range of 0 to 37. Results showed that nurses in the medical-
surgical units have insufficient knowledge and negative attitudes toward pain management.
statistically, a significant difference was found regarding education level, working unit, whether a
pain management course had been taken, whether a book or journal on pain had been read, and the
evaluation of the nurse's efficacy regarding pain (p<0.05). A quasi-experimental pre-and post-test
design was conducted by Machira, Kariuki, and Martindale (2013) to implement and evaluate an
educational pain management program (PMP) for nurses in Kenya. Twenty-seven nurses from two
units in a single health institution in Kenya participated in a baseline assessment using the Nurses’
Knowledge and Attitudes Survey Regarding Pain (NKASRP). Nine randomly selected nurses then
received seven hours of focused education, then they completed the assessment again both
immediately after and two weeks after the (PMP). Findings recorded a deficit in knowledge and
attitudes related to pain management was prominent at baseline. The nurses who received the PMP
scored significantly higher on the NKASRP following the PMP. The PMP appeared to be effective
in improving nurses’ pain knowledge and attitudes.
In Jordan, a study was implemented by Omran et al. (2016) to assess the level of nurses’
knowledge and attitudes toward pain management using a sample of 263 nurses from three
Jordanian hospitals. The Nurses' Knowledge and Attitudes Survey Regarding Pain (NKASRP)
were used to measure the nurses' knowledge and attitudes regarding pain management. Results
indicated that 64% were between the ages of 21 and 32 years, with a mean age of 30.9 years and
a total of 89% of the nurses had a baccalaureate degree. The average correct response rate was
42.7%, ranging from 10.5% to 75%. No significant differences between nurses' characteristics and
pain knowledge were found. Nurses' pain knowledge differed significantly according to their
educational level previous pain education related to cancer (P < 0.007), regular cancer pain care
(P = 0.010), knowledge score and attendance of conferences related to pain management (P =

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Running head: Nursing knowledge and attitude toward pain management in the critical care unit

0.002), knowledge score and in-services training, modules, protocols, and other knowledge and
skills related to pain management (P = 0.004), knowledge score and nurses' rate of their experience
with pain (P < 0.001), and adequate professional training preparation regarding pain management
(P < 0.001). Results indicated that Jordanian nurses have insufficient knowledge and negative
attitudes toward the management of cancer-related pain. According to the previous studies, it's
concluded that the majority of patients have insufficient knowledge and a negative attitude towards
pain management. Moreover, Salameh (2018) implemented a cross-sectional descriptive study to
evaluate the level of knowledge and attitude of nurses regarding pain management in high acuity
care units of Palestine. Data were obtained from seven hospitals in Palestine. Nurses were recruited
from high acuity care units, including nurses from the medical and surgical wards. Their
knowledge on the degree of pain was measured using the survey for “Knowledge and Attitudes
Survey Regarding Pain.”. About 123 nurses took part in the survey. Results showed that there were
no statistically significant differences between the nurses’ total average score and demographic
characteristics, except for their initial level of education. Results indicated that nurses in critical
care units possess inadequate knowledge and attitude about pain management.

Majeed, Hassan, and Abid (2020) conducted a descriptive cross-sectional design study to assess
nurses' attitudes about patient's pain management and to find out the relationship between
knowledge, attitudes, and their demographical characteristics. The study was carried out among
100 nurses working in male and female surgical wards, ICU, surgical ward, emergency, and
operating theatres. Data was collected by distributing a structured self-administered questionnaire
(NKASRP) developed by Ferrel and McCaffery. Results showed that the majority of the study
were male who accounted for (63%) of the total participants while females constituted (37%).
Most of the participants (49%) were ages between (18 – 27) years old, a high percentage of them
were have institute graduate (40%), (50%) of the nurses were single and the remainder was
married. The majority of them (37%) were employees (1-5) years in employment in nursing. The
majority of them (45%) were employees (1-5) years in the intensive care unit, and finally, the
majority of nurses (77%) have training sessions about patient pain management. From the previous
studies, we can conclude that nurses have a negative attitude toward pain management.

2.Conclusion

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Running head: Nursing knowledge and attitude toward pain management in the critical care unit

The subject of nursing knowledge and attitude toward pain management is a significant
topic that has been researched in the literature. Patients' rehabilitation and pain relief are aided by
effective and accurate pain management, which has an impact on patient outcomes and length of
stay in the hospital. Inadequate and inadequate information, as well as a negative attitude among
nurses, have been identified as the most common problems.
3.Implication
1. The results of this study could guide the development and implementation of continuing
education programs for nursing staff in providing patients with evidence-based pain
management.
2. This research will develop relevant knowledge for the practices and profession of nursing
according to effective pain management that is related to health and well-being.
3. It is recommended to considered pain management in continuous education and nursing
undergraduate curricula.
4. Future research should be implemented to guide managing pain in challenging
circumstances.
5. This research indicates the need for nursing schools and the ministry of health to work
together to educate nurses to a higher level of preparation for pain assessment and
management.

4.Recommendation

Findings in the literature identified that nurses had less adequate knowledge and attitudes
regarding pain management, education to address these deficits should highlight research gaps. It's
recommended to provide a short course in education and training in pain management.

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 Running head: Nursing knowledge and attitude toward pain management in the critical care unit

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