DISCUSSION

Adapted from FYP from Faculty of Health and Social Sciences

The overall average score of 25 items was 46.4% of a possible score of 100%. Compared to the study of Kubecka, Simon, Boettcher, (1996) in North Carolina with same design and instrument, and 28 items chosen, the overall average score was 67.4%, the mean score was 18.8. Her findings indicate a knowledge deficit in pain management. In this study, the mean score was 11.6, less than half of the respondents 38.5% (n=261) answered 13 of the 25 items correctly. Therefore, the findings of this study support the concern of inadequate knowledge and attitudes regarding pain management. These findings are consistent with past research. (Dalton, 1989; Ferrell et al., 1993; Brunier et al., 1995; McCaffery, 1997).

This study revealed significant findings related to the education level, working experience, course on pain management attendance and knowledge and attitudes on pain management. An additional finding was the relationship of nurses' scores on the NKAS and the years of experience and frequency of caring for patients in pain.

In this study, the mean scores of Bachelor and Master Nurses were higher on the NKAS than Diploma nurses. Nurses who have more working experience have higher mean score on the NKAS than the nurses who have less working experience. These findings have not been supported in the literature (Watt-Watson, 1987; Hamilton, 1992; Perry & Heidrich, 1982; Choiniere et al., 1990). The difference in this study may be due to nurses attended different universities after graduation in their nursing school. The nursing curriculums in Bachelor and Master level have included the courses of pain management. Working experience may be due to the respondents in this study have years of experience and frequency in caring for patients in pain in their clinical practice that have the higher score of NKAS. Some of the literature found no significant correlation between scores and frequency in caring for patients with pain (Sheidler, McGuire, Grossman and Gilbert, 1992; Brown et al., 1999), some of the literature found that there was relationship between them (Brunier, Carson and Harrsion, 1995;Clarke, French, Bilodeau, Capasso, Edwards and Empoliti, 1996; O' Brien et al., 1996). It may be due to the clinical practice, knowledge base and the own belief of the nurses and it also can demonstrate the sensitivity of this tool.

Nurses who had attended courses on pain management scored significantly higher on the NKAS than nurses who had not attended the courses. Most of the literature found the similar relationship between them. (Watt-Waton, 1987; Graffam, 1990; Zalon, 1995.) These studies also have documented that nurses are not adequately prepared to deal with patients in pain because they perceive that they have not received adequate knowledge from their basic nursing education. There is a great need for continuing education in pain management for them. Other studies found a relationship between attendance at courses or programs on pain management and improvement in knowledge and attitudes (Ferrell, 1995; Howell, Buttler, Vincent, Watt-Watson and Stearns, 2000; Wright and Bell, 2001). They also found that the effectiveness of pain management needed to be reviewed during a period to update the knowledge of pain management.

McCaffery & Ferrell, (1992) recommended using a total score rather than breaking down items into knowledge and attitudes because each items of the questionnaire can measure both knowledge and attitude. Analysis individual items can reveal the barriers in knowledge and attitude about pain according to the questions with the most answered incorrectly. (Refer to table 6). These items related to pain assessment, pharmacological and non-pharmacological interventions.

In this study, more than 85% of the respondents showed that they believed the patients over-report the pain they have. McCaffery & Ferrell (1995) stated that possible answers ranged from 0 to 100% in increments of 10%, with 0 to 10% being the preferred choice. The studies by Brown et al., 1999, Brunier et al., 1995; Clarke et al., 1996, have the same result of over-report pain. Because the nurses believe the patients over-report pain, it causes underestimation and undertreatment of pain through the pain assessment in nurses' report. In this study, less than 30% of the sample could assess the rating of pain scale correctly according to the level of patient's pain. Many studies (Cohen, 1980; Brunier et al., 1995; Ferrell et al., 1993; Mackintosh, 2000) also found the nurses underestimated the amount of pain that patients experienced, demonstrating nurses do not believe what the patients state about their pain.

According to McCaffery and Beebe (1989), pain is difficult to measure because it is subjective, only the persons experiencing the pain know how it feels, its intensity and location. Although patients' self-reports of pain are not valued by nurses, the patient is the one with pain, not the caregiver. It demonstrated some self-awareness among the nurses of the difficulties they experience assessing patients' pain. Nurses need to change their attitude and must accept and trust patients' report of pain.

This study also found that the nurses required to assess the patient's level of pain from the patient's own self rating, nurses tended not to believe the patient if the body language and facial expression were incongruent with the expressed feelings, and the vital sign of the patients may be changed when in pain. In the questions of pain expression and symptoms of the pain, the nurses believe the patients may not sleep in spite of severe pain and observable changes in vital signs must be relied upon to verify a patient's statement that he has severe pain.

According to Bonica (1990), physiological adaptation that occurs with pain, results in the absence of evidence of sympathetic over activity, such as increases in pulse, blood pressure and respirations, response indicators, such as changes in mood, sleeping and eating. Pain cannot be objectively measured according to blood pressure or heart rate since pain is a subjective symptom. (Strong, Unruh, and Wright, 2002).

Therefore, nurses cannot believe those patients in severe pain when they have no changes in their vital signs. In this study, less than 25% answered correctly, it may be due to some misconception of pain theory, assessment skills of pain intensity and attitudinal barriers which the nurses make their decisions based on personal attitudes or own learned judgment. Studies (Graffam, 1990; Ferrell et al., 1993; Wallace et al., 1995) found the nurses lack of knowledge in pain management will affect the belief and skill of pain assessment of nurses that can mislead the intervention in pain relief. The reasons of inadequate knowledge of pain management are due to no curricular contents in the nursing education and no clinical practice in their clinical setting.

The findings from this study revealed several misconceptions related to use of pharmacology and non- pharmacology. One of the risks is the respiratory depression when the patients receiving opioid therapy. According to the report of Schmidt, Eland, and Weiler (1994), the risk of respiratory depression is less than 1%. The incidence of respiratory depression is rare when using of opioid drug. (deLeon-Casasola, Parker, Lema, Harrison, & Massey, 1994)

In many studies (McCaffery et al., 1990; Hamilton, 1992; Brunier et al., 1995; Fielding, 1994; Brown et al., 1999) found nurses overestimated the incidence of addiction during receiving the opioid therapy. Most of the nurses concern over addiction and respiratory depression are evident.
In this study, 70% of the nurses falsely believed that patients who have received opioids over a period of months that respiratory depression occur. This misbelief will make the nurses not to offer the opioid medication to the patient for pain relief and spread this belief to the patients out of taking their medications on the basis of their bias and misconception.

Another pharmacologic item related to the use of non-steroidal anti-inflammatory drug (NSAIDs) and the route of opioid administration.

There are less than 23 % of the response were aware that Aspirin and other NSAIDs are effective analgesics for bone pain caused by metastasis. These drugs have been proven to be especially effective in patients with pain particularly bone tumor and bone metastasis (American Pain Society, 1992). Trwycross, (1994) stated that non-opioid medications which included Aspirin and NSAIDs are effective for mild to moderate pain and are often combined with opioid analgesics to enhance pain control in causes of severe pain. The mechanism of action of these drugs can inhibit the transmission of pain, which are the choices in the management of pain (Goodman, Goodman and Rall, 1985). In this study, only 22.7% of the respondents related to use of Non-steroidal anti-inflammatory drugs.

Coluzzi (1996) stated the oral route is the preferred route of analgesic administration because it is the most convenient and cost-effective method of administration. According to Salerno and Willens (1996), if the patient is able to swallow, is not vomiting and is not in acute pain, the oral route is more comfortable than injections. Oral doses of opioids at equianalgesic doses are as potent as intramuscular opioids. Patients with chronic or persistent pain should not be receiving routine injections, because injections add to patients discomfort and the potential for skin breakdown. However, in this study, only 17.7% (N=120) of the sample selected oral route of opioids, while 42.2% (N=286) indicated intravenous administration as the recommended route.

Knowledge of the pharmacological pain management is important for effective and safe management in patients' pain relief. From the results of pharmacological items in this study, nurses have inadequate knowledge about pharmacologic properties of drugs and clinical application of this knowledge.

Hence nurses need to reinforce and update their knowledge regarding pharmacological pain management through the programs to eliminate knowledge deficits and change attitudes which are barriers to effective pain management.

Many non-pharmacologic interventions have been used effectively in the management of patients in pain. According to Rowlingson & Hamill (1994), non-pharmacologic pain interventions include heat and cold, acupressure and massage, mental imaging, music and distraction. They can be very effective for all types of pain intensities and are definitely recommended when used concurrently with pharmacological interventions in the treatment of severe pain (McCaffery & Beebe, 1989, Acute Pain Management Guideline panel, 1992). In this study, only 15.6% of the respondents believed that non-drug interventions (e.g. heat, music, imagery etc) are very effective for mild to moderate pain control but are rarely helpful for more severe pain. The reasons of inadequate knowledge related to this area is also due to no curricular content in the nursing education and no clinical practice in their clinical setting. Non-pharmacologic interventions provide the nurses with additional tools to manage the patient's pain effectively. Even though so much focus has been placed on pharmacologic intervention, the use of the combination of pain-relieving mechanisms should be considered.