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What were they thinking? Nursing students' thought processes underlying pain management decisions.

ABSTRACT Patients' pain has not been adequately controlled due to inaccurate assessments, inadequate treatments, and inconsistent nursing care. The purpose of the study was to determine the extent of nursing students' accuracy in assessment ratings and treatment choices for patients in a case vignette who were experiencing pain and then to determine the thought processes underlying their decisions. Written rationales in response to two patient scenarios reveal students' thought processes when recording pain intensity levels on a numerical scale and choosing corresponding dosages of analgesics. Data collected from junior and senior nursing students provide insight for nurse educators and point to areas where curricula and instruction may be enhanced. Reforming teaching and learning practices when educating students about pain management could decrease patient suffering and lead to improved comfort and satisfaction.

Key Words Pain Assessment--Pain Management--Nursing Education--Andrew-Robert Survey--Subjective Pain Rating


ONE HINDRANCE TO EFFECTIVE PAIN ASSESSMENT AND TREATMENT IS THE INABILITY TO ACCURATELY MEASURE AND MONITOR THE INTENSITY OF A PATIENT'S PAIN. Health care providers are responsible for assessing and treating pain based on a patient's verbal and nonverbal communication. But inconsistencies exist in the nursing process, based largely on such variables as a nurse's educational preparation, specialty area, and personal experience caring for others. These various factors may influence nurses' responses to and beliefs about pain (Brunier, Carson, & Harrison, 1995). * When treatment decisions are based on patients' behavioral responses, at the exclusion of verbal ratings, misinterpretation is likely to occur. Schilling (2003) recommends the following pain assessment technique: "Ask the patient to rank his pain on a scale of 0-10, with o denoting lack of pain and 10 denoting the worst pain level." According to McCaffery (1968), "Pain is what the experiencing person says it is, existing whenever he says it does" (p. 95). * As nursing students hold their own beliefs about proper ways to manage pain, it is important that faculty, early in the course of study, assess students' knowledge and attitudes about the treatment of pain. The nursing curriculum and instruction should not only include pathology and pain management, but current research on common misconceptions held by nurses about pain control. THE PURPOSE OF THIS STUDY WAS TO DETERMINE NURSING STUDENTS' ACCURACY IN ASSESSMENT RATINGS AND TREATMENT CHOICES FOR PATIENTS EXPERIENCING PAIN, AND THEN TO DETERMINE THE THOUGHT PROCESSES LEADING TO THEIR DECISIONS.

Review of the Literature Although some advancements have been made, knowledge deficits and misconceptions held by nurses, patients, and family members continue to inhibit pain relief and limit quality of life. The literature points to numerous reasons why this situation continues to exist in health care, including myths held by the general public, exaggerated fears about addiction, and knowledge deficits (Lasch et al., 2002).

McCaffery and Ferrell (1991) developed a case vignette instrument to assess how nurses rate a patient's pain intensity on a numerical rating scale. The researchers surveyed 456 hospital staff nurses in six cities, using a vignette where one patient displays expected or typical behavioral manifestations, while another expresses unexpected verbal and nonverbal reactions to pain. Both patients rate their own pain as 4 on a 0-5 scale. Using this scale, 40.7 percent of the nurses recorded the smiling patient's pain as 4, in contrast to 71.6 percent who recorded the grimacing patient's pain as 4. The authors noted that "a simple behavior such as smiling or grimacing isn't strong enough evidence to conclude that a patient's pain rating is anything other than what he says it is. In fact, research has repeatedly shown that many patients with pain deliberately smile or laugh, either to help themselves cope with the pain or to try to hide their pain from others" (p. 37).

Chuk (2002) used the same case vignette instrument with 198 nursing students in Hong Kong. In both scenarios, the patients rated their pain intensity as 4 on a 0-5 scale; behavioral differences were the only variation. Results showed significant differences (p < 0.01) in pain ratings documented by the students for the two scenarios. The objective signs of pain overruled the patient's own self-rating in the responses of 59.2 percent of the students.

Sigsby (2001) recommended enhancing student learning experiences in pain management through perioperative clinical experiences. From a population of 147 junior nursing students, 49 (33 percent) participated in a perioperative rotation; settings included the holding area prior to surgery and the operating and recovery rooms. Randomly assigned students spent 16 hours per week with patients having various types of surgical procedures. Data were collected in clinical conferences where students were asked one open-ended question: "What was your overriding impression of learning in the perioperative rotation?" Findings indicated enhanced student understanding of pain by the end of the semester; at that time, the three most prevalent themes were "learning about interdisciplinary professionals," "anatomy and physiology," and "patients in pain."

The Research Study The purpose of this research study was to replicate aspects of Chuk's study on the issue of pain assessment accuracy in nursing students (2002). The current study attempted to replicate aspects of Chuk's design to determine if similar results would be found in a sample of nursing students from the United States. It also expanded on Chuk's design by eliciting written rationales from nursing students for their assessment ratings and treatment choices for two patients who behaved differently in response to pain. The focus on qualitative data provides rich findings that have implications for nursing education, curricula, and instruction.

Three research questions were asked:

1. To what extent do nursing students correctly rate patients' verbal reports of pain intensity in two case vignettes?

2. To what extent do nursing students, who correctly rate a patient's stated pain intensity, also correctly administer the recommended dosage of analgesic under the conditions provided in the case vignette?

3. What rationales do students identify for their ratings of pain intensity and medication administration in the case vignettes?

Method The population included classes of junior and senior nursing students at two schools of nursing (N = 270 students). Juniors and seniors were selected because they had completed two years of general education requirements and prerequisites and had began upper-division nursing courses. Both schools of nursing had similar learning objectives for pain management, presented pain content in the first semester of nursing courses, and used the same textbook and chapter for teaching pain in the fundamentals of nursing course. Each school designated three hours of classroom instruction for this topic, and faculty members used lecture-style teaching methods.

The instrument used in this study was the Patient Behavior Case Vignette, often referred to as the "Andrew-Robert Survey," developed by McCaffery and Ferrell (see Figure on following page). This instrument was selected because the data yielded was relevant to the research questions and because of its wide use in other studies. Ferrell and McCaffery (1998) discussed the validity and reliability of the vignette instrument. A panel of experts in pain management established content validity, and the survey was pilot tested at workshops with at least 100 participants.

The case vignette requested that participants read two patient scenarios and answer four questions after each case was presented. The only difference in the two vignettes was the patient's name and his behavior in response to pain. Participants were asked to rate the patient's pain intensity level on a numerical rating scale and select a dosage of pain medication from a range of choices.

For the purposes of this study, two questions were added to the original instrument to determine the rationales for students' assessment ratings and treatment decisions. Because these questions were not part of the original survey, the researcher requested feedback from six nurse faculty prior to data collection to determine validity and the ability to elicit rationales for student responses. All six educators were in agreement that questions B and D (see Figure) were appropriate additions to the tool and that the multi-method approach, combining quantitative and qualitative data, would enrich the results of the study.

The study received human subjects review board approval after an expedited review process. Nursing students were greeted during class time by the researcher and were given the option of participating in the study; they were guaranteed no consequences for declining. Each participant signed a written informed consent prior to completing the survey. All data remained confidential, and names were not used as part of the research instrument.

To answer the first two research questions, quantitative data were viewed in terms of percentage of the entire population of participants. Qualitative data were analyzed to determine the most frequently occurring rationales and then categorized into themes to accurately report the findings. Examples of written statements are presented here.
Figure. Case Vignette Instrument

DIRECTIONS Two patient case studies are presented. For each patient
you are asked to make decisions about pain and medication. Patient
A Robert is 25 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 turns 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),
Robert 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 in bold) 0 1 2 3 4 5 6      7 8 9 10
                         No pain/discomfort Worst pain/discomfort

B. What influenced your decision and led you to record this
intensity level? (Correct answer: This is the pain level the
patient stated.)

C. Your assessment, above, is made two hours after Robert received
morphine 2 mg IV. Half hourly pain ratings following the injection
ranged from 6 to 8, and he had no clinically significant
respiratory depression, sedation, or other untoward side effects.
Robert has identified 2 as an acceptable level of pain relief. His
physician's order for analgesia is "morphine IV 1-3 mg q 1 h 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.

--4. Administer morphine 3 mg IV now. (Correct answer)

D. What influenced your decision and led you to administer this
dosage of pain medication? (Correct answer: At the last
administration of pain medication, morphine 2 mg was inadequate for
Robert's acceptable level of pain relief; therefore, increase the

Patient B Andrew is 25 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),Andrew 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 in bold) 0 1 2 3 4 5 6      7 8 9 10
                         No pain/discomfort Worst pain/discomfort

B. What influenced your decision and led you to record this
intensity level? (Correct answer: This is the pain level the
patient stated.)

C. Your assessment, above, is made two hours after Andrew received
morphine 2 mg IV. Half hourly pain ratings following the injection
ranged from 6 to 8 and he had no clinically significant respiratory
depression, sedation, or other untoward side effects. Andrew has
identified 2 as an acceptable level of pain relief. His physician's
order for analgesia is "morphine IV 1-3mg q 1 h 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

--4. Administer morphine 3 mg IV now. (Correct Answer)

D. What influenced your decision and led you to administer this
dosage of pain medication? (Correct answer:At the last
administration of pain medication, morphine 2 mg was inadequate for
his acceptable level of pain relief; therefore, increase the

Note. Permission for publication was granted by Margo McCaffery,
who created the original version of this instrument.

Results RESEARCH QUESTION 1 It was found that 87.41 percent of the nursing students in the sample correctly rated pain intensity for Patient A (Robert) in the case vignette, in contrast to 69.63 percent for Patient B (Andrew). The difference for the two patients with differing behavioral manifestations was 17.78 percent.

RESEARCH QUESTION 2 Two hundred thirty-six nursing students correctly rated pain intensity in the Robert vignette; 119 (50.42 percent) of those students also correctly administered the correct dosage of morphine. When responding to the Andrew vignette, 188 students correctly rated pain intensity; 73 (38.83 percent) of those students also administered the correct amount of pain medication.

RESEARCH QUESTION 3 Ten themes emerged from the qualitative data. Rationales for pain assessment ratings and treatment choices are grouped by theme, with a statement about the data and narrative examples from students.

Rationales for Correct Pain Assessment Ratings

DOCUMENT SUBJECTIVE REPORT Accepting, respecting, and documenting the patient's self-report of pain was the correct response, which many students chose by circling the number 8 on the pain scale. A junior wrote, "Even though he is smiling, talking, and joking with his visitor, pain is a subjective finding. The patient stated 8, so chart an 8." A senior wrote, "It was his rating of pain. My assessment would have been much lower, but he rated it."

ETHICAL RESPONSIBILITY OF NURSE When asked what influenced their decisions to record pain intensity levels and choose dosages of medications, many students correctly responded with answers based on ethical obligations of the caregiver. A junior wrote, "Since pain is subjective, it is important to believe he is honest about his level of pain." Another wrote, "Because that is what the patient stated and I don't have the right to chart any other answer except what he told me." In response to the Andrew vignette, a senior wrote, "I would have to trust what he said. Different people perceive pain in different ways and he could have been telling the truth."

PATIENT'S USE OF DISTRACTION Nursing students who correctly assessed patients in the vignettes referred to distraction as a possible reason for the atypical behaviors such as talking and joking with the visitor. A junior wrote, "I wouldn't really believe him because of his actions, but he may hide pain well." Another junior wrote, "That is what Andrew stated. Even though he is smiling, talking, and making jokes, [this] does not mean that he is not in pain. This may just help him keep his mind off of it."

Rationales for Incorrect Pain Assessment Rating

STABLE VITAL SIGNS Students documented incorrect pain ratings for patients in the vignettes due, in part, to behavioral signs and vital signs that did not coincide with the stated pain intensity level. A junior who chose an incorrect dosage of morphine in the Andrew vignette wrote, "In assessing the patient, vitals are normal range; therefore, he needs no further pain reeds at this time." A junior provided the following reason for the incorrect assessment of Robert: "Even though he is in pain because he grimaces, his heart rate is not up a great amount, so he is definitely in pain, but not extremely severe."

SOCIAL STIGMA Students referred to the social stigma associated with patients who report pain. Students referenced stigma when referring to the visitor present in the Andrew vignette. A senior who incorrectly assessed Andrew's pain wrote, "He could be pretending (lying) because of his friend/visitor." Another senior wrote, "He may not want to show his friend that he is in any pain, so he hides it."

AVERAGE OF SUBJECTIVE AND OBJECTIVE FINDINGS A curious finding not identified in previous studies was that students averaged subjective and objective findings to yield a numerical pain rating. This rationale emerged several times in the assessment of Andrew. A junior, who incorrectly rated pain intensity, wrote, "I gave a 4 because he probably is in pain, but he's probably exaggerating the 8 because he is smiling and joking. He probably would not be doing this if he really had pain level of 8." Another junior wrote, "He says he is in a lot of pain (8) but he is joking and laughing with his visitor. His vitals are within normal ranges and he shows no physical signs of pain. A 6 is somewhere between the 8 he says and the 4 you think he is, because of context clues."

Rationales for Incorrect Dosage of Analgesic

PATIENT MUST ASK FOR MEDICATION PRIOR TO RECEIVING IT Some students chose not to increase the dosage of morphine because the patient in the vignette did not explicitly ask for more medication. A junior student who administered the incorrect dosage of pain medication to Andrew provided the following reason: "Because he doesn't appear to be in that much pain and I wouldn't give him anything unless the patient asked for it." Another junior provided a similar response to the Robert vignette: "If he asks for more, give up to 3 mg every 1 hour, but do not give the max unless asked for. Do not want to build dependence to drug." A senior who administered an inadequate dosage of morphine to Andrew wrote, "First, does the patient indicate he wants pain medication? Second, begin with minimal dose unless otherwise indicated by the patient."

FEAR OF ADDICTION Respiratory depression, addiction, and withdrawal were listed among the reasons for not increasing the dosage of morphine in the case vignettes. A junior who administered an incorrect dosage of morphine for Andrew wrote, "Because the patient still expressed pain and I don't want to overdose the patient." Responding to the same vignette, a senior wrote, "He has not reached a comfortable state of pain management. Administering the smallest dose first is appropriate because it may achieve his goal and not oversedate him." Another senior wrote about Robert: "He is allowed dosage-wise to get more so I would give him 1 mg simply because I see lots of people need pain medicine psychologically to feel better, but I am not going to load him up just to sleep."

BEHAVIORAL MANIFESTATIONS Many students were swayed by behavioral manifestations when choosing the medication dosage. A junior student who chose the incorrect dosage of morphine for Andrew gave the following rationale: "He seems to not be having relief of pain (even though I felt he wasn't in that much pain). I feel that if he had a pain level of 8, he would not be joking around. I only gave 1 mg to see how he would respond." A senior responded to the same vignette in this way: "He needs pain management, but it does not appear that he needs the maximum dose at this time as evidenced by physical signs and symptoms and nonverbal assessment." A junior wrote, "I would give him 1 mg of morphine since it is ordered and would wait to see if he showed any visible signs of pain before I would give him a higher dose."

MISINTERPRETATION OF THE CASE VIGNETTE Rationales provided by a number of students indicated that they either misread or did not fully understand the scenarios, a problem not identified or accounted for in the literature. Although question C in the vignettes states, "Half hourly pain ratings following injection ranged from 6 to 8.... [Patient] has identified 2 as an acceptable level of pain relief," some students mistakenly thought the patients' current pain level was 2, an acceptable level, rather than 6 to 8. Actually, the patients rated their pain as 8 on the 0-10 scale. For example, rationales for incorrect dosages of morphine from students at both nursing programs are as follows:

* "His pain level is now 2, so there is no need for morphine."

* "He has verbalized to me a 2 on the pain scale and this is acceptable to him at this time."

* "Patient still states 6-8 pain; administer 1 [mg] and go from there."

* "He tolerated the previous dosage well and pain level is still 6-8...."

Discussion It was encouraging that many students understood the principle of accepting, respecting, and documenting the patient's self-report of pain. The findings that students included statements about the ethical responsibilities of a nurse and recognized that Andrew may be using distraction as a comfort measure were also positive.

As expected, rationales for incorrect pain ratings included references to behaviors and vital signs that remained within normal limits. Some students were cognizant of the visitor present in the room and thought that his presence may have affected the patient's behavior and reported pain level.

Surprisingly, one theme that emerged from students' written rationales for incorrectly rating pain intensity had not been noted in previous research studies. Students calculated a "middle ground" or "average" by documenting a number between the patient's self-report and the number they believed to be correct, based on the patient's behavior.

When 2 mg of medication was ineffective in controlling the patient's pain at the previous administration, students were reluctant to increase the dosage. Based on the responses provided, students in this sample did not understand the concept of titration, or starting with a low dosage and slowly increasing until pain relief is achieved. Morphine is a drug that has no ceiling in its dosage; it can be increased until analgesia is achieved if there are no untoward side effects (McCaffery & Pasero, 1999).

Misinterpretation of the case vignette may indicate that students were not reading the vignette closely enough, or that the contents of the vignette were not clear to the students. One may question whether the students understood the phrase, "an acceptable level of pain relief."

The fact that students from the two nursing schools were conveniently selected based on proximity of the researcher to the schools is a possible limitation of this study. It is also important to note that results were based on responses to a hypothetical patient situation. There is no certainty that students would have the same response in an actual clinical situation.

Conclusion Analysis of the quantitative data reveals that more than half of the students in the sample tended to assess pain accurately; however, rather than documenting verbal ratings provided by the patient, many were swayed by behavioral factors. It is misleading for educators to believe that students who accurately assess pain will also administer adequate amounts of analgesics. Qualitative data reveal the reasons why many students continue to hold inaccurate knowledge and beliefs about pain management.

For best practices in teaching and learning, faculty should assess students' knowledge, attitudes, and misconceptions early in the curriculum prior to the presentation of new content. Nurse faculty may also deem it necessary to revisit the topic of pain management throughout the course of study to ensure that students are maintaining appropriate practice.

Students should be taught not only to report and document patients' self-reports of pain, but also to follow through with recommended amounts of pain medication. For the two schools of nursing represented in this study, a three-hour lecture in the classroom was not adequate to ensure that all learners would respond correctly to patients experiencing pain. Evaluation of the research data suggests that alternative, or additional, teaching innovations are needed to enhance student learning and understanding.

Sigsby's (2001) report of enhanced student knowledge about patients in pain while in perioperative clinical experiences should be considered. Curriculum revisions are warranted in the area of medication titration, especially for analgesics that patients can develop a physical tolerance to over time.

In future development and evaluation of program curricula within schools of nursing, faculty may wish to consider the written rationales provided by students in this study as a springboard for educating students about common myths and misconceptions. The Andrew-Robert survey is easily administered in the classroom setting and opens the door for rich classroom discussions. In response to the findings of this study, evidence-based reform will lead to improved critical thinking and decision making on part of nursing students, as well as increased patient comfort and satisfaction.


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Chuk, P. (2002). Determining the accuracy of pain assessment of senior student nurses: A clinical vignette approach. Nurse Education Today, 22, 393-400.

Ferrell, B. R., & McCaffery, M. (1998, January). Reliability and validity of the pain vignettes. Retrieved from controlling_pain.pdf

Lasch, K., Greenhill, A., Wilkes, G., Carr, D., Lee, M., & Blanchard, R. (2002).Why study pain? A qualitative analysis of medical and nursing faculty and students' knowledge of and attitudes to cancer pain management. Journal of Palliative Medicine, 5(1), 57-71.

McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain, and man-environment interactions. Los Angeles: University of California at Los Angeles Students' Store.

McCaffery, M., & Ferrell, B. R. (1991). How would you respond to these patients in pain? Nursing 91, 21, 34-37.

McCaffery, M., & Pasero, C. (1999). Pain clinical manual (2nd ed.). St. Louis, MO: Mosby.

Schilling, J.A. (2003). Best practices: A guide to excellence in nursing care. Springhouse, PA: Lippincott Williams & Wilkins.

Sigsby, L. M. (2001). Effective learning about the concept of pain from a perioperative clinical rotation. Pain Management Nursing, 2(1), 19-24.

Crista L. Briggs, EdD, RN, CNE, is an assistant professor in the School of Nursing, Western Kentucky University, Bowling Green, Kentucky. For more information, contact her at
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Title Annotation:RESEARCH
Author:Briggs, Crista L.
Publication:Nursing Education Perspectives
Geographic Code:1USA
Date:Mar 1, 2010
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