SciELO - Scientific Electronic Library Online

 
vol.1 issue4Attitudes facing pain and the spirituality of chronic renal patients in hemodialysisPrevalence and characteristics of chronic pain in Brazil: a national internet-based survey study author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Indicators

Related links

Share


BrJP

Print version ISSN 2595-0118On-line version ISSN 2595-3192

BrJP vol.1 no.4 São Paulo Oct./Dec. 2018

http://dx.doi.org/10.5935/2595-0118.20180062 

ORIGINAL ARTICLES

Nursing students’ knowledge about pain assessment

Amanda Francielle Santos1 

Rafaela Ribeiro Machado2 

Caíque Jordan Nunes Ribeiro3 

José Marden Mendes Neto4 

Maria do Carmo de Oliveira Ribeiro3 

Míriam Geisa Virgens Menezes4 

1Universidade Federal de Sergipe, Programa de Pós-Graduação em Biologia Parasitária, Aracaju, SE, Brasil.

2Universidade Federal do Vale de São Francisco, Programa de Pós-Graduação em Gestão Pública Municipal, Petrolina, SA, Brasil.

3Universidade Federal de Sergipe, Programa de Pós-Graduação em Enfermagem, Aracaju, SE, Brasil.

4Universidade Federal de Sergipe, Programa de Pós-Graduação em Fisiologia, Aracaju, SE, Brasil.

ABSTRACT

BACKGROUND AND OBJECTIVES:

The difficulty of the nursing staff in assessing pain, the low adherence to the registry of pain and the quality reported in other studies brings the need to assess the related factors and one of them can be the lack of knowledge. The objective of this study was to evaluate the knowledge of nursing students about pain assessment.

METHODS:

A cross-sectional, descriptive and quantitative study, conducted in a Higher Education School in Aracaju, Brazil. The sample was composed of 169 nursing students over the last period of graduation. The data were obtained through a form that contained sociodemographic information, questions about pain assessment, and knowledge sources used.

RESULTS:

The scales to assess pain in children and in adults are known by 70 and 66% of the students, respectively. They reported that pain assessment and the incorrect pain treatment may impair the clinical picture and aggravate the disease, both in the child (17.2%) and the adult (15.4%). The rate of correct answers about pain assessment ranged from 26.6 to 87%. Most of them use articles to gain knowledge about pain (56.2%). The fact of having already used a scale to assess the patient’s pain (p=0.045) showed significant differences in the average of hits.

CONCLUSION:

Nursing graduates are aware of the existence of scales to assess pain, but they do not have the ability to perform them. The prior use of scales promotes learning. The lack of knowledge about pain impacts on the patient’s health.

Keywords: Knowledge; Nursing students; Pain assessment

INTRODUCTION

Pain is a subjective experience of complex assessment and management. However, its relief is a patient right1. The painful sensation can occur due to surgeries, injuries, diseases or medical procedures, causing distress to patients and their family members. Therefore, the nurse should be knowledgeable on physiology, assessment, treatment, and impact of pain on the patient2.

The assessment of pain using scales and appropriate monitoring indicators make it possible to measure the intensity and check the effectiveness of the interventions3. Many instruments have been validated for the assessment of pain in different age groups and clinical conditions. As the unidimensional scales that are indicated to identify and measure the pain and are adopted to rapidly obtain information, as well as the multidimensional scales that are used to evaluate sensorial, affective and evaluative elements that are reflected in the language that reports painful experience4.

Despite pain being one of the most frequent reasons for the demand for health services, many times its relief is not reached. Despite the advances in pain analgesia, there are still obstacles related to its management, especially the assessment5.

The difficulty for the nursing staff to evaluate pain, the low adhesion to the use of pain record and its quality reported in other studies, brings out the need to evaluate related factors, and the lack of knowledge during training can be one of them.

The objective of this study was to evaluate nursing academic knowledge on pain assessment.

METHODS

This study is a cross-sectional, descriptive and quantitative, developed in a higher education private institution in October 2017, Aracaju, SE, Brazil.

All nursing students attending the last term of the course were included in the study. There were no exclusion criteria. Data collection occurred after the students being properly informed about the study and signed the Free and Informed Consent Form (FICT). The initial sample was expected to have 200 graduate students, according to the institution, but 31 of them refused to participate in the study. The sample consisted of 169 nursing graduate students.

The questionnaire for data collection was divided into three parts with questions about the students’ profile; questions on pain assessment in children and adults, and the sources of knowledge used by the students. This instrument was elaborated by the researchers and validated by a board composed of three examiners with experience in the field of study before the beginning of the data collection. A pilot with five participants for the final adequacy of the instrument was conducted, and the data of the pilot has been discarded.

The study followed the recommendations of Resolution 466/2012 of the National Health Council and was approved by the Research Ethics Committee of the Estácio de Sergipe College (CAEE: 70838717.0.0000.8079) with opinion 2,269,667.

Statistical analysis

A descriptive univariate analysis was carried, and the categorization of the extracted data with the respective frequencies and percentages presented as tables. Inferential analysis was performed crossing the proportion of right answers on the knowledge test of pain assessment with the socioeconomic variables and sources of knowledge. The crossing between qualitative and quantitative variables was checked initially through the Shapiro-Wilk test if the proportion of right answers showed a normal distribution (p=0.000). Since normality was not observed, nonparametric tests were adopted for the analysis. For the crossing of variables with more than two categories, it was used the Kruskal-Wallis test, and for variables with two categories, the test was the Mann-Whitney.

In all hypothesis tests conducted, the conclusion was obtained through the interpretation of the p-value. Adopting a significance level of 5% whenever the value of the calculated p is less than 0.05, it is inferred that there is a relationship between the analyzed variables. The software used was R, version 3.4.2 and the significance level adopted was 5%.

RESULTS

The sample was composed predominantly of women (90.5%), aged between 20 and 50 years, students of the night (53.3%) and morning (46.7%) periods. More than half of the respondents were not active in the labor market (61%). Among the economically active, 71.2% worked as nurse technicians. Regarding the years of experience, the majority (18.3%) had between 5 and 10 years, most of them (5.33%) worked in the Urgency and Emergency Unit.

Seventy percent of the respondents had knowledge of the pain assessment scales in children, the faces pain rating scale being the most mentioned among the students (40.2%). Other scales has also been cited, as the numeric pain rating scale (8.3%), visual analog scale (VAS) (8.9%), Behavioral Pain Scale (BPS) (0.6%) and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) (2.4%). As for how many scales are known, 61.3% knew only one scale (Table 1).

Table 1 Knowledge of nursing students on the assessment of pain in children and in adults, Aracajú, SE, 2017 

Variables Frequency %
Known scale for pain assessment in children
Faces pain rating scale. 68 40.2
Visual analog scale. 15 8.9
Numeric pain rating scale. 14 8.3
Leeds Assessment of Neuropathic Symptoms and Signs 4 2.4
Behavioral pain scale. 1 0.6
Yes, but did not specify which. 32 18.9
Unfamiliar 33 19.5
Did not answer 17 10,1
Why inadequate assessment of pain affects the clinical picture of the pediatric patient
Because of inappropriate treatment of pain worsening the disease. 28 17.2
Because of inadequate diagnosis and treatment worsening the disease. 23 14.1
By causing discomfort. 15 9.2
By not identifying the fifth vital sign. 10 6.1
For undermining the diagnosis. 8 4.9
By causing changes in other vital signs. 6 3.7
By causing psychological trauma. 3 1.8
By causing psychological suffering and inappropriate treatment. 1 0.6
Yes, but did not specify the reason. 37 22.7
Did not answer 32 19.6
Known scale for pain assessment in adults
Numeric pain rating scale 53 31.4
Faces pain rating scale 24 14.2
Leeds Assessment of Neuropathic Symptoms and Signs 14 8.3
Visual analog scale 10 5.9
Behavioral pain scale 1 0.6
Yes, but did not specify which. 30 17.8
Unfamiliar 35 20.7
Did not answer 23 13.6
Why inadequate assessment of pain affects the clinical picture of the adult patient
Because of inadequate diagnosis and treatment worsening the disease. 25 15.4
Because of inappropriate treatment of pain worsening the disease. 24 14.8
By causing discomfort. 13 8.0
By not identifying the change of the fifth vital sign. 9 5.6
By causing changes in other vital signs. 9 5.6
By causing psychological trauma. 3 1.9
By inappropriate treatment of pain. 5 3.1
By causing psychological suffering and inappropriate treatment. 1 0.6
Yes, but did not specify the reason. 35 21.6
Did not answer 38 23.5

In relation to the knowledge of scales to assess pain in adults, 66% of the students claimed to know, and the numeric scale was the most cited (31.4%), and the BPS the least cited (0.6%). It was also cited the faces scale (14.2%), VAS (5.9%), and LANSS (8.3%). As for how many scales are known, 56.8% knew only one scale (Table 1).

Among the students, 96.4% stated that an inadequate assessment of pain affects the clinical picture of adult and pediatric patients. However, about 22.7% did not specify the reason. The most cited reason for inadequate assessment of pain affecting the clinical picture was to induce the inadequate treatment and to worsen the disease in children (17.2%) and in adults (15.4%) (Table 1).

Regarding the students’ knowledge on pain assessment, the study found that the highest percentage of hits, 147 (87%), referred to the item: “the pain report of the child must be considered.” The largest number of incorrect answers, 108 (63.9%), was attributed to the question: “isolated body expression assessment may indicate that the child is in pain.” Thus, the hit rate ranged from 26.6 to 87%, and the rate of errors was between 4.7 and 63.9% (Table 2).

Table 2 Knowledge test applied to nursing students on pain assessment, Aracajú, SE 2017 

Hits Errors NI
n % n % n %
There are specific pain assessment scales for newborn, children and adults. 119 70.4 41 24.3 9 5.3
The numeric scale and faces scale can be used to assess pain in children as of six years. 83 49.1 70 41.4 16 9.5
The assessment of pain by the faces scale is made by attributing colors to represent the intensity, the greater the intensity of the pain. 72 42.6 81 47.9 16 9.5
The assessment by the numeric scale is made by assigning numeric values to the level of crying. 65 38.5 85 50.3 19 11.2
Isolated body expression assessment may indicate that the child is in pain. 45 26.6 108 63.9 16 9.5
The isolated observation of crying can determine the pain intensity. 55 32.5 96 56.8 18 10.7
The pain report of the child must be considered. 147 87.0 8 4.7 14 8.3
The scales to assess pain in children are a safe instrument, allowing to identify not only the presence but also the intensity of pain. 119 70.4 30 17.8 20 11.8

NI = not informed.

In relation to the sources of information used by students to acquire knowledge about the methods of pain assessment, most said they seek knowledge in articles (56.2%), followed by books (44.4%), only the information received in class (39.1%), internet videos-class (33.1%) courses and training courses (25.4%). Only 38.5% seek information on other sources. There were no differences in the average of hits with the information sources that are used by students to acquire knowledge about the methods of pain assessment (Table 3).

Table 3 Information sources used and its comparison with the result of the student on the knowledge test, Aracajú, SE, 2017 

Frequency % Mean Standard deviation Median P value
Information transmitted by the teachers during class
No - - 54.42 50.00 20.93 0.701
Yes 66 39.1 53.52 50.00 19.98
Books
No - - 55.56 50.00 20.28 0.476
Yes 75 44.4 52.23 50.00 20.76
Scientific papers
No - - 51.07 50.00 18.03 0.134
Yes 95 56.2 56.32 62.50 22.01
Training courses
No - - 54.92 50.00 20.30 0.648
Yes 43 25.4 51.52 50.00 21.14
Internet video-classes
No - - 54.36 50.00 21.07 0.993
Yes 56 33.1 53.47 50.00 19.49

Kruskal-Wallis test p<0.05.

Sociodemographic variables, to work, have technical training in the nursing field, years of experience in nursing, in internship have noticed pain scales in the patient’s record and be encouraged to use the pain assessment scales in children or adults did not show significant differences in the average hits. Only those who claimed to have already used some scale to assess patients’ pain presented significant differences in the average of hits (p=0.045) (Table 4).

Table 4 Comparison of the proportion of hits on the knowledge test and the sociodemographic and academic variables, Aracajú, SE, 2017 

Variables Mean Standard deviation Median p Value
Gender
Male 55.10 62.50 20.73 0.311
Female 44.53 50.00 15.79
Age group (years)
20 to 25 53.85 50.00 22.85 0.500
26 to 30 50.00 50.00 21.48
31 to 35 58.17 62.50 14.98
36 to 40 55.56 62.50 14.99
41 to 50 59.09 62.50 20.98
Working
No 52.25 50.00 21.79 0.106
Yes 56.94 62.50 18.07
Technician or nursing assistant
No 54.02 50.00 21.69 0.774
Yes 54.17 62.50 17.55
Experience (years)
Less than 5 56.94 62.50 14.13 0.629
5 to 10 58.06 62.50 16.94
11 to 20 55.83 62.50 17.59
Above 20 37.50 37.50
During internship, it was observed pain scales on patient's record
No 53.81 50.00 20.49 0.285
Yes 57.41 62.50 18.43
Was encouraged to use pain assessment scales in children or adults
No 54.58 50.00 20.55 0.993
Yes 53.57 62.50 20.91
Already used some pain assessment scale to assess patient's pain
No 52.79 50.00 20.63 0.045*
Yes 58.16 62.50 19.36

Kruskal-Wallis and Mann-Whitney tests

*p-value <0.05.

DISCUSSION

The knowledge of pain management is essential in the clinical nursing practice, with a direct impact on the patient’s health1. That’s why the ability to assess the pain is critical3.

Little more than half of the nursing students have heard of an instrument to assess pain in adults, the most cited was the numeric scale. Many of them knew some scale for pain assessment in children, the most cited was the faces scale. Other scales were also cited as BPS, VAS, and LANSS, though in a lesser extent for both. Most claimed to know just one pain assessment instrument. Pain scales for assessment in a sedated patient with communication difficulty and multi-dimensional are still little mentioned, which is a risk factor for the inadequate assessment of these patients.

The VAS was cited as an option to assess pain in children, but they can have difficulty in understanding it. Some instruments use more appropriate visual resources for this age group6. The study showed that the nursing trainees may have difficulty in choosing the most adequate scale for each age.

In the objective test of students’ knowledge on pain assessment, the highest frequency of hits refers to the affirmation that the child’s report of the pain must be considered. A positive fact, because the self-report is the gold standard for assessment of the patient’s pain7.

The largest number of incorrect answers relates to statements that the isolated assessment of body language and cry can be considered as an indicator of the presence of pain or to determine the intensity of pain in children. Changes in facial expression, body movement and crying are still quite considered by health professionals as a parameter of pain, but they should not be used alone, because the patient may present them for other reasons such as discomfort, hunger or fear8. Moreover, even if an isolated feature confirms the presence of pain, the health professional would not be able to quantify the intensity, which is of paramount importance for the choice of the appropriate drug.

Many students erroneously consider true the statement that the assessment with a numerical scale is used by assigning numeric values to the level of the child’s crying. And the same happened in the statement that the pain assessment by faces scale is accomplished by assigning colors to represent the intensity of pain. This result is inconsistent with another result of this study, which may represent that despite being the most cited scales by nursing students, they don’t know how to use them, knowing them only by name.

In the numeric scale, the patient chooses a number from one to 10 to represent the intensity of their pain. These numbers represent the intensity of pain, incrementally9. The faces scale is constituted by six faces, the first is a smiling expression, that is transforming until it reaches the last face, very sad. The child can choose the one he/she most identifies with4.

The average of hits was a little more than half the total of the questions. This study corroborates a study with nursing students to assess their knowledge about pain, where it was observed that the majority failed to answer correctly less than 50% of the questions, mostly about drugs and pain assessment2. It is evidenced that most of the future nursing professionals have deficiencies in the basic knowledge of the fundamental stage of pain management.

Pain assessment is crucial, because the acute pain, if left untreated, increases the time of activation of neural pathways, extending the harmful effects such as elevation of vital signs, reduced tissue oxygenation10, impairing the sleep which may lead to exhaustion11, and is associated with risk of progression to chronic pain12.

Most nursing students agree that inadequate pain assessment undermines the patient’s clinical condition, as it compromises the diagnosis, treatment and leads to worsening of the disease. But they think that pain has similar consequences in adults and children, attributing more psychological suffering to the adult. In a study by Nascimento et al.13 it is stated that in children, the impact of pain may be even greater by the lack of ability to report the pain or by the way they perceive the painful sensation. Therefore, most of the students have an incorrect view of the impact caused by the pain in adults and children. The lack of proper understanding of pain influences and undermines its follow-up.

Most students seek information about pain primarily in papers, followed by books, teachers, video-classes and training courses. However, a great number is limited to what is taught by the professor. A similar result was showed in a study conducted with nursing students of three universities of Jordan. The majority has not searched information sources on pain and reported that has never participated in courses14. Both students and nursing professionals must seek the improvement of their knowledge, as they have responsibilities in the management of pain15.

Opposing the common sense, to have the technical education or to work in the nursing field have not intervened with the level of knowledge. Perhaps this result is because this subject is of easy understanding. Therefore, the time dedicated to work does not harm the learning. But the technical training will work only if the assessment of pain is taught in the technical training of the professional or if the institution adheres to the use and provides continued education on the topic.

Students who have used a scale to assess patient’s pain showed significant differences in the mean of correct answers, that is, the students who have had the experience of applying the scales have greater knowledge in the assessment of the pain. According to these outcomes, in a study conducted with nursing students in Jordan, the ones who used more the pain rating scales showed significantly greater knowledge15. Therefore, it is necessary to ally the theoretical instruction with the practical experience in the education of future health professionals.

When the pain of the hospitalized patient is properly managed, it results in shorter hospitalization, avoids aggregated comorbidity and improves the well-being of patients and their families. It is essential that health professionals master the knowledge about pain to guide the decision-making in clinical practice16.

CONCLUSION

Nursing students know about the existence of scales for pain assessment, but often do not have specific knowledge on how to use them or to choose the appropriate one for each type of patient. The previous use of scales promotes learning. The little knowledge of the students about pain goes beyond assessment, and it impacts the health of the patient.

Sponsoring sources: none.

REFERENCES

1 Ucuzal M, Dogan R. Emergency nurses' knowledge, attitude and clinical decision-making skills about pain. Int Emerg Nurs. 2015;23(2):75-80. [ Links ]

2 Gadallah MA, Hassan AM, Shargawy SA. Undergraduate nursing students' knowledge and attitude regarding pain management of children in Upper Egypt. J Nurs Educ Pract. 2017;7(6):101-8. [ Links ]

3 Teixeira JM, Durão MC. Monitorização da dor na pessoa em situação crítica: uma revisão integrativa da literatura. Rev Enferm Referência. 2016;Série IV(10):135-42. [ Links ]

4 Sousa FA. [Pain: the fifth vital sign]. Rev Lat Am Enfermagem. 2002;10(3):446-7. Portuguese. [ Links ]

5 Pretorius A, Searle J, Marshall B. Barriers and enablers to emergency department nurses' management of patients' pain. Pain Manag Nurs. 2015;16(3):372-9. [ Links ]

6 Kanai KY, Fidelis WM. Conhecimento e percepção da equipe de enfermagem em relação à dor na criança internada. Rev Dor. 2010;11(1):20-7. [ Links ]

7 Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain. 1986;27(1):117-26. [ Links ]

8 Herr K. Pain assessment strategies in older patients. J Pain. 2011;12(3):S3-S13. [ Links ]

9 Gonçalves B, Holz AW, Lange C, Maagh SB, Pires CG, Brazil CM. Care of children in pain admitted to a pediatric emergency and urgency unit. Rev Dor. 2013;14(3):179-83. [ Links ]

10 Posso IP, Pires PW, Birolini D. Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Divisão Clínica III. Divisão de Anestesia. A dor como 5º sinal vital. Controle da dor aguda no pós-operatório. São Paulo: Cristália; 2006. 56p. [ Links ]

11 Silva FS, Fernandes MV, Volpato MP. Diagnósticos de enfermagem em pacientes internados pela clínica ortopédica em unidade médico-cirúrgica. Rev Gaúcha Enferm. 2008;29(4):565-72. [ Links ]

12 Souza RC, Garcia DM, Sanches MB, Gallo AM, Martins CP, Siqueira IL. Conhecimento da equipe de enfermagem sobre avaliação comportamental de dor em paciente crítico. Rev Gaúcha Enferm. 2013;34(3):55-63. [ Links ]

13 Nascimento LC, Strabelli BS, de Almeida FC, Rossato LM, Leite AM, de Lima RA. Mothers' view on late postoperative pain management by the nursing team in children after cardiac surgery. Rev Lat Am Enfermagem. 2010;18(4):709-15. [ Links ]

14 Al-Khawaldeh OA, Al-Hussami M, Darawad M. Knowledge and attitudes regarding pain management among Jordanian nursing students. Nurse Educ Today. 2013;33(4):339-45. [ Links ]

15 Lobo AJ, Martins JP. Dor: conhecimentos e atitudes dos estudantes em um ano de seguimento. Texto Contexto Enferm. 2013;22(2):311-7. [ Links ]

16 Ribeiro MC, Costa IN, Ribeiro CJ, Nunes MS, Santos B, Santana JM. Knowledge of health professionals about pain and analgesia. Rev Dor. 2015;16(3):204-9. [ Links ]

Received: May 06, 2018; Accepted: July 17, 2018

Correspondence to: Av. Marechal Rondon, s/n - Jd. Rosa Elze 49100-000 São Cristóvão, SE, Brasil. E-mail: francyelly_amanda@hotmail.com

Conflict of interests: none

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.