Knowledge and attitudes toward pediatric pain management among nursing interns from a selected university in Riyadh, Saudi Arabia: a descriptive cross-sectional quantitative study

Introduction

As one of the key symptoms of many health conditions, pain can be experienced for a variety of etiological reasons. Pain negatively affects individuals’ social life, physical and mental health, and overall quality of life. It is a considerable source of distress for children and their families, as well as health-care workers. Surgery, trauma, acute and chronic illnesses, and medical or surgical treatments can all cause pain. Although pain affects individuals of all ages, it can have long-term physiological, psychosocial, and behavioral effects on children if untreated (Gadallah, Hassan & Shargawy, 2017).

Dezfouli & Khosravi (2020) observed that treating pain in children can be challenging, considering the need to minimize opioid use to avoid their adverse effects. However, a variety of pharmacologic and nonpharmacologic pain management options are available for children who experience acute and chronic pain. For example, nociceptive and neuropathic pain can be targeted by opioids and opioid-sparing medicines. Thus, the early use of a combination of pharmacological and integrative nonpharmacological pain management options is crucial for the treatment of pediatric pain.

Nurses are in a unique position to effectively diagnose and manage pediatric pain because they constitute the majority of health-care workers and spend the most time interacting with children and their families during hospitalization (Alotaibi, 2019). However, unresolved pediatric pain remains an issue due to a lack of information and prevailing attitudes toward its management among most health-care professionals, including nurses. Therefore, nurses and other health-care workers must have sufficient information and positive attitudes to enhance the assessment and management of pediatric pain. As core members of health-care teams, nurses play a vital role in the assessment and management of pain.

Pediatric nursing is included in the undergraduate nursing curriculum as a whole, which makes learning about pain management difficult. Mediani, Windiany & Maryam (2020) found that undergraduate nursing students have insufficient knowledge about and poor attitudes toward pain assessment and treatment in children, which influences their provision of pediatric nursing care. In providing improved pain management outcomes for their pediatric patients, nurses should ideally become change agents in their hospitals. If nursing students are not well versed in pediatric pain and its management, they will not be able to appropriately relieve the pain experienced by their pediatric patients. Thus, nursing students should have adequate knowledge about pain assessment and management in pediatric patients and should endeavor to improve their pain management practices by collaborating with other health-care professionals. Furthermore, nursing students must understand how to develop positive attitudes toward pain management and apply their knowledge in a clinical setting while studying in their undergraduate nursing programs. Pediatric patients experiencing pain will suffer if nursing students lack the necessary information and training to adequately assess and manage pediatric pain. Therefore, nursing students must gain a thorough understanding of pain and how to manage it while completing their undergraduate nursing programs.

Materials and Methods

Statistical analysis

The data were coded and analyzed using the Statistical Package for the Social Sciences (SPSS) for Windows (v. 21.0; IBM SPSS, Armonk, NY, USA). Tables 1–4 and a bar chart (Fig. 1) were developed to organize the data collected from each question, including descriptive statistics for frequency, percentage, mean, and standard deviation (SD). The r value was used as a measure of association. The frequency and percentage distributions were used to summarize and organize the respondents’ demographic profiles, academic performance, areas of work, and levels of knowledge and attitudes toward pediatric pain management. No missing data and no questions received more than one response from any of the participants.

Table 1:

Frequency and percentage distribution of the nursing students according to their demographic profiles.

Profile	Frequency	Percentage
Age (years)
18–20	2	1.7
21–23	109	91.6
24–25	8	8.6
Marital status
Single	109	91.6
Married	10	8.4
GPA
2.00–2.74	1	0.8
2.75–3.74	6	5.0
3.75–4.49	83	69.7
4.50–5.00	29	24.4
Clinical area
Pediatric unit	23	19.3
Non-pediatric unit	96	80.7

DOI: 10.7717/peerj.19288/table-1

Table 2:

Frequency and percentage distribution of knowledge and attitudes toward pediatric pain management (mean = 36.59, SD = 13.02).

Grade	Performance level	Frequency	Percentage
75–100	Good	3	2.5
51–74	Average	13	10.9
≤50	Poor	103	86.5

DOI: 10.7717/peerj.19288/table-2

Table 3:

Top 10 correctly answered test items.

Knowledge and attitude test items	Freq	% age
1. Item 22. After the initial recommended dose of opioid analgesic, subsequent doses should be adjusted in accordance with the individual patient’s response.	96	80.7
2. Item 8. Children who require repeated painful procedures (eg, 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.	89	74.8
2. Item 11. Combining analgesics (eg, acetaminophen and topical anesthetics) with non-drug therapies (eg, sucrose and nonnutritive sucking) that work via different mechanisms may result in better pain control with fewer side effects than using a single analgesic agent.	89	74.8
4. Item 30. Analgesics for postoperative pain should be given initially.	80	67.2
5. Item 5. Comparable stimuli produce the same intensity of pain in different people.	73	61.3
6. Item 20. Based on one’s religious beliefs, a child/adolescent may think that pain and suffering are necessary.	69	58.0
7. Item 32. Analgesia should be given for chronic cancer pain.	67	56.3
8. Item 14. Parents should not be present during painful procedures.	65	54.6
8. Item 18. A child/adolescent with pain should be encouraged to endure as much pain as possible before resorting to a pain relief measure.	65	54.6
10. Item 10. Acetaminophen 650 mg orally is approximately equal to codeine 32 mg orally in analgesic effect.	64	53.8

DOI: 10.7717/peerj.19288/table-3

Table 4:

Top 10 incorrectly answered test items.

Knowledge and attitude test items	Freq	% age
1. Item 26. The recommended route of administration of opioid analgesics to children with prolonged cancer-related pain.	108	91.0
2. Item 40. Your assessment above was made 2 h 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 identified 2 as an acceptable level of pain. His physician’s order for analgesia was “morphine IV 1–3 mg 1 h PRN pain relief.” Check the action you would take at this time.	105	88.2
3. Item 7. Evidence-based non-drug interventions are effective for mild–moderate pain control but are rarely helpful for more severe pain.	96	80.7
4. Item 1. Observable changes in vital signs must be relied upon to verify a child’s/adolescent’s statement that they have severe pain.	95	79.8
4. Item 15. Adolescents with a history of substance abuse should not be given opioids for pain because they are at a high risk of addiction loop.	95	79.8
6. Item 42. Your assessment above was made 2 h after he received morphine 2 mg IV. After he received 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 identified 2 as an acceptable level of pain. His physician’s order for analgesia was “morphine IV 1–3 mg 1 h PRN pain relief.” Check the action you would take at this time.	93	78.2
7. Item 31. A child with chronic cancer pain has been receiving daily opioid analgesics for 2 months. The doses gradually increased during this period. Yesterday, the child received morphine 20 mg/h intravenously. Today, he has been receiving 25 mg/hour intravenously for 3 h. The likelihood that the child will develop clinically significant respiratory depression is as follows:	91	76.5
7. Item 36. Which of the following describes the best approach for cultural considerations in caring for a child/adolescent in pain?	91	76.5
9. Item 25. For effectiveness, heat and cold should be applied directly to painful areas.	87	73.1
10. Item 17. Young infants less than 6 months of age cannot tolerate opioids for pain relief.	82	68.9

DOI: 10.7717/peerj.19288/table-4

Results

Of the 119 nursing interns who participated in the survey, the majority (109, 91.6%) were aged 21–23 years, 24–25 years (8, 8.6%), and 18–20 years (2, 1.7%). Almost all participants (109, 91.6%) were single, and only 10 (8.4%) were married. The largest proportion of participants (83, 69.7%) had a GPA of 3.75–4.49, followed by 29 (24.4%) with a GPA of 4.50–5.00, and 6 (5%) with a GPA of 2.75–3.74. Only 1 (0.8%) had a GPA of 2.00–2.74. Approximately 23 (19.3%) of the respondents were assigned as interns in pediatric units, while the majority (96, 80.7%) were assigned as interns in various nonpediatric areas (Table 1).

Discussion

The present study aimed to assess nursing interns’ levels of knowledge and attitudes toward pediatric pain management at an academic institution. All participants were female nursing interns, unlike the earlier studies by Al Omari (2016) and Alotaibi (2019). To the best of our knowledge, our study is the first to include only female nursing interns from an academic institution in Riyadh, Saudi Arabia.

The current study revealed that the nursing interns’ overall knowledge and attitudes with respect to pediatric pain management were poor, with a mean score of 36.59 (SD, 13.02). Shdaifat, Al-Shdayfat & Sudqi (2020) used the same instrument among nursing students and recorded higher scores on average (mean, 42.6; SD, 9.1). This finding is congruent with previous studies (Chow & Chan, 2015; Ortiz et al., 2015; Al Omari, 2016; Laprise, 2016; Gadallah, Hassan & Shargawy, 2017; Kusi Amponsah et al., 2020; Mediani, Windiany & Maryam, 2020; Shdaifat, Al-Shdayfat & Sudqi, 2020). An exception was a study by Aydın & Bektaş (2020) who administered a pain management knowledge questionnaire among nursing interns and found a moderate level of knowledge.

A recent study in Saudi Arabia (Alotaibi, 2019) also had comparable results. Based on the findings of this study and others, nursing students currently appear to be insufficiently prepared for pediatric pain management. Moreover, the little time spent with children in the clinical field and the limited opportunities provided were reasons suggested for this study’s results.

The most correctly answered items in this study were similar to those obtained by Gadallah, Hassan & Shargawy (2017), Alotaibi (2019), Kusi Amponsah et al. (2020), and Shdaifat, Al-Shdayfat & Sudqi (2020). The items with correct responses about pain assessment and individualized pain experiences and their treatments may be due to the simplicity of the questions, which made them more comprehensible to the nursing interns.

Insufficient knowledge of pain assessment was evident in the nursing interns’ incorrect responses. More than two-thirds of the nursing interns’ responses were incorrect for the item about changes in vital signs as an indicator of severe pain. The nursing interns did not understand that children present changes in vital signs as a physiological response to pain. This finding was also evident in the studies by Chiang et al. (2006), Al Omari (2016) and Gadallah, Hassan & Shargawy (2017). This finding indicates that nursing students must be taught appropriate pediatric pain assessment.

The study results imply that nursing interns’ responses regarding pharmacological management were mostly incorrect. For example, most of the study participants showed extremely poor knowledge of the route of administration of opioid analgesics and pharmacological items related to the two case studies. This result echoes the studies by Chow & Chan (2015), Al Omari (2016), and Alotaibi (2019), which showed a similar percentage of responses.

It was also evident from this study that the nursing interns exhibited poor knowledge about nonpharmacological approaches to pediatric pain management, as represented by their incorrect responses to items 7 and 25. Similarly, Chiang et al. (2006) and Mediani, Windiany & Maryam (2020) found that a considerable number of nursing students provided incorrect responses in this area.

The study results indicated no significant differences in the nursing interns’ knowledge and attitude scores with regard to their demographic data. While this finding is similar to the findings of Karaman, Vural Doğru & Yıldırım (2018), it contradicts a study by Alotaibi (2019) conducted in Saudi Arabia, which found that nursing students’ scores showed substantial differences according to their gender, age, clinical experience, and qualifications.

For several of these results, multiple factors may explain the nursing interns’ or students’ poor knowledge and attitudes toward pediatric pain assessment and its management. For example, the nursing curriculum may lack conceptual content describing the assessment and management of pediatric pain, and nursing students may be provided with less clinical exposure to pediatric care.

Conclusion

Despite pain management in children being a vital aspect of pediatric practice, this study demonstrated nursing interns’ poor knowledge and attitudes toward pediatric pain management, especially pharmacological and nonpharmacological pain management. This finding could be the result of a lack of details included in the nursing school curriculum and their short clinical training period as students in pediatric care in hospitals, which was mostly observational rather than practical.