Development and Testing of the Pediatric Nurses' Knowledge and Attitudes Survey Regarding Pain.
In January of 2001, standards for the care of patients in pain will become part of the Joint Commission on Accreditation of Health Care Organization's (JCAHO) accreditation process (JCAHO, 1999). The purpose of these standards is to assure appropriate pain assessment and pain treatment as well as an organizational commitment to patients in pain. The new JCAHO standards state that "patients have the right to appropriate assessment and management of pain" (RI.1.2.8, JCAHO, 1999). The intent of this standard includes, "education of all relevant providers in pain assessment and management" (RI.1.2.8, JCAHO, 1999). These new standards not only require health care organizations to provide educational offerings on pain assessment and pain management, but they also hold organizations accountable for obtaining evidence of providers' competency in pain assessment and treatment (RI.1.2.8, JCAHO, 1999). To comply with these new JCAHO standards, health care organizations will need tools to assess and evaluate pediatric nurses' knowledge and attitudes regarding pain and pain management. Such tools would be used to document staff competency as well as identify knowledge deficiencies that require additional educational interventions.
The purpose of this article is to present a tool that has been developed to assess pediatric nurses' knowledge and attitudes regarding pain and pain management. This tool is a modification of McCaffery and Ferrell's (1997) Nurses' Knowledge and Attitudes Survey Regarding Pain (NKAS). This modification was developed with Ferrell's permission and assistance (B.R. Ferrell, 1998, personal communication). The rationale for modifications of the original survey and specific items in the final Pediatric Nurses' Knowledge and Attitudes Survey Regarding Pain (PNKAS) are presented. Content validity, test-retest reliability, and internal consistency of the pediatric nursing tool are described. Implications are also identified for using the tool to comply with JCAHO's clinical practice standards for care of patients in pain.
Prior to implementing a pain management competency program at our children's medical center, the literature was reviewed to identify a tool that could evaluate the pediatric nursing staff members' knowledge regarding pain and pain management. Tools consistent with the published pain management standards and tools designed for pediatric nurses were reviewed. While several such tools were identified, they were judged inappropriate for quickly surveying a large multispecialty pediatric nursing staff because they: (a) were based on adult care rather than pediatric care standards (Gujol, 1994; McCaffery & Ferrell, 1997); (b) were oriented toward select pediatric subspecialties rather than general pediatric pain care (Armstrong, Pegelow, Gonzalez, & Martinez, 1992; Pederson, Matthies, & McDonald 1997; Read, 1994); (c) measured beliefs and attitudes using a Likert scale, rather than knowledge and attitudes in ways that could be definitively scored as correct or incorrect (Margolius et al., 1995); (d) had no reported validity and reliability (Beyer, DeGood, Ashley, & Russell, 1983; Burokas, 1985; Gadish, Gonzalez, & Hayes, 1988); or (e) required interviews, observations, and chart reviews (Hamers, Huijer Abu-Saad, Halfens, & Schumacher, 1994).
Among all the tools identified, McCaffery and Ferreil's (1997) NKAS was the tool most frequently cited in the literature (Brunier, Carson, Harrison, 1995; Clarke et al., 1996; Ferrell, Dean, Grant, Coluzzi, 1995; Ferrell, Grant, Ritchey, Ropchan, & Rivera, 1993; Ferrell, McGuire, & Donovan, 1993; McCaffery & Ferrell, 1995, 1996, 1997). The NKAS is a self-administered, 37-item inventory that takes 20 to 30 minutes for the subject to complete. Content of the NKAS was based on the standards from the APS, WHO, and the AHCPR. Content validity of this tool was established by review of a panel of experts. Construct validity was established by comparing survey scores of nurses from a variety of levels of expertise. Test-retest was established (r = 0.80) by repeat testing of 60 nurses in a continuing education class. Internal consistency reliability of the tool was established using Cronbach's alpha (alpha = 0.70) (B.R. Ferrell & M. McCaffery, personal communication, 1997). In addition, the tool was also accessible for testing, and its use was encouraged through the City of Hope Pain Resource Center Web site (http://prc.coh.org). After reviewing the NKAS, the author determined that the tool could be successfully modified for use with pediatric nurses.
Pediatric Nurses' Survey Development
The NKAS was modified to reflect pediatric pain management standards that differed from adult practice standards. The modifications fit into four categories: (a) modification of medication dosages, (b) removal of questions related to meperidine and aspirin, (c) addition of procedural pain management items, and (d) identification of patients as infant, child, and/or adolescent.
First, medication dosages were changed in the PNKAS to proportionally smaller dosages for children. Doses were changed in two of the questions (see Table 1). The purpose of one of the NKAS questions (Question 28) was to determine the nurses' knowledge of opioid tolerance and the risk of respiratory depression in an opioid tolerant patient. The doses mentioned in the PNKAS were lowered to avoid inadvertently misleading the subject with uncommonly large doses for even an opioid-tolerant child.
Table 1. Changes in Medications and Medication Doses Rationale for Change Consistent with Pediatric Resultant Original NKAS Question Practice PNKAS Question Question 26 Question 29 Which of the following A typical dose of Which of the IV doses of morphine IV morphine is 0.1 following IV doses administered over a mg/1kg. The lowest of morphine 4-hour period would be dose in the original administered would equivalent to 30 mg of question would be a be equivalent oral morphine? good dose for a 50 to 15 mg of oral 5 mg/IV kg individual. Most morphine? 10 mg/IV pediatric patients 3 mg/IV (correct answer) weigh significantly 5 mg/IV (correct 30 mg/IV less than 50 kg. By answer) 60 mg/IV halving the oral 10 mg/IV doses in the 15 mg/IV question and answers, the answers are reasonable and proportionate for children Question 28 Question 31 A patient with chronic In this item, the A child with chronic cancer pain has been doses were merely cancer pain has been receiving daily opioid divided by 10, receiving daily analgesics for 2 again leaving the opioid analgesics months. The dose proportions the for 2 months. The increased during this same. The patient dose increased during time period. Yesterday was also identified this time period. the patient was as a child in this Yesterday the child receiving morphine 200 question, rather was receiving mg/hr IV. Today he has than an infant or morphine 20 mg/hr been receiving 250 mg/hr an adolescent, IV. Today he has been IV for 3 hours. The The answer remains receiving 25 mg/hr likelihood of the <1%. IV for 3 hours. The patient developing likelihood of the clinically significant patient developing respiratory clinically depression is: significant respira- <1% (correct answer) tory depression is: 1-10% <1% (correct answer) 11-20% 1-10% 21-40% 11-20% >41% 21-40% >41% Question 11 Question 12 The usual duration of The word "action" The usual duration action of meperidine was changed to of analgesia of (Demerol) IM analgesia to both morphine IV is is 4-5 hours. emphasize pain 4-5 hours. True or False relief for the True or False (False (False is the correct patient and enhance is the correct answer) the clarity of the answer) question. Meperidine was changed to morphine since morphine is the gold standard" analgesic for severe pain. The IM route was changed to the IV route because the least painful route should be chosen for analgesia administration. Question 9 Question 10 Aspirin 650 mg PO is Aspirin is Acotaminophen 650 approximately infrequently used mg PO is equal in analgesic for children approximately equal effect to meperidine due to the risk of in analgesic effect (Demerol) 50 mg PO. Reye syndrome, to codeine 32 mg PO. True or False Meperidine is not True or False (True is the correct recommended due to (True is the correct answer) its toxic answer) metabolite. Acetaminophen and codeine are commonly-prescribed analgesics for children. Question 6 Question 6 Aspirin and other Aspirin is Ibuprofen and other nonsteroidal anti- infrequently used nonsteroidal anti- inflammatory agents for children inflammatory agents are NOT effective due to the risk of are NOT effective analgesics for bone Reye syndrome, analgesics for bone pain caused by Ibuprofen is a pain caused by metastases, commonly-prescribed metastases. True or False over-the-counter True or False (False is the correct analgesic, (False is the answer) correct answer)
Second, three of the questions on the NKAS that referred to the analgesics meperidine or aspirin were modified (see Table 1). Meperidine is no longer recommended as an analgesic because of the effects of its toxic metabolite, normeperidine (APS, 1999; WHO, 1998). The use of more than one to two doses is discouraged (AHCPR, 1992a&b, 1994). Yet, meperidine remains a popular alternative to other parenteral analgesics. To prevent further endorsement of meperidine as an appropriate analgesic for children, meperidine was replaced by morphine, the "gold standard" for acute pain, in the PNKAS question that measured nurses knowledge of its analgesic properties (Question 12). Meperidine was not removed from the list of possible answers in another PNKAS question that tested the nurses' knowledge of the "drug of choice" for prolonged moderate to severe cancer pain (Question 28). Codeine, a popular oral opioid analgesic, was used to replace meperidine in the PNKAS question that tested nurses' knowledge of the equianalgesia of opioids to nonopioids (Question 10). The nonopioid in the same question was changed from aspirin to acetaminophen. Aspirin is uncommonly used for pain in children because of the risk of Reye syndrome (APS, 1999; McCaffery & Pasero, 1999). In another question, aspirin was replaced by ibuprofen, an over-the-counter analgesic that is often prescribed for children (Question 6).
The third tool modification included the addition of procedural pain management items (see Table 2). These questions were developed from the AHCPR guidelines (1992a). Procedural pain remains a common experience in children's interactions with health care providers. Children have expressed the greatest dissatisfaction with this type of pain (Eland & Anderson, 1977; Fowler-Kerry, 1990; Jay, Ozolins, Elliott, & Caldwell, 1983; Weekes & Savendra, 1988). To avoid grouping the procedural pain questions together, the three new test questions were dispersed throughout the survey by inserting them in a randomized fashion into the tool.
Table 2. Questions Added to Original Survey: New Procedural Pain Management Questions in PNKAS
Question 8: Children who will require repeated painful procedures (e.g., daily blood draws) should receive maximum treatment for the pain and anxiety of the first procedure to minimize the development of anticipatory anxiety before subsequent procedures. True or False (True is the correct answer)
Question 14: Parents should not be present during painful procedures. True or False (False is the correct answer)
Question 21: Anxiolytics, sedatives, and barbiturates are appropriate medications for the relief of pain during painful procedures. True or False (False is the correct answer)
The fourth tool modification was to refer to patients as "infants," "children," "adolescents," or a combination of these categories. This modification was suggested by several of the content experts to focus the thinking of pediatric nurses in utilizing developmental principles for pain identification and management. This modification was made to 19 of the original questions. In four additional questions, ages of the patients were modified from those in the original NKAS questions (see Table 3).
Table 3. Changes from Adult to Pediatric Focus Pediatric Original Question Change/Rationale Nursing Survey Questions 36 and 37 Only the ages were Questions 39 and 40 In the two case study changed to reflect The patient ages questions, the the area of expertise were changed to 15. patient ages were 25. of the pediatric nurse. The content of the questions and answers remained unchanged since pain assessment and treatment should be similar for a developmentally appropriate 15-year-old and a 25-year-old. Question 13 Question 15 Patients with a Adolescents have Adolescents with a history of substance the highest incidence history of substance abuse should not be of substance abuse abuse should not be given opioids among the pediatric given opioids for for pain because they populations. Even pain because they are at high risk if an adolescent has are at high risk for for repeated addiction, a history of substance repeated addiction. True or False abuse, they should True or false (False is the correct be given opioids (False is the answer) for severe pain. correct answer) Question 15 Question 17 Elderly patients The elderly and Young infants, less cannot tolerate young infants are at than 6 months opioids for pain the greatest risk of age, cannot relief, for opioid-related tolerate opioids True or False respiratory for pain relief. (False is the correct depression, True or False answer) Recommended starting (False is the doses for opioids are correct answer) lower for these populations. Careful titration of opioids is recommended. That does not mean these populations cannot tolerate opioids. Question 17 Question 19 Children less than 11 Valid and reliable Children, less than years old cannot tools exist to 8 years, cannot reliably report pain assess children as reliably report pain intensity and, young as three intensity and, therefore, the nurse years of age to therefore, the nurse should rely on provide a self-report should rely on the parents' of pain intensity. the parents' assessment of the This question was assessment of the child's pain changed after child's pain intensity, several of the intensity. True or False content experts True or False (False is the correct suggested a lower (False is the answer) age. correct answer) Question 35 Question 35 The most accurate A child's self-report The most accurate judge of the intensity of pain intensity judge of the of the patient's pain is the most accurate intensity of the is: measure of the child's/adolescent's -- a. the treating child's pain. pain is: physician Pediatric nurses -- a. the treating -- b. the patient's rely on parents to physician primary nurse provide information -- b. the child's/ X c. the patient about their child's adolescent's -- d. the pharmacist pain expressions, primary nurse -- e. the patient's past pain X c. the child/ spouse or family experiences, and adolescent successful pain -- d. the pharmacist interventions. This -- e. the child's/ information, however, adolescent's parent should not replace the child's self-report. Wording was also changed from patient to "child/adolescent."
Following the modifications of the tool for use with pediatric nurses, the final draft of the PNKAS consisted of 42 items. It is a self-administered tool in which a total score is computed using the number of correct responses. Scores range from 0-42, with a high score reflecting content mastery. Content of the PNKAS reflects the standards for pediatric pain management from the APS, WHO, and AHCPR. Questions test the subjects' knowledge and attitudes regarding pain assessment, general pain management, and use of analgesics (see Table 4 for PNKAS with answer key).
Table 4. Pediatric Nurses' Knowledge and Attitudes Survey Regarding Pain (with answer key) True or False - Circle the correct answer F 1. Observable changes in vital signs must be relied upon to verify a child's/adolescent's statement that he has severe pain. F 2. Because of an underdeveloped neurological system, children under 2 years of age have decreased pain sensitivity and limited memory of painful experiences. F 3. If the infant/child/adolescent can be distracted from his pain this usually means that he is not experiencing a high level of pain. T 4. Infants/children/adolescents may sleep in spite of severe pain. F 5. Comparable stimuli in different people produce the same intensity of pain. F 6. Ibuprofen and other nonsteroidal anti-inflammatory agents are NOT effective analgesics for bone pain caused by metastases. F 7. Non-drug interventions (e.g., heat, music, imagery, etc.) are very effective for mild- moderate pain control, but are rarely helpful for more severe pain. T 8. Children who will require repeated painful procedures (e.g., daily blood draws), should receive maximum treatment for the pain and anxiety of the first procedure to minimize the development of anticipatory anxiety before subsequent procedures. T 9. Respiratory depression rarely occurs in children/adolescents who have been receiving opioids over a period of months, T 10. Acetaminophen 650 mg PO is approximately equal in analgesic effect to codeine 32 mg PO. F 11. The World Health Organization (WHO) pain ladder suggests using single analgesic agents rather than combining classes of drugs (i.e., combining an opioid with a non-steroidal agent). F 12. The usual duration of analgesia of morphine IV is 4-5 hours, F 13. Research shows that promethazine (Phenergan[R]) is a reliable potentiator of opioid analgesics, F 14. Parents should not be present during painful procedures. F 15. Adolescents with a history of substance abuse should not be given opioids for pain because they are at high risk for repeated addiction. F 16. Beyond a certain dosage of morphine increases in dosage will NOT provide increased pain relief. F 17. Young infants, less than 6 months of age, cannot tolerate opioids for pain relief. F 18. The child/adolescent with pain should be encouraged to endure as much pain as possible before resorting to a pain relief measure. F 19. Children, less than 8 years, cannot reliably report pain intensity and, therefore, the nurse should rely on the parents' assessment of the child's pain intensity. T 20. Based on one's religious beliefs a child/adolescent may think that pain and suffering is necessary. F 21. Anxiolytics, sedatives, and barbiturates are appropriate medications for the relief of pain during painful procedures. T 22. After the initial recommended dose of opioid analgesic, subsequent doses should be adjusted in accordance with the individual patient's response. F 23. The child/adolescent should be advised to use non-drug techniques alone rather than concurrently with pain medications. F 24. Giving children/adolescents sterile water by injection (placebo) is often a useful test to determine if the pain is real. F 25. In order to be effective, heat and cold should be applied directly to the painful area. Multiple Choice - Place a check by the correct answer. Choose the best answer (one per question). 26. The recommended route of administration of opioid analgesics to children with prolonged cancer-related pain is -- a. intravenous -- b. intramuscular -- c. subcutaneous x d. oral -- e. rectal -- f. I don't know 27. The recommended route of administration of opioid analgesics to children with brief, severe pain of sudden onset, e.g., trauma or postoperative pain, is x a. intravenous -- b. intramuscular -- c. subcutaneous -- d. oral -- e. rectal -- f. I don't know 28. Which of the following analgesic medications is considered the drug of choice for the treatment of prolonged moderate to severe pain x d. All of the above cancer? -- a. Brompton's cocktail -- b. codeine x c. morphine -- d. meperidine (Demerol [R]) -- e. methadone -- f. I don't know 29. Which of the following IV doses of morphine administered would be equivalent to 15 mg of oral morphine. -- a. morphine 3 mg IV x b. morphine 5 mg IV -- c. morphine 10 mg IV -- d. morphine 15 mg IV 30. Analgesics for post-operative pain should initially be given x a. around the clock on a fixed schedule -- b. only when the child/adolescent asks for the medication -- c. only when the nurse determines that the child/adolescent has moderate or greater discomfort 31. A child with chronic cancer pain has been receiving daily opioid analgesics for 2 months. The doses increased during this time period. Yesterday child was receiving morphine 20 mg/hour intravenously. Today he has been receiving 25 mg/hour intravenously for 3 hours. The likelihood of the child developing clinically significant respiratory depression is x a. less than 1% -- b. 1-10% -- c. 11-20% -- d. 21-40% -- e. > 41% 32. Analgesia for chronic cancer pain should be given a. around the clock on a fixed schedule b. only when the child asks for the medication c. only when the nurse determines that the child has moderate or greater discomfort x a. around the clock on a fixed schedule -- b. only when the child asks for the medication -- c. only when the nurse determines that the child has moderate or greater discomfort 33. The most likely explanation for why a child/adolescent with pain would request increased doses of pain medication is x a. The child/adolescent is experiencing increased pain. -- b. The child/adolescent is experiencing increased anxiety or depression. -- c. The child/adolescent is requesting more staff attention. -- d. The child's/adolescent's requests are related to addiction. 34. Which of the following drugs are useful for treatment of cancer pain? -- a. ibuprofen (Motrin[R]) -- b. hydromorphone (Dilaudid[R]) -- c. amitriptyline (Elavil[R]) x d. All of the above 35. The most accurate judge of the intensity of the child's/adolescent's pain is -- a. the treating physician -- b. the child's/adolescent's primary nurse x c. the child/adolescent -- d. the pharmacist -- e. the child's/adolescent's parent 36. Which of the following describes the best approach for cultural considerations in caring for child/adolescent in pain: -- a. Because of the diverse and mixed cultures in the United States, there are no longer cultural influences on the pain experience. -- b. Nurses should use knowledge that has defined clearly the influence of pain on culture (e.g., Asians are generally stoic, Hispanics are expressive and exaggerate their pain, etc.) x c. Children/adolescents should be individually assessed to determine cultural influences on pain. 37. What do you think is the percentage of patients who over report the amount of pain they have? Circle the correct answer. (correct answer is underlined) 0 or 10 20 30 40 50 60 70 80 90 100% 38. Narcotic/opioid addiction is defined as psychological dependence accompanied by overwhelming concern with obtaining and using narcotics for psychic effect, not for medical reasons. It may occur with or without the physiological changes of tolerance to analgesia and physical dependence (withdrawal). Using this definition, how likely is it that opioid addiction will occur as a result if treating pain with opioid analgesics? Circle the number closest to what you consider the correct answer. (correct answer is underlined) < 1% 5% 25% 50% 75% 100% Two patient case studies are presented. For each patient you are asked to make decisions about pain and medication. 39. Patient A: Andrew is 15 years old and this is his first day following abdominal surgery. As you enter his room, he smiles at you and continues talking and joking with his visitor. Your assessment reveals the following information: BP =120/80; HR = 80: R = 18; on a scale of 0 to 10 (0 = no pain/discomfort, 10 = worst pain/discomfort), he rates his pain as 8. A. On the patient's record you must mark his pain on the scale below. Circle the number that represents your assessment of Andrew's pain. (correct answer is underlined) 0 1 2 3 4 5 6 7 8 9 10 No pain/discomfort Worst Pain/disconfort B. Your assessment, above, is made two hours after he received morphine 2 mg IV. After he received the morphine, his pain ratings every half-hour ranged from 6 to 8 and he had no clinically significant respiratory depression, sedation, or other untoward side effects. He has identified 2 as an acceptable level of pain relief. His physician's order for analgesia is "morphine IV 1-3 mg q1h PRN pain relief." Check the action you will take at this time: -- 1) Administer no morphine at this time. -- 2) Administer morphine I mg IV now. -- 3) Administer morphine 2 mg IV now. x 4) Administer morphine 3 mg IV now. 40. Patient B: Robert is 15 years old and this is his first day following abdominal surgery. As you enter his room, he is lying quietly in bed and grimaces as he tuns in bed. Your assessment reveals the following information: BP =120/80; HR = 80; R = 18; on a scale of 0 to 10 (0 = no pain/discomfort, 10 = worst pain/discomfort), he rates his pain as 8. A. On the patient's record you must mark his pain on the scale below. Circle the number that represents your assessment of Robert's pain. (correct answer is underlined) 0 1 2 3 4 5 6 7 8 9 10 No pain/discomfort Worst Pain/discomfort B. Your assessment, above, is made two hours after he received morphine 2 mg. IV. After he received the morphine, his pain ratings every half-hour ranged from 6 to 8 and he had no clinically significant respiratory depression, sedation, or other untoward side effects. He has identified 2 as an acceptable level of pain relief. His physician's order for analgesia is "morphine IV 1-3 mg q1h PRN pain relief." Check the action you will take at this time: -- 1) Administer no morphine at this time. -- 2) Administer morphine 1 mg IV now. -- 3) Administer morphine 2 mg IV now. x 4) Administer morphine 3 mg IV now.
Content validity of the PNKAS was established by a panel of five nurses who are nationally known experts in pain management because of their clinical practice, research, and publications on this topic (Lynn, 1986). These experts rated the relevance of each item in measuring pediatric nurses' knowledge and attitudes regarding pain on a scale of 1 to 4 as follows: 1 - being not relevant, 2 - being unable to assess relevance without major revisions, 3 - being relevant but needs minor revisions, and 4 - being relevant. Based on the panel's ratings, all items received a 3 or 4 rating from all experts except one item by two experts and five items by one expert. All of these items were revised according to the suggestions of the experts. The experts also rated the overall relevance of the survey. All rated the overall survey as a 4 except one expert. This expert rated the survey a 3 and made the suggestion of specifying the patient as an infant, child, and/or adolescent. This change was made.
Following revision of the tool based on the recommendations of the content experts, test-retest reliability of the PNKAS was determined using 12 subjects - 6 nurses and 6 child life specialists. These subjects were sent the final version of the PNKAS twice, the second time 8 weeks after the first. Results of the test-retest reliability were r = 0.67, indicating an acceptable level of stability for the tool.
Next, the internal consistency of the PNKAS was tested by using the data obtained from the responses of 247 pediatric nurses who worked in a 322-bed children's medical center. The result of the Cronbach's alpha was 0.72 indicating an acceptable level of internal consistency for the tool. Moreover, if any of the items were deleted during the analysis, Cronbach's alpha remained at 0.70 or greater, with a range of 0.70-0.73, indicating that all items were measuring knowledge and attitudes of pediatric nurses regarding pain.
The internal consistency of the tool was tested again by using the PNKAS with 88 members of the American Pediatric Surgical Nurses Association (APSNA). APSNA is a pediatric nursing specialty organization committed to improving the care of children requiring surgery. These nurses come from a wide variety of health care organizations from the United States and Canada. Internal consistency reliability of the tool from this group was Cronbach's alpha = 0.77. If any item of the tool was deleted during the analysis, Cronbach's alpha remained at 0.75 or greater, with a range of 0.75 to 0.78. Again, these reliability coefficients indicate that all items contributed to the tool.
The recent initiative by the JCAHO to include pain management in the health care organization accreditation process will significantly impact nurses and health care organizations. When confronted with the mandate to demonstrate nurses' competency in providing pain management to children, pediatric facilities will be in need of valid and reliable tools to evaluate and document compliance with the JCAHO standards.
The PNKAS, modified from a well-documented survey with established psychometric properties, was developed to evaluate pediatric nurses' knowledge and attitudes regarding pain. The survey is based on current clinical practice standards as published by leading authorities in pediatric pain management. In modifying the tool, specific questions addressing pain, pain assessment, pain management, and procedural pain of infants, children, and/or adolescents were added. Content validity of the PNKAS was established based on a review by a panel of national pain experts. Reliability in the forms of stability and internal consistency were supported by the analyses.
Since the PNKAS can be completed in 20-30 minutes and is scored based on correct versus incorrect answers, it can be used to quickly assess the knowledge of individual nurses, nursing units, and entire hospital nursing staff. Analysis of the individual PNKAS items (i.e., item analyses) can be used to identify strengths as well as deficiencies in knowledge and attitudes regarding pain management. The weakest areas of knowledge identified from the survey can be used to structure educational offerings that focus on pediatric pain management interventions. Educational offerings should be directed to improve nurses' knowledge, attitudes, and accountability for pain relief. These can include inservice trainings, continuing education programs, and self-directed learning modules. Educational offerings and quality assurance activities such as chart audits, patient satisfaction surveys, and interviews must be considered in a comprehensive effort to improve the clinical practice of pediatric pain management through knowledge attainment and accountability.
Use of the PNKAS for clinical and educational purposes is encouraged. The complete PNKAS tool and answer key can be downloaded from the City of Hope Pain Resource Center Web site (http://prc.coh.org). The tool is copyrighted by the author, but duplication for clinical practice and education is permitted as long as results are reported to the author for ongoing analysis of the tool. Ongoing internal consistency evaluations and construct validation are needed to determine how the survey performs with other samples in various pediatric settings. The use of the PNKAS for pre- and posttest assessments of knowledge attainment by participants in educational programs is recommended, but use of the PNKAS for this purpose requires further validation. Additional data is also needed to determine if satisfactory results on the PNKAS correlate to satisfactory clinical practice in providing pain relief to pediatric patients.
Previous research has concluded that measuring nurses' knowledge and attitudes is not enough. It is merely a method of identifying possibilities for improvement. True progress in pediatric pain management will require professional and organizational commitments to pain relief practices. The PNKAS is a tool to identify now far we still need to go. The JCAHO standards are the impetus to get us there at an accelerated pace.
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Renee C. B. Manworren, MS, RN, WOCN, is Pain Management Clinical Nurse Specialist, Children's Medical Center of Dallas, Dallas, TX.
Acknowledgment: The author would like to thank Cathie Guzzetta, PhD, RN, for her assistance throughout the development of the study and the preparation of the manuscript; Marion E. Broome, PhD, RN, FAAN; Betty Ferrell, PhD, RN, FAAN; Betsy Heiner, MSN, RN, CNS; Sandy Sentivany-Collins, MS, RN; and Donna L. Wong, PhD, RN, PNP, CPN, FAAN, for reviewing the tool as content experts; Linda Hynan, PhD, for the statistical analysis; the members of the American Pediatric Surgical Nurses Association; and the nurses and child life specialists at Children's Medical Center of Dallas who supported and participated in the study.
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|Author:||Manworren, Renee C. B.|
|Date:||Mar 1, 2001|
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