Objectives:

Objectives:
• Identify the components of a research article
How to Review a Research Article
• Use a systematic approach to evaluate a
nursing research article
Bernice D. Mowery, PhD, PNP, RN
Pediatric Nursing Conference
What do you need to appropriately use
research?
• Fears?
• Learn terminology
• Get help with statistics
• Evidence Based Practice (EBP)/Best Practice
• How do you determine if a research article is
applicable?
• Is one article enough to support practice change?
• Plan
• Learn components of a Research Study
• Evaluate the quality of how it was done
• Use a systematic format to evaluate studies
Evidence-Based Practice: Six Steps
1. Formulation of an answerable question to address a specific
patient problem or situation
2. Systematic searching for the research evidence that could
be used to answer the question
3. Appraisal of the validity, relevance and applicability of the
research evidence
4. Integration of the research evidence with other information
that might influence the management of the patient's
problems: clinical expertise, patient preferences, available
resources
5. Implementation of the evidence-based practice decision
6. Evaluation of the outcome of the decision
http://ktclearinghouse.ca/cebm/syllabi/nursing/intro
COMPONENT
Clarity of the problem & Significance for nursing
Aims/Research ?s/Hypotheses
Conceptual/Theoretical Framework
Literature Review
Tips for Review
Type of Study: Quantitative; Qualitative or Mixed Method
• Use same approach each time
• Develop your own system
• Use a form to record your evaluation
• Write notes in margins as you read or use Track
Changes
• May need to review several times before final evaluation
• Review all articles on subject - then review again
• Rank them for relevance and quality
• Synthesize
Study Design/Methodology
Research Article
Evaluation Form
• Quantitative: Experimental,
Quasi-experi, Non- experi
• Qualitative: Grounded theory, Phenomenology, Ethnography
Ethical considerations
Procedures: Operational Definitions
Study Population/Sample: Types of participants/subjects
• Number of subjects
• Gender, Race, Age Group
Bernice D. Mowery,
PhD, PNP, RN
Article
Information: …
• Setting
• Sampling Method
Interventions Studied
• Intervention or Exposure or Treatment
• Outcomes
Mode of Measurement
• Psychometric Characteristics
• Multidimensional
Attrition/ Withdrawals for adverse reactions
Findings/Results
• Data Analysis/Themes
• Scoring
• Significance
• Effect Size
Validity Threats
•
•
•
•
Construct Validity
Internal Validity
External Validity
Statistical Conclusion Validity Threat
Methodological Strengths
Limitations/Weaknesses
Authors’ Conclusions and General Comments
Conclusions:
COMMENTS
Critique of the Research Process
Overview of the Article
• Author(s)
• Not just “yes” or “no” for each step
• Date of the research
• Evaluate quality
• Title clear?
• No such thing as “perfect” research
• Abstract helpful?
• Want the most strengths possible with limitations in areas
of least importance for this study
• What are clinical implications?
• Priority area for nursing research
• Focus of EBP (evidence based practice)
• Is the approach quantitative or qualitative?
Purpose/Problem Statement
• Clarity of the problem
Aims/Objectives/ Research Questions
•
Different words used to describe
– Goals of the research
– Are they logical and realistic
– May include hypotheses (recognizes bias)
•
Theoretical/Conceptual Framework/Model
– Adequately described
– Appropriate
– Controversial if this is an absolute requirement
• Research aims/questions/hypotheses
• Builds on previous research
• Significance for nursing
Background/Literature Review
•
Review comprehensive
•
Support for the current research questions
•
Includes most current information
•
Includes all pertinent variables
•
Establishes significance
Methods:
•
•
•
Type of study approach
– Should match questions
– Qualitative
– Quantitative
– Mixed methods
IRB approval/human rights protection
Procedures
– Operational definitions for Measures and Outcomes
– Participants
– Plan for analysis
Study Design
Quantitative vs. Qualitative
• Quantitative
• Study of phenomena that can be precisely measured and quantified
• Statistical analyses
• Quantitative
• Experimental
• Random Controlled Trial
• Quasi-experimental Design
• Qualitative
• Study of phenomena in an in-depth and holistic manner
• Participant’s perspective of the phenomena (narrative data)
• Non-experimental
• Descriptive
• Correlational
• Blinding
• Intervention (independent variable)
• Mixed methods
• Combine Quantitative and Qualitative methods
• Triangulation: research process along with data is analyzed from
different directions – decreases bias and increases validity of results
Quantitative Design
Study Design
• Investigation of phenomena that that allows precise
measurement and quantification
• Qualitative
• Grounded theory
• Usually involves rigorous and controlled design (Polit & Beck, 2012)
• Phenomenology
• Characterized by
• Systematic collection and statistical analysis of
numerical data
• Relatively controlled conditions (Norwood, 2010)
• Gathering and analyzing empirical evidence
• Goal is generalizability (Polit and Beck, 2012)
• Ethnography
Qualitative Design
• Study of phenomena in an in-depth and
holistic manner
• Participant’s perspective of the phenomena
(narrative data)
• The “lived experience”
Ethical Considerations
•
•
•
•
Human rights protection
All risks identified
Participants fully informed
Consent/Assent given
• The National Commission for Protection of Human Subjects of
Biomedical and Behavioral Research established age 7 as a
reasonable minimum age for involving children in some kind of
assent process
• Younger may be able to assent
• Funding influences
• Investigator bias
Procedures
• Described adequately
– To allow reviewer to evaluate
– For duplication
• Operational definitions for
– Interventions/Exposure/Treatment (Independent
variable)
– Outcomes (Dependent Variable)
• Realistic
– Is it cost-effective?
– Would this ever work in practice?
Sample/Study Population
•
Sample Size: Power Analysis or Saturation
•
Gender
•
Race
•
Setting
•
Age group
•
Sampling method
•
Same group as your interest
Findings/Results
Measurements
•
•
Multidimensional
• Different tools to measure different dimensions of
outcome
• Different tools to measure same dimension of
outcome
• Mono-measurement is a threat to validity of the
study
Psychometric Characteristics
• Reliability
• Validity
Statistics
•
•
•
•
Data and Analyses
• Statistical analysis planned met assumptions
• Do graphs and tables correlate with statistical report
Significance
• Statistical
• Clinical
Effect size
Qualitative:
• Themes and meaning elicited
• Saturation reached
Statistical tests
• Bivariate:
• t-test
• ANOVA
• Chi-Square
• Pearson’s r
• Multivariate
• MANOVA
• Multiple Regression
• Logistical Regression
Rigor
•
•
•
•
•
Striving for excellence in the research process
Uses discipline
Strict adherence to detail
Extremely accurate
Precision
• Control over confounding/extraneous/intervening variables that could
affect the dependent variable
• Effect size and Power
• Effect size = the magnitude of difference the intervention makes on
the outcome
• Maximize differences made by the independent variable
• Power is probability that a statistical test will detect a difference
Validity threats
•
Construct Validity
•
Internal Validity
•
External Validity
•
Statistical Conclusion Validity Threat
Internal validity
• Did the experimental treatment(s), and not some
extraneous variable, make the difference in this
specific experimental instance?
• Common Threats:
• Selection-Treatment interaction
• History
• Maturation
• Mortality/Attrition
• Fishing/Error rate
Random Controlled Trial (RCT):
Most Rigorous
Three areas required:
1. Randomization
• Random sample
• Random assignment to control and experimental
groups
• Difficult to obtain random sample in clinical setting
so most researchers use a convenience sample
with random assignment
2. Comparison or control group
3. Controlled manipulation of the treatment/
independent variable
Construct Validity
• Most often associated with measurements
• Key questions:
• What is the instrument measuring?
• Does it validly measure the abstract concept of
interest?
• Use both logical and empirical procedures to evaluate
• Use what is known to evaluate relationships in
variables
• Factor analysis – statistical method to identify clusters
of related items on a scale
Selection-Treatment Interaction
• Bias from pre-existing differences
• RCT helps control for this
• If not RCT, this is most significant threat to internal
validity
• Also an issue if many elect not to receive the
treatment
History
• Occurrence of events simultaneously with the
intervention/independent variable
• Not sure which one is causing the effects
• Controlled by RTC – both groups (experimental
and control) are affected by history
Mortality/Attrition
• Longitudinal studies may loose participants over time
• Those who drop out may be different from those that
continue
• Attrition bias is same as selection bias
• Higher rates of attrition pose great validity threats
Maturation
• Time causes effects rather than intervention
• Lots of issues we study are affected by time
• Coping
• Wound healing
• One-group before – after design is most
vulnerable
• Control: RCT – both groups affected
Fishing/Error rate
• If you keep evaluating enough variables,
something will be significant when really it is not
• Analysis of variables without any theoretical or
other support
• Outcomes report should match research
aims/questions
• Rates > 20% yield concerns about bias
Methodological Strengths
External Validity
•
Control of extraneous variables
• Degree to which you can apply findings of this study to
other settings and samples
•
Sample large enough
• Consider the characteristics of the study participants
•
Does the experimental design control for
competing influences = confounding variables
•
Experimental rigor
• Threats:
• Reliability of treatment implementation
• Statistical Regression
• Best control for threats is RCT design
Reliability of Treatment Implementation
• Described thoroughly enough?
• Were treatments consistent?
• Consistent person did all treatments
• Workshop training for those providing treatments
• Checks for consistency
Statistical Conclusion Validity
•
Affected by
• Sample size and Power
• Strength of intervention (independent variable)
• Strength of the outcomes (dependent variable)
• Were effects dependent on the person who
provided the treatment?
Conflicts for validity
Tight study for internal validity may make
the intervention not applicable to
the real world
Discussion, Author’s Conclusions and
General Recommendations
• Comparison with other findings discussed?
• Did author recognize threats and limitations of
study?
• Recommendations for improvements to
repeat study or to build on study results?
Conclusions
Generalizability
• Drawn from the findings
• Logical
• Infers that findings can be generalized from the
study sample to a broader group (i.e. population)
• Comparison with other findings discussed?
• If contradictory, explanations postulated?
• If consistent, next steps suggested?
• Important for evidence based practice to
determine if the findings of this study are
applicable to your interest group
• Generalized to other groups
• Limitations affect generalizability
• For example:
• Would findings from a study evaluating an
intervention for chronic pain be applicable for
post-operative pain management?
Conclusions, Implications and
Recommendations
• Was the study rigorous enough?
• Can I apply the findings to my practice
and EBP questions?
• Is further research needed to answer my
EBP question?
PRACTICE, PRACTICE, PRACTICE
How to Understand Research: Strategies for Reviewing a Research Article
Bernice D. Mowery, PhD, PNP, RN
References
Boswell, C., & Cannon, S. (2011). Introduction to nursing research: Incorporating
evidence-based practice (2nd ed.). Sudbury, Mass: Jones and Bartlett Publishers.
Coughlan, M., Cronin, P., & Ryan, F. (2007). Step-by-step guide to critiquing research.
Part 1: Quantitative research. British Journal of Nursing, 16(11), 658-663.
Fain, J. A. (2009). Understanding and applying nursing research (3rd ed.). Philadelphia: F.
A. Davis Co.
Grove, S. K., Burns, N., & Gray, J. R. (Eds.) (2013). The practice of nursing research:
Appraisal, synthesis, and generation of evidence (7th ed). China: Elsevier.
Hulley, S. B., Cummings, S. R., Browner, W. S., Grady, D., Hearst, N., & Newman, T.
B. (2001). Designing clinical research (2nd ed.). Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins.
Joint Program in Knowledge Translation (2012). Center for Evidenced-Based Medicine.
The KT Clearinghouse Website. Retrieved from
http://ktclearinghouse.ca/cebm/syllabi/nursing/intro.
Kraemer, H. C. (2010). Evaluation of comparative treatment trials: Assessing clinical
benefits and risks for patients, rather than statistical effects on measures. JAMA.
304(6), 683-684.
Mateo, M. A., Kirchhoff, K. T. (Eds.) (2009). Research for advanced practice nurses:
From evidence to practice. New York: Springer Publishing Company.
Melnyk, B. & Fineout-Overholt, E. (2005). Making the case for evidenced-based
practice. In B. Melnyk, & E. Fineout-Overholt (Eds.), Evidenced-based practice
in nursing and healthcare: A guide to best practices (pp 3 – 24). Philadelphia:
Lippincott Williams and Wilkins.
McLaughlin, M. M. K., & Bulla, S. A. (2010). Real stories of nursing research: The quest
for Magnet recognition. Sudbury, Mass: Jones and Bartlett Publishers.
Norwood, S. L. (Ed.) (2010). Research essentials: Foundations for evidence-based
practice. Boston: Pearson Education, Inc.
1
Polit, D. F., & Beck, C. T. (2010). Nursing research: Appraising evidence for nursing
practice (7th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins.
Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence
for nursing practice (9th ed.). Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins.
Ryan, F., Coughlan, M., & Cronin, P. (2007). Step-by-step guide to critiquing research.
Part 2: Qualitative research. British Journal of Nursing, 16(12), 738-744.
Trochim, W. M. (2012). The Research Methods Knowledge Base, 2nd Edition.
Retrieved from http://www.socialresearchmethods.net/kb.
2
Research Article Review Form
Bernice D. Mowery, PhD, PNP, RN
Article Information:
COMPONENT
Clarity of the problem &
Significance for nursing
Aims/Research ?s/Hypotheses
Conceptual/Theoretical Framework
Literature Review
Type of Study: Quantitative;
Qualitative or Mixed Method
Study Design/Methodology
• Quantitative: Experimental,
Quasi-experi, Non- experi
• Qualitative: Grounded theory,
Phenomenology, Ethnography
Ethical considerations
Procedures: Operational Definitions
Study Population/Sample: Types of
participants/subjects
• Number of subjects
• Gender, Race, Age Group
• Setting
• Sampling Method
Interventions Studied
• Intervention or Exposure
or Treatment
• Outcomes
Mode of Measurement
• Psychometric Characteristics
• Multidimensional
Attrition/Withdrawals for adverse
reactions
Findings/Results
• Data Analysis/Themes
• Scoring
• Significance
• Effect Size
Validity Threats
• Construct Validity
• Internal Validity
• External Validity
• Statistical Conclusion Validity
Threat
Methodological Strengths
Limitations/Weaknesses
Authors’ Conclusions and General
Comments
Conclusions:
COMMENTS
Continuing Nursing Education
Objectives and instructions for completing the evaluation can be found on page 171.
Relationship Between Knowledge,
Attitudes, and Self-Efficacy of Nurses
In the Management of Pediatric Pain
Mercedes Stanley, Deborah Pollard
P
ain management is a very important aspect of nursing care
of the pediatric patient. According to the International
Association for the Study of Pain
(IASP), Special Interest Group on Pain
in Childhood (2005), pain relief is a
human right. Since 2001, pain management standards require that providers be educated in the assessment
and management of pain, and that
they recognize the right of patients to
appropriate assessment and management of pain (Joint Commission of
Accreditation of Healthcare Organizations, 1999; The Joint Commission,
2011). Pain is a subjective experience
and can only be judged by the patient
experiencing it (McCaffrey & Pasero,
1999). Pain in children is a subjective
experience that “has sensory, emotional, cognitive, and behavioral components that are interrelated with
environmental, developmental, sociocultural, and contextual factors,” and
is often considered inadequately
assessed and undertreated (American
Academy of Pediatrics [AAP] &
American Pain Society [APS], 2001, p.
793). The role of the nurse in pain
management encompasses the entire
nursing process. The nurse assesses for
the presence of pain, plans pharmacological and non-pharmacological pain
management strategies with the medical team, implements the plan, and
evaluates the effectiveness of the
interventions (American Nurses Association [ANA], 2001).
Mercedes Stanley, BSN, RN, is a Pediatric
Staff Nurse, Novant Health, Hemby Children’s
Hospital, Charlotte, NC.
Deborah Pollard, PhD, RNC, CNE, is
Associate Professor, University of North
Carolina Wilmington, Wilmington, NC.
Statements of Disclosure: Please see page
171 for statements of disclosure.
Pain management is a very important aspect of nursing care of the pediatric
patient. A nurse’s knowledge and attitude can affect his or her ability to adequately provide pediatric pain management. This study examined the level of knowledge of pediatric pain management, the attitudes of nurses, and the level of selfefficacy of pediatric nurses in acute care. In addition, the relationship between
the years of experience and the levels of knowledge, attitudes, and self-efficacy
were examined. A cross-sectional, correlational design was used in a convenience, non-probability sample of 25 pediatric nurses. Nurses volunteering to participate in the study were asked to complete two instruments: Pediatric Nurses’
Knowledge and Attitudes Survey Regarding Pain (PNKAS-Shriners Revision)
(Manworren, 2000, 2001) and Nurses’ Self-Efficacy in Managing Children’s Pain
(Chiang, Chen, & Huang, 2006). There was no statistically significant relationship
between knowledge and self-efficacy (r = 0.039, p = 0.853) or knowledge and
years of nursing experience (r = 0.050, p = 0.822). There was a statistically significant relationship between the level of knowledge and the years of pediatric
experience (r = 0.404, p = 0.05) and knowledge and the membership in a professional nursing organization (t = 4.050, p = 0.004). Years of pediatric nursing
experience correlated with significantly higher knowledge levels, as did a membership in a professional nursing organization. Further, education may benefit
pediatric nurses in regard to their management of pediatric pain. Research is
needed to examine the effects of self-efficacy on pediatric pain management and
how it relates to the level of knowledge.
Far too often, pediatric pain goes
undertreated. Although increased effort has been placed into pain management improvement over the last
decade, research shows that up to 81%
of hospitalized children report moderate to severe levels of pain (Pölkki,
Pietilä, & Vehviläinen-Julkunen, 2003)
and that nurses administer only 23%
to 43% of analgesics ordered (Jacob &
Puntillo, 1999; Vincent & Denyes,
2004). Walco, Cassidy, and Schechter
(1994) found that there are six main
barriers to treatment of pain in children: 1) the myth that children do not
feel pain the way adults do; 2) lack of
assessment and reassessment for the
presence of pain; 3) misunderstanding
of how to conceptualize and quantify
a subjective experience; 4) lack of
knowledge of pain treatment; 5) the
notion that addressing pain in children takes too much time and effort;
and 6) fears of adverse effects of analgesic medications, including respirato-
PEDIATRIC NURSING/July-August 2013/Vol. 39/No. 4
ry depression and addictions. The researchers go on to say that the health
care team’s personal values and beliefs
about the meaning and value of pain
greatly affect the use of pain treatments. For example, 55% to 90% of
nurses believe that children overreport their pain (Manworren, 2000).
The purpose of this study was to
examine the level of knowledge of
pediatric pain management, the attitudes of nurses, and the level of selfefficacy of a group of pediatric nurses
in North Carolina.
Theoretical Framework
The theoretical framework guiding
this study is the concept of self-efficacy as developed by Bandura’s Social
Cognitive Learning Theory. Bandura
(1994) defined self-efficacy as a person’s belief in his or her capability to
successfully perform a specific task.
Self-efficacy is different than self-con165
Relationship Between Knowledge, Attitudes, and Self-Efficacy of Nurses in the Management of Pediatric Pain
fidence in that it is much more specific, and it changes more quickly. Further, just because one’s self-efficacy is
high in one area does not mean that
it is high in every area (Heslin &
Klehe, 2006).
According to Bandura (1994), selfefficacy is affected through four main
psychological processes: cognitive,
motivational, affective, and selection.
These processes shape a person’s view
of their abilities and efficacy. There
are three central sources of self-efficacy: enactive self-mastery, role-modeling, and verbal persuasion. Enactive
self-mastery is by far the most powerful source of gaining or losing self-efficacy and is experienced through situations that provide many opportunities to succeed and few opportunities
to fail (Heslin & Klehe, 2006). For
example, regarding pediatric pain
management, a new pediatric nurse
would be given the ability to assess
and treat pain under the instruction
of an experienced nurse multiple
times before ever assessing or treating
the pain on his or her own.
Role-modeling would be experienced by watching the practiced
nurse give pain medications on a regular basis. This allows novices to picture themselves in the situation and
to visualize being successful. From
this source, it is important that the
role-model be willing to accept setback as a normal part of learning and
continue to be persistent in the development of skill. Verbal persuasion is
mixed between positive self-talk and
words of encouragement and praise
from managers and others who have
the ability to approve of skill (Heslin
& Klehe, 2006).
In this study, the relationship
between knowledge and self-efficacy
was examined. By receiving coaching
and by participating in pain management, nurses should have gained
knowledge through enactive self-mastery. Based on Bandura’s Social Cognitive Learning Theory, increased
knowledge should play a role in
increased self-efficacy for these nurses.
Review of the Literature
els of pain. The nurse must be aware
of the different methods to evaluate
pain: physiologic, self-report, behavioral, and parent input (Merkel &
Malviya, 2000).
Physiologic indicators of acute
pain include an increase in heart rate,
blood pressure, or respirations. Numerous self-report tools are available for
almost every age group and level of
development. Because self-report is
considered the golden standard for
pain assessment, it is necessary that it
be obtained as much as possible and
that there are reliable tools to measure
it (Merkel & Malviya, 2000).
Tools available for self-report
include Hester’s Poker Chip tool, the
Oucher Scale, the Wong-Baker FACES
Scale, the Visual Analog Scale (VAS),
and the Finger Span Scale. When selfreport is not attainable, the nurse
should use a behavioral scale. This is
more often used for preterm and fullterm infants who are unable to communicate. The Face, Legs, Activity,
Cry, and Consolability (FLACC) Scale,
the Premature Infant Pain Profile
(PIPP), the Toddler-Preschooler Pain
Scale (TPPPS), and the Preverbal, Early
Verbal Pediatric Pain Scale (PEPPS) are
all behavior tools that have shown
effectiveness in behavioral pain assessment. Lastly, asking the parents of
the child the usual pain responses of
their child may be beneficial. Each
method has strengths and weaknesses, and it is important that the nurse
uses them in conjunction with each
other (Merkel & Malviya, 2000).
Although numerous reliable tools
are available for nurses to use in pediatric pain management, many nurses
do not use them. In a study performed
by Simons and MacDonald (2004),
nurses’ views were explored concerning
children’s pain tools. The researchers
found that even though these nurses
were treating pain, they did not necessarily use any pain tool. The nurses felt
they were not knowledgeable enough
about the tools to use them properly.
They believed proper instruction on
the tools would not only aid in their
care of the child in pain, but it would
also help in their documentation
(Simons & MacDonald, 2004).
Pain Assessment in Children
Barriers to Pain Assessment
Many tools have been created in
the effort to aid nurses in the correct
pain assessments of their pediatric
patients. Pain is a subjective phenomenon, but young children are often
not able to properly express their lev-
As mentioned, self-report is considered the gold standard for pain
assessment, yet a study of 20 nurses
found that only 65% of the group
relied on patient self-report as the
most important indicator for pedi-
166
atric pain (Vincent, 2007). Other findings conclude that even though much
importance is attributed to correct
pain management, it is not enough to
motivate nurses to improve in this
area. Because many nurses know that
some pain should be expected in
many situations, it is not abnormal
for a child to report a certain level of
pain. This study urges the importance
of exploring nurses’ attitudes and
beliefs toward pediatric pain management (Twycross, 2008).
A qualitative study of 21 nurses
concluded that a barrier to pain management is a lack of education about
pain assessment. Nurses reported that
if they were better prepared and
understood children’s pain behavior
better, they would be able to manage
it more effectively (Gimbler-Berglund,
Ljusegren, & Enskär, 2008). Not only
are nurses often undereducated on
pain management, Rieman and
Gordon (2007) identified that those
who are educated do not consistently
carry out proper pain management
techniques. In a study of 295 registered nurses (RNs), a weakness most
nurses reported was the understanding of pharmacology and its effects on
the respiratory system. Specifically,
many nurses reported a fear of respiratory depression in their pediatric
patients (Rieman & Gordan, 2007).
The AAP and APS (2001) concur
that even though there is sufficient
knowledge supporting the correct
ways to treat pediatric pain, it is not
universally applied. In opposing literature, a descriptive study by Griffin,
Polit, and Byrne (2008) surveyed a
convenience sample of 334 registered
nurses in the United States and concluded that appropriate treatment is
generally given to pediatric patients.
The authors of the study clarify that
the surveys consisted of vignettes and
did not necessarily accurately portray
the clinical setting. They identified
overall barriers as nurses’ attitudes
toward pain management, the lack of
knowledge, and the lack of a universally applied method for pain assessment and management. In addition,
barriers related to work security, time
constraints, inconsistencies in practice, and perceived lack of power by
nurses may impact their ability to
promote effective pain management
(Ellis et al., 2007; Ely, 2001).
Nurses’ Knowledge of Pain
Management
Inadequate pain management has
PEDIATRIC NURSING/July-August 2013/Vol. 39/No. 4
been shown to affect patient outcomes by potentially increasing hospital length of stay and delaying
recovery (Schechter, Berde, & Yaster,
2003); thus, the management of pain
has major implications for nursing. A
nurse’s knowledge and attitude can
affect his or her ability to adequately
provide pediatric pain management.
In one study by Rieman and Gordon
(2007), although the level of knowledge of pediatric pain management
did not differ significantly based on
education preparation, nurses with
more than two years of experience or
who participated in continuing education courses had significantly higher knowledge and attitude scores
regarding pediatric pain management.
Schechter (2008) noted that even
in nurses with the best intentions,
gradual erosion of the level of attention to pain is often inevitable in the
face of increasing patient volume, frequent understaffing, and continued
resource limitations. Faced with these
challenges, it is important to identify
the knowledge, attitudes, and confidence of pediatric staff and address
these barriers through planned educational activities. Without an acknowledgement of ownership in each
nurse, any pain management technique will not be complete (Schechter,
2008).
This review of the research literature demonstrates some common
limitations in the literature, such as
the use of convenience samples, small
samples sizes (less than 20 participants), and an unequal set of demographics. A limited set of studies depicted strengths, including larger sample
sizes, national random samples, and
pre- and post-test evaluations.
Research clearly points toward the
importance of correct pediatric pain
management. It is imperative that
nurses be knowledgeable in the area,
and forceful steps should be taken to
remove barriers in the clinical setting.
Although studies have noted that
knowledge and attitudes may affect
pediatric pain management, the relationship between the two and selfefficacy has not been examined.
Methodology
Design
A cross-sectional, correlational
design was used in a convenience,
non-probability sample of pediatric
nurses in two regional hospitals in
North Carolina. Following Institutional Review Board approval, nurses
meeting the following inclusion criteria were invited to participate in the
study: registered professional nurses
and currently employed on a pediatric acute care unit. Nurses volunteering to participate in the study
were asked to complete two research
instruments: the Pediatric Nurses’
Knowledge and Attitudes Survey Regarding Pain (PNKAS-Shriners Revision)
(Manworren, 2000, 2001) and Nurses’
Self-Efficacy in Managing Children’s
Pain (Chiang, Chen, & Huang, 2006).
Pediatric Nurses’ Knowledge and
Attitudes Survey Regarding Pain (PNKASShriners Revision) (Manworren,
2000, 2001). This survey includes 40
questions measuring knowledge and
attitudes in managing pediatric pain.
The survey has an acceptable level of
stability with a test-restest reliability
of 0.67 and an acceptable level of internal consistency with a Cronbach’s
alpha of 0.72 to 0.77. Content validity was established by five national
content experts in pediatric pain
(Manworren, 2001). The Cronbach’s
alpha for this study was 0.82.
Nurses’ Self-Efficacy in Managing
Children’s Pain (Chiang et al.,
2006). This survey includes six questions addressing self-efficacy in pediatric pain management. The survey has
high internal consistency (Cronbach’s
alpha 0.88 at pre-test and 0.91 at posttest), and content validity was established by a panel of three pediatric
experts (Chiang et al., 2006). The
Cronbach’s alpha for this study was
0.81.
Procedure
Surveys were distributed in the
mailboxes of pediatric nurses at both
hospitals. Brochures were made and
distributed with the surveys and
placed throughout the units inviting
the nurses to join the study. A locked
drop-box was placed in the manager’s
office to ensure confidentiality for the
returned surveys. The study was presented to the nurses at their staff
meetings and through multiple
e-mails, and a candy bowl was located
at the lock-box as an incentive and
thank you to the participants. The
data collection period for the study
was four weeks from the time the
brochures were distributed until the
due date for the completed surveys.
Participants were given four weeks for
survey completion. A total of 60 in-
PEDIATRIC NURSING/July-August 2013/Vol. 39/No. 4
strument packets were delivered to
staff, and 26 were returned for a
return rate of 43.3%. One packet was
incomplete, and thus, not used in the
statistical analysis.
Data Analysis
All statistical data were analyzed
using the Statistical Package for the
Social Sciences (SPSS), Version 18.
Descriptive and inferential statistics
were used to describe and synthesize
the data. Frequencies, percentages,
ranges, means, and standard deviations were used for the demographic
variables and to describe the scores on
the study variables. The Pearson correlation was used to examine any relationships between the study variables.
The t-test was used to measure differences between the mean scores on the
study variables of level of knowledge
and level of self-efficacy to examine
any differences between comparison
groups. The level of significance set
for the study was p < 0.05.
Findings
Sample Characteristics
Twenty-five nurses (N = 25) participated in the study. Thirteen nurses (n
= 13) participated from a regional hospital in western North Carolina
(Hospital 1) and 12 nurses (n = 12)
participated from a regional hospital
in southeast North Carolina (Hospital
2). As shown in Table 1, the mean age
of the participants was 36.64 years
(Range = 22 to 58 years, SD = 9.21).
The mean number of years since nursing graduation was 9.39 years. The
years of nursing experience averaged
10.17 years, and pediatric nursing
experience was 7.92 years. The respondents estimated they spent an
average of 59.44% of their time caring
for patients in pain.
The majority of the participants
were female (92%), worked full time
(84%), and had an associate degree in
nursing (52.4%); others had a bachelor’s degree (42.9%), and one had a
diploma in nursing (4.8%). Of the
respondents, 56% served on a nursing
committee, 12% were a member of a
professional nursing organization,
and they reported reading an average
of 0.67 professional journals monthly.
Research Question 1:
Level of Knowledge
The PNKAS was used to measure
the level of knowledge of the pediatric
167
Relationship Between Knowledge, Attitudes, and Self-Efficacy of Nurses in the Management of Pediatric Pain
Table 1.
Characteristics of the Sample (N = 25)
Variable
Range
Mean
SD
Age
22 to 58
36.64
9.214
Years Since Nursing Graduation
1 to 30
9.39
8.038
Years of Nursing Experience
1 to 30
10.17
7.772
Years of Pediatric Experience
Estimated Percentage of Day Spent Caring for Patients in Pain (%)
1 to 30
7.92
7.265
10 to 100
59.44
29.670
0 to 3
0.67
0.868
Number of Professional Journals Read Monthly
Frequency
Gender
Male
2
(8.0%)
23
(92.0%)
1
(4.8%)
11
(52.4%)
9
(42.9%)
0.8 to 1.0 FTE
21
(84.0%)
0.5 to 0.7 FTE
4
(16.0%)
Female
Degree
Diploma
AD
BSN
Full-Time Status
Registered Nurse
25 (100.0%)
Currently Providing Nursing Care
24 (100.0%)
Member of a Professional Organization
22
(88.0%)
Serves on a Nursing Committee
14
(56.0%)
nurses. As shown in Table 2, the total
mean of PNKAS was 26 (maximum
score = 39), indicating that the participants answered an average of 66.6%
of the questions correctly. Between the
two groups, nurses at Hospital 1 (n =
13) scored significantly higher on the
PNKAS than the nurses at Hospital 2
(n = 12) (t = 2.044, p = 0.05).
Table 2.
Level of Knowledge of Pediatric Nurses
Group
% Correct
Mean PNKAS
SD
Hospital 1
69.0%
27.08
2.90
t = 2.044
Hospital 2
63.6%
24.83
2.58
p = 0.050
All
66.6%
26.00
2.93
Research Question 2:
Level of Self-Efficacy
The Nurses’ Self-Efficacy in Managing Children’s Pain (SET) tool was
used to measure the level of self-efficacy of pediatric nurses. As shown in
Table 3, the total mean on the SET
was 26.28 (maximum score = 30),
indicating that overall, the participants had a high level of self-efficacy
in regard to pediatric pain management. There was no statistically significant difference between the two
groups (t = -1.054, p = 0.303).
Research Question 3:
Correlation Between Years
Of Experience, Knowledge,
And Self-Efficacy
Pearson correlation analysis did
not reveal a statistically significant
168
t-Score
Table 3.
Level of Self-Efficacy of Pediatric Nurses
Group
Mean SET
SD
I-Score
Hospital 1
25.69
3.093
t = -1.054
Hospital 2
26.92
2.712
p = 0.303
All
26.28
2.923
relationship between the level knowledge and years of nursing experience
(r = 0.050, p = 0.822) or the level of
knowledge and the self-efficacy score
(r = 0.039, p = 0.853). As shown in
Table 4, there was also no statistically
significant relationship between the
level of self-efficacy and the years of
nursing experience (r = -0.171, p =
0.425) or the level of self-efficacy and
the years of pediatric nursing experience (r = 0.031, p = 0.885). However,
the analysis did show a statistically
significant positive relationship between the level of knowledge and the
years of pediatric nursing experience
(r = 0.404, p = 0.05). Nurses with more
years of pediatric experience scored
higher on the PNKAS.
PEDIATRIC NURSING/July-August 2013/Vol. 39/No. 4
Table 4.
Correlation Between Years of Experience, Knowledge,
and Self-Efficacy
Variables
PNKAS and Years of Nursing Experience
PNKAS and Years of Pediatric Nursing Experience
SET and Years of Experience
SET and Years Pediatric Nursing Experience
PNKAS and SET
Test Statistic
r = 0.050
r = 0.404
r = -0.171
r = 0.031
r = 0.039
p-Value
p = 0.822
p = 0.050
p = 0.425
p = 0.885
p = 0.853
Figure 1.
Level of Knowledge and Self-Efficacy Related to Degree Held
28
27
25
24
27.27
27.00
26
25.36
25.33
PNKAS
AD
BSN
SET
Table 5.
Top 11 Questions Answered Correctly by Nurses
% Correct
Question [Correct Answer]
96.2
Observable changes in vital signs must be relied upon to verify a
child’s/adolescent’s statement that he has severe pain. [False]*
96.2
The child/adolescent should be advised to use non-drug techniques
alone rather than concurrently with pain medications. [False]
92.3
Comparable stimuli in different people produce the same intensity of
pain. [False]
92.3
Giving children/adolescents sterile water by injection (placebo) is often
a useful test to determine if the pain is real. [False]*
88.5
88.5
88.5
Infants/children/adolescents may sleep in spite of severe pain. [True]*
Parents should not be present during painful procedures. [False]
The child/adolescent with pain should be encouraged to endure as
much pain as possible before resorting to a pain relief measure. [False]
88.5
Children less than 8 years cannot reliably report their pain intensity, and
therefore, the nurse should rely on the parents’ assessment of the
child’s pain intensity. [False]
88.5
After the initial recommended dose of opioid analgesic, subsequent
doses should be adjusted in accordance with the individual patient’s
response. [True]
88.5
The recommended route of administration of opioid analgesics to
children with brief, severe pain of sudden onset (e.g. trauma or
postoperative) pain is: [intravenous].*
88.5
The most likely explanation for while a child/adolescent with pain would
request increased doses of pain medication is: [The child/adolescent is
experiencing increased pain.]
Note: Due to a tie in numbers, 11 questions are reported here.
*There were four questions on this list not reported in the top 10 questions answered
correctly by nurses completing the PNKAS
Source: Copyright 2002 Shriners Revision. From Rieman & Gordon, 2007. Used with
permission.
PEDIATRIC NURSING/July-August 2013/Vol. 39/No. 4
Additional Findings
Although not statistically significant, nurses with an associate degree
(AD) had a lower knowledge but a
higher level of self-efficacy than nurses with a bachelor’s degree (BSN) (t =
-1.212, p = 0.245), as shown in Figure
1. In reverse, nurses with a BSN had a
higher level of knowledge but a lower
level of self-efficacy (t = 1.526, p =
0.150). This may be that increased
education allows recognition of
knowledge deficits. There was a statistically significant difference between
groups of nurses who either participated or who did not participate in
professional organizations. Nurses
who participated in professional
organizations scored higher on the
PNKAS (t = 4.050, p = 0.004).
As in previous studies, the strengths
and weaknesses of the nurses in
regard to knowledge of pain management were acknowledged by identifying the top 11 questions answered
correctly (see Table 5) and the top 10
questions answered incorrectly (see
Table 6) by the nurses who took the
PNKAS.
Discussion
The overall purpose of this study
was to assess the relationship between
knowledge and self-efficacy of pain
management for pediatric nurses.
Although no relationship was found
between the level of pediatric pain
knowledge and the level of self-efficacy, it is important to note that practicing pediatric nurses may feel a high
level of self-efficacy without the corresponding high level of knowledge in
regard to pain management. Feeling
overly confident could potentially be
dangerous to patients in need of pain
management.
The findings of this study were
mostly consistent with findings of
Rieman and Gordon (2007) regarding
the level of knowledge of pediatric
pain management. A range from 53.8
to 82% on the PNKAS may suggest a
need for increased education for pediatric nurses. Patients have a right to
receive adequate pain assessment and
management, and it is important for
hospitals to be aware of their nurses’
abilities to perform these tasks.
Also noted was that the years of
nursing experience did not demonstrate a relationship with the level of
pain management knowledge or selfefficacy. However, the years of pediatric experience demonstrated a posi169
Relationship Between Knowledge, Attitudes, and Self-Efficacy of Nurses in the Management of Pediatric Pain
Table 6.
Top 10 Questions Answered Incorrectly by Nurses
% Incorrect
Question [Correct Answer]
96.2
Acetaminophen 650 mg PO is approximately equal in analgesic
effect to codeine 32 mg PO. [True]
80.8
Respiratory depression rarely occurs in children/adolescents who
have been receiving opiods over a period of months. [True]
76.9
A child with background (continuous, persistent) pain has been
receiving daily opioid analgesics for 2 months. The doses increased
during this time period. Yesterday the 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 [less than 1%].
76
What do you think is the percentage of patients who over report the
amount of pain they have? [0 or 10%]*
73.1
Beyond a certain dosage of morphine, increases in dosage will
NOT provide increased pain relief. [False]
73.1
Which of the following drugs are useful for treatment of pain in
children? [All of the above – Ibuprophen, morphine, amitriptyline]
73.1
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 physiological changes of tolerance to analgesia or
physical dependence (withdrawal).
Using this definition, how likely is it that opioid addiction will occur
as a result if treating pain with opioid analgesics? [Less than 1%]*
61.5
Research shows that promethazine (Phenergan®) is a reliable
potentiator of opioid analgesics. [False]
61.5
Which of the following analgesic medications is considered the drug
of choice for the treatment of prolonged moderate to severe pain in
children? [Morphine]
61.5
Patient A: Andrew is 15 years old, and this is his first day following
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.
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. [8]*
*There were three questions on this list not reported in the top ten questions answered
incorrectly by nurses completing the PNKAS.
Source: Copyright 2002 Shriners Revision. From Rieman & Gordon, 2007. Used with
permission.
tive relationship to knowledge but
not self-efficacy. Nurses generally reported a high level of self-efficacy but
scored lower than comparison studies
on knowledge of pain management.
Limitations to this study included
the small sample size (N = 25) that the
respondents were from only two hospitals, and the education provided for
nurses on pain management and the
presence of pain management protocols was not considered. Respondents
170
were self-selected and may relate to
their interest in pain management.
Therefore, those who had little to no
interest in pain may not have taken
the survey, indicating that the actual
level of knowledge may be much
lower than what was found. Further,
the PNKAS does not correlate to actual clinical practice, and consequently,
may not identify actual clinical abilities (Manworren, 2000; Rieman &
Gordon, 2007).
With the level of knowledge being
lower than deemed acceptable by
most nursing standards (less than
85%), further research should be conducted to verify these low levels in
regard to pediatric pain management.
Continued validity of the PNKAS and
SET tool is imperative, as is the need
for potential other tools used to assess
the level of knowledge and the level
of self-efficacy. In regard to the level
of self-efficacy, it is important that
nurses are not overly confident in
their abilities to assess and treat pain.
Education on pediatric pain management would be suggested for pediatric units. Nurses are continually
faced with the challenge of treating
pain, and to ensure the best quality of
care for patients, nurses need effective
knowledge, skills, and attitudes to
address pediatric pain needs. To meet
nurses’ educational needs, it is essential to provide ongoing education that
focuses on their individual needs and
is provided in a method of delivery
that is receptive to and effective for
the practicing nurse. Further research
should also focus on the implementation of pediatric pain education programs and their effectiveness. There is
a need for continued examination on
the effects of self-efficacy in pediatric
pain management and how it relates
to the level of knowledge.
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Instructions For
Continuing Nursing Education
Contact Hours
Relationship Between
Knowledge, Attitudes,
And Self-Efficacy of Nurses
In the Management of Pediatric
Pain
Deadline for Submission:
August 31, 2015
PED 1306
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Goal
To provide an overview of knowledge,
attitudes, and self-efficacy of nurses and
their relationship to the management of
pediatric pain.
Objectives
1. Explain the importance of pain
management in the nursing care of the
pediatric patient.
2. Discuss the relationship between the
years of nursing experience and the
levels of knowledge, attitudes, and selfefficacy in relation to pediatric pain
management.
Statements of Disclosure: The author
reported no actual or potential conflict of
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This article was reviewed and formatted for
contact hour credit by Hazel Dennison, DNP,
RN, APNc, CPHQ, CNE, Anthony J. Jannetti
Education Director; and Judy A. Rollins, PhD,
RN, Pediatric Nursing Editor.
PEDIATRIC NURSING/July-August 2013/Vol. 39/No. 4
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