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Development and Testing of the Pediatric Nurses' Knowledge and Attitudes Survey Regarding Pain.

The amount of information about pain management available to pediatric nurses has dramatically increased over the past 20 years. Clinical practice guidelines and standards for pain management have been published and are readily available from government agencies and professional health care specialty organizations (Agency for Health Care Policy and Research [AHCPR], 1994, 1992a, 1992b; American Academy of Pediatrics, 1990; American Pain Society [APS], 1999; Association for the Care of Children's Health [in McGrath, Finley, & Ritchie, 1994]; World Health Organization [WHO], 1998). Despite all the information currently available to pediatric nurses, studies indicate that current guidelines and standards have not been applied consistently in the care of children's pain (Hamers, Huijer Abu-Saad, van den Hout, & Halfens, 1998; Jacob & Puntillo, 1999; Margolius, Hudson, & Michel, 1995; Romsing, 1996). Pediatric nurses have not been held accountable for understanding, believing in, or providing pain management consistent with these published standards (Jacob & Puntillo, 1999; Margolius et al., 1995; McCaffery & Pasero, 1999).

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.

Literature Review

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."


Survey Validation

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.

Nursing Implications

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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Date:Mar 1, 2001
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