A Survey of Registered Nurses Knowledge and Attitudes Regarding Paediatric Pain Assessment and Management: An Irish Perspective Thursday 26th March 2009 RCN International Research Conference Cardiff, Wales. Eileen Tiernan eileen.tiernan@olhsc.ie
Research Question What is the knowledge base and attitudes of registered nurses regarding paediatric pain assessment and management who work in an Irish paediatric hospital?
Data Collection Tool Self report questionnaire Manworren (2001) Paediatric Nurses Knowledge and Attitude Survey (PNKAS)
Sample Registered nurses in one paediatric hospital in Ireland Variety of paediatric units/ wards to cover all specialities Simple Random Sampling Gatekeepers employed - Clinical Nurse (Education) Facilitators Proposed sample size 300
Inclusion Criteria All registered nurses working on designated units. Paediatric qualification not essential Exclusion Criteria Gatekeepers Nurses undertaking paediatric nurse training Agency nurses Newly appointed nurses (orientation / preceptorship, < 4 months) Clinical Nurse Specialists CNM 3 and above (Middle Management) Nurses on long term leave i.e. sick / maternity
Response Rate 292 questionnaire distributed by gatekeepers Response rate of 60% (n = 174) was achieved
Demographics Female 99% Age 51% (n = 89) - 26-35 years 71% (n = 84) < 40 years Nursing Experience 52.6% (n = 49) qualified between 6-15 years 75.7% (n = 89) qualified < 20 years Paediatric Experience 28.7% (n = 50) 6-10 years 56.3% (n = 98) < 10 years experience Nursing Grade 1:4 Ratio Clinical Nurse Manager 2 (Ward Sister Grade) : S/N
Country of Initial Registration Other (4) 2% UK (21) 12% Philippines (33) 19% Ireland (97) 56% India (19) 11% Philippines India Ireland UK Other
Speciality Nursing Specialities TCU Theatre - Recovery / Anaesthetics 1 Renal / Urology 0.57% Surgery - Children PICU - Cardiac PICU - General / HDU OPD / IV / Pheb Orthopaedics Oncology Medicine - Children Infants (Medical / Surgery) Day Unit / Radiology Cardiology Burns A/E Dept 6 3.45% 9 5.17% 8 4.6% 8 4.6% 7 4.02% 11 6.32% 11 6.32% 11 6.32% 11 6.32% 16 9.2% 16 9.2% 18 10.34% 18 10.34% 23 13.22% 0 5 10 15 20 25 Frequency
Nursing Qualifications No Data (1) 1% RGN/RNID (1) 1% RCN (19) 11% RGN (52) 30% RCN/RNID (4) 2% RCN RCN/RGN RCN/RGN/RM RCN/RNID RGN RGN/RNID No Data RCN/RGN/RM (12) 7% RCN/RGN (85) 48%
Percentage Highest Academic Education Staff Nurse Clinical Nurse Manager 30 25 25 25 27 23 28.1 20 15 15.6 17 15.6 10 9.4 5 5 0 Certificate Diploma Degree Higher Diploma Academic Qualification Post Graduate Diploma 1 3.1
Results Total mean score on the PNKAS scale was 62% Majority of nurses scored <80% which has been identified as a satisfactory level for practice standards
Knowledge Deficits Pharmacology and Pharmacokinetics Also most requested for continuing education by nurses Opiates & Incidence of: Respiratory Depression Risk of Addiction Non-Pharmacological Interventions
Opiates - (chronic pain in child, receiving opiates for 2 month old) Risk of Respiratory Depression 29.9% (n = 52) answered correctly risk < 1% 61.5% (n = 107) believed the risk to be higher 11% (n = 19) of nurses believed it to be extremely high i.e. > 40% Risk Of Addiction 42% of nurses answered correctly risk of opioid addiction < 1% 52.3% (n = 91) believed risk to be higher 10.3% (n = 18) believed the risk to be > 50%
Pain Assessment Over-Report of Pain The majority of nurses 53% (n = 92) believed that children over reported the amount of pain 43.7% (n = 76) believed the percentage to be 20-50% 9.2% (n = 16) of respondents believed the percentage to be > 50%
Pain Assessment -Self Report 120 Vignettes 100 112 80 60 40 67 Andrew Robert 20 0 0 22 1 1 6 1 4 13 2 13 17 19 22 1 3 8 11 3 4 5 6 Pain Score 7 7 12 8 9 0 3 10 0 3 Robert Andrew
Pain Assessment Childs self report Gold Standard of pain assessment intensity (RCNI, 1999) Contradiction 83.3% (n = 145) respondents child/ adolescent, most accurate judge of own pain Study supports Coyne et al (2006) Irish children's views Children's reports of pain are not believed and ignored by many nurses
No differences were demonstrated between Nurses age Years of nursing experience Years of paediatric experience Nursing grade Highest academic qualification Pain education during hospital orientation on the mean PNKAS score A statistically significant difference (p = <0.001) of moderate to large effect was demonstrated between nurses whose main qualification was Registered Children s Nurse (RCN) compared to RGN on the mean PNKAS score Also between nurses who worked in different specialities on the mean PNKAS score (p = 0.003) Nurses who had received pain education within the previous two years demonstrated a positive difference (p = 0.003) of small to moderate effect on the total PNKAS scale
Continuing Education 68% nurses (n = 127) did not have pain education in previous 2 years Nurses motivated to learn - 87% (n = 151) wanted pain education Presently ad hoc need for structure / pathway (post graduate) Pain education needs reinforcement at regular intervals nurses requesting mandatory study days / in-service
Paediatric Pain Education Requested by Nurses Pharmacology Pain Assessment Pain- management specific groups of patients Non-pharmacological Interventions Twycross (2001) Delphi study (managers / educators) Pain Assessment Pharmacological Interventions Non-pharmacological Simons (2002) Action research Pharmacology nurses what they were allowed to do
Perceived Barriers Unsatisfactory analgesic prescriptions Unsatisfactory pain assessment Attitudes and beliefs of nurses and doctors Lack of knowledge Fears Environmental Factors (time, shortage of staff, workloads, culture etc)
Summary Findings support concerns regarding unsatisfactory pain assessment, management, attitudes and knowledge in nurses. Registered Children s Nurse (RCN) qualification and continuing education within previous 2 years including nurses area of expertise had a positive influence on nurses knowledge. There is a need for intensive continuing education for nurses regarding paediatric pain management and special consideration in relation to non-paediatric qualified nurses. Education is needed in: pain assessment, including self report; pharmacology and pharmacokinetics of analgesia especially in relation to opiates to dispel fears and non-pharmacological interventions. Educational strategies i.e. problem based learning and reflection should also be considered.
Acknowledgements Nurses who completed questionnaires, colleagues who assisted in testing the reliability of the tool, the expert content panel and the gatekeepers. Special thanks to my supervisor: Carmel Doyle, Lecturer in Nursing, School of Nursing and Midwifery, Faculty of Health Sciences, Trinity College Dublin, Ireland. Copyright Eileen Tiernan
References Burnard, P. (1991) A method of analyzing interview transcripts in qualitative research. Nurse Education Today 11: 461-466. Coyne, I. Hayes, E. Gallagher, P. and Regan, G. (2006) Giving Children a Voice: Investigation of Children s Experiences of Participation in Consultation and Decision Making in Irish Hospitals. Dublin: Office of the Minister for Children. Manworren, R.C.B. (2001) Development and testing of the pediatric nurses knowledge and attitudes, survey regarding pain. Pediatric Nursing 27 (2): 151-158. McCaffrey, M. and Ferrell, B.R. (1997) Nurses knowledge of pain assessment: how much progress have we made? Journal Of Pain and Symptom Management 14 (3): 175-188. Simons, J.M. (2002) An action research study exploring how education may enhance pain management in children. Nurse Education Today 22, 108-117. Twycross, A. (2001) Achieving consensus about pain content for child branch curricula. Journal of Advanced Nursing 34 (1): 51-60.