Knowledge and Attitudes of Italian Medical Staff Towards the Approach and Treatment of Patients in Pain

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1 Vol. 22 No. 5 November 2001 Journal of Pain and Symptom Management 925 Original Article Knowledge and Attitudes of Italian Medical Staff Towards the Approach and Treatment of Patients in Pain Marco Visentin, MD, Leonardo Trentin, MD, Roberto de Marco, PhD, ScD, and Elisabetta Zanolin, MS, PhD Unita Operativa di Terapia del Dolore e Cure Palliative (M.V., L.T.), Ospedale S. Bortolo, Vicenza; and Sezione di Epidemiologia e Statistica Medica (R.d.M., E.Z.), University of Verona, Verona, Italy Abstract This study is part of the project, Towards a Pain-Free Hospital, which aims at improving the approach and treatment of the patient in pain. The objective of the study was to evaluate the knowledge and attitudes of doctors and nurses on the wards of a 1000-bed general hospital located in a rather densely-populated, industrialized area of Italy regarding the following topics: attention paid to pain, the use of analgesic drugs, and pain in children. In total, 669 nurses and 225 doctors completed a 16-item questionnaire evaluating knowledge and beliefs about pain. The overall percentage of correct answers was 61% (9.7/16). The score varied among the different wards and ranged from 48% (7.8/16) to 76% (12.3/16). Physicians scored 65% and nurses 59% (p 0.001). The percentage of correct answers varied widely among the different items (from 30% to 96%). From these results, we conclude that there are still significant knowledge deficits and erroneous beliefs that may hamper treatment of the patient in pain. These results will help in conducting educational programs aimed at improving pain treatment in the different departments of the hospital. J Pain Symptom Manage 2001;22: U.S. Cancer Pain Relief Committee, Key Words Pain knowledge, pain attitudes, Towards a Pain-Free Hospital Introduction It has generally been stated that little attention is paid to the patient in pain and that pain tends to be underestimated and inadequately treated. 1 3 Studies have shown that medical staff have little basic knowledge and inadequate behavior towards the assessment of pain Address reprint requests to: Marco Visentin, MD, Unita Operativa di Terapia del Dolore e Cure Palliative, Ospedale S. Bortolo, Vicenza, Italy. Accepted for publication: January 25, and its treatment with analgesics The main deficiencies for both nurses 4,6,7,10 and physicians. 5,7,8 regard the correct use of analgesic drugs, particularly the pharmacological properties of opioids and the fear of addiction, 4 10 the erroneous belief that patients exaggerate their pain, 9 the role that patients should have in the management of their pain, 6 and the difficulty in assessing pain in children. 7 The project Towards a Pain-Free Hospital ( which has been launched at the Vicenza Hospital, aims to heighten awareness of the problem of pain among citizens and medical staff, and to pro- U.S. Cancer Pain Relief Committee, /01/$ see front matter Published by Elsevier, New York, New York PII S (01)

2 926 Visentin et al. Vol. 22 No. 5 November 2001 vide medical staff with the technical and practical know-how to improve the care of patients in pain. 11,12 The initial part of this project involved the collection of data concerning the prevalence of pain among patients admitted to the hospital and how the pain was treated, and a survey on the knowledge and attitudes of both doctors and nurses. This paper reports on the findings of this second survey. This was conducted prior to an awareness and educational campaign and was intended as a guide to the educational intervention. Methods As part of the project Towards a Pain-Free Hospital, a questionnaire was prepared to assess how appropriate were the behaviors and opinions of caregivers towards a patient in pain. There were 16 items on the questionnaire, and the interviewees were asked to reply in three ways: 1 I agree; 2 I don t know; 3 I disagree. Their answers were assessed on the basis of how far they corresponded to the criteria of pain therapy commonly recognized by the international medical community. The response I don t know was considered wrong. No response was given in a limited number of cases (up to 2% for Item 12) and was also included in the category of mistaken answer. The choice of items was inspired by the survey of Lebovits et al., 8 which took place in three New York hospitals and used 17 items collated from various medical papers. The questionnaire used in the Lebovits et al. study has not been yet analyzed psychometrically. Of the 16 items in our survey, 11 were translated from the Lebovits et al. study (Nos. 1 10, 16) and 5 were prepared by the authors (Nos ). The 16 items were aimed at three basic areas: 1) attention paid to pain (Nos. 6, 11, 13 16); 2) the use of analgesics (Nos. 1 7, 12); and 3) pain in children (Nos. 8 10). The questionnaire was handed to the head nurse of each hospital ward, who undertook to give it to all doctors and nurses on the ward. They were instructed to keep the questionnaire anonymous but to indicate qualifications and the name of the ward. The questionnaire was to be completed quickly and without consulting medical texts. To obtain interpretable data, hospital departments were grouped into 4 main areas: Anesthesiology and Emergency, Surgery, Pediatrics, and Medicine. Results are presented as percentages and/or means with 95% confidence interval according to the type of variables. Comparisons between groups were performed through the student t-test, one- and two-way analysis of variance, and the chi-squared test, as the situation required. Item-total correlation and Cronbach s alpha were computed using SPSS for Windows (1997). Results Of 782 nurses and 324 doctors directly involved in patient care, 669 nurses (85%) and 225 doctors (69%) completed the questionnaire. Ten did not indicate their level of qualification. Therefore, of 904 caregivers who completed the questionnaire, 25% were doctors and 74% were nurses, and 1% did not give correct information concerning professional qualifications (Table 1). The overall percentage of correct answers (here given to mean conforming to the general practice and theory of pain treatment as recognized by international bodies) was 61% (95% confidence intervals [C.I.] 57% 64%). The average number of correct answers was 9.7/16. The average number of correct answers was 10.4/16 (65%) for doctors and 9.4/16 (59%) for nurses (Figure 1). There was a statistically significant difference between the two groups (t-test; p 0.001). Analysis of the results by department shows the number of correct answers varying from a minimum of 7.8 to a maximum of There was a significant difference among Anesthesiology and Emergency, Surgery, Pediatrics, and Medicine in the average number of correct answers (ANOVA, p 0.001). Anesthesiology had the highest mean score (10.8) and Surgery had the lowest one (9.1) (Table 2). Table 3 shows the percentage of correct answers for each question. The question that had the highest percentage of correct answers (96%) was No. 14 ( For effective treatment of cancer pain, it is necessary to continuously assess the pain and the efficacy of the therapy; Table 1 Number of Interviewees According to Profession Profession No. of Interviewees Doctor 225 (24.9%) Nurse 669 (74%) Missing 10 (1.1%) Total 904

3 Vol. 22 No. 5 November 2001 Knowledge and Attitudes Towards Pain 927 Fig. 1. Average number of correct answers according to profession (statistically significant difference between the two groups (p 0.001). correct answer: I agree ). The question with the lowest number of correct answers (30%) was No. 13 ( It may often be useful to give a placebo to a patient in pain to assess if he is genuinely in pain; correct answer: I disagree ). Table 3 also presents the item-total correlation, a psychometic measure calculated as the correlation coefficient between the score on the individual item and the sum of the scores on the remaining items. This correlation was minimum for Item 11 (0.02) and maximum for Item 9 (0.30). Cronbach s alpha, measuring the internal consistency of the questionnaire was equal to 0.46; it reached 0.47 when deleting Item 11, once again indicating the poor relationship of this item with the others. The questions were grouped into the three previously defined categories concerning the use of analgesics, attention given to pain, and pediatric pain. Figure 2 shows the percentage of correct answers in the three groups from doctors and nurses: The highest percentage of correct answers concerned attention given to pain, followed by the use of analgesics, and finally pediatric pain. Doctors received higher scores in all groups than nurses; the difference was statistically significant between both the groups of questions and professional groupings (two-way ANOVA, p for both criteria). Table 2 Average Number of Correct Answers (Standard Deviation) to 16 Questions by Clinical Practice Area Area No. of Doctors/Nurses Mean (Standard Deviation) Anesthesiology (2.6) and Emergency Surgery (2.4) Pediatrics (2.9) Medicine (2.3) Fig. 2. Percent of correct answers by area and professional qualifications (statistically significant difference between both the groups p 0.001). Discussion This report provides a basic overview of doctors and nurses knowledge and attitudes towards pain in a medium-sized general hospital in Italy. The response rate to the questionnaire was high (85% of nurses and 65% of doctors) and we can assume that the questionnaire accurately reflects the medical staff s actual situation. The overall percentage of correct answers (61%) is very similar to that obtained by Hamilton et al. 4 and by Clarke et al. 6 In these nurse surveys, the percentage was 64% and 62%, respectively. A further comparison with these questionnaires is not possible because the latter two surveys involved only nurses and the questionnaire was different from ours as regards type and number of items. A questionnaire quite similar to ours was used by Lebovits et al. 7 (indeed, 11 of the 16 items were the same) to analyze the knowledge and attitudes of 686 nurses, physicians, pharmacists and medical/nursing students. They obtained an overall percentage of correct answers of 56%, which is again not significantly different from ours. Physicians scored significantly higher than nurses 7 and those practicing in anesthesiology scored higher than those in other practice areas. In our study, the mean difference between doctors and nurses correct answers was statistically significant, but actually quite small (10.4/16 correct answers for doctors and 9.4/ 16 for nurses). A difference of this magnitude does not deserve much attention.

4 928 Visentin et al. Vol. 22 No. 5 November 2001 Item Table 3 Perecentage of Correct Answers and Item-Total Correlation Percent Correct Answer Item-Total Correlation 1. Giving narcotics on a regular schedule is preferred over prn schedule for continuous pain. 90 (y) A patient should experience discomfort prior to giving the next dose of pain meds. 59 (n) The preferred route of administration of narcotic pain relievers to patients with cancer-related pain 67 (n) 0.28 is intramuscular. 4. When a patient requests increasing amounts of analgesics to control pain, this usually indicates that 63 (n) 0.25 the patient is psychologically dependent. 5. Patients receiving narcotics on a prn basis may be likely to develop clock-watching behaviors. 48 (y) The most accurate judge of the intensity of the patient s pain is the patient. 63 (y) When a patient in pain is receiving analgesic medication on a prn basis, it is appropriate for the 43 (y) 0.06 patient to request pain meds before the pain returns. 8. Staff can always pick up cues from children that indicate that they are in pain. 61 (n) Since narcotics can cause respiratory depression, they should not be used in pediatric patients 43 (n) Children cry all the time; therefore, diversional activities are indicated rather than actual pain meds. 57 (n) For the majority of patients (80%), pain can be controlled with analgesics. 63 (y) The most suitable dose of morphine for a patient in pain is a dose which best controls the symptoms; 34 (y) 0.19 there is no maximum dose (ie. a level which must not be exceeded) for morphine. 13. It may often be useful to give a placebo to a patient in pain to assess if he is genuinely in pain. 30 (n) For effective treatment of cancer pain, it is necessary to continuously assess the pain and the efficacy 96 (y) 0.13 of the therapy. 15. It is a patient s right to expect total pain relief as a consequence of treatment. 64 (y) Lack of pain expression does not mean lack of pain. 87 (y) 0.09 (y) The correct answer is yes. (n) The correct answer is no. This survey reveals that the hospital staff is well prepared as regards certain principles of pain therapy. A high percentage of correct answers was obtained to questions regarding: 1) continuous assessment of cancer pain (No. 14: 96%); 2) the treatment of chronic pain at fixed times and not as needed (No. 1: 90%); and 3) the low correlation between facial expression and pain intensity (No. 16: 87%). On the other hand, certain fundamental concepts do not as yet seem to be understood, such as: 1) the limited usefulness of a placebo in clinical practice (No. 13: only 30% correct answers) and 2) the unfounded fear that large doses of opioids can be dangerous (No. 12: 34% correct answers). These results are in agreement with those obtained by other authors. While the preference for the regular dose schedule has been accepted, there are still concerns about the adverse effect of opioids. 5 While an exaggerated fear of opioids, due to the lack of knowledge of their pharmacological properties, has been stressed in many surveys, 4 10 we have not found any item regarding placebo in previous reports. We were pressed to add such an item in our questionnaire, having realized how frequent was the use of placebo in the wards of the local hospital. Comparing the three areas addressed by the items, that of pain in children scored less than attention to pain and the use of analgesics. This reflects the tendency towards a particular underestimation and undertreatment of pain in children. Nurses and physicians in Broome et al. s survey 13 agreed that the younger the child, the less effective was pain management in their institution. The three items about pain in children (Nos. 8 10) are the same used by Lebovits et al. 7 While Item 10 (children cry all the time) got 57% of correct answers in both surveys, Item 9 (narcotics should not be used in children for fear of respiratory depression) scored 60% in Lebovits et al. s and only 47% in our survey. On the contrary, Item 8 (pick up cues from children) scored 28% in Lebovits et al. s and 61% in our survey. There are few other studies available on the topic of pain in children. Pederson et al. 14 surveyed pediatric critical care nurses knowledge of pain management and found a mean score of 63% of correct answers. Salanterä et al. 10 found a mean score of 63% and 51% in the nurses

5 Vol. 22 No. 5 November 2001 Knowledge and Attitudes Towards Pain 929 knowldge of nonpharmacological and pharmacological pain management, respectively. The results of the present survey point to the necessity for educational programs on pain management to achieve improved knowledge and attitudes of the medical staff. 15 Pain is a neglected topic in the educational programs of both nurses and physicians. It was addressed in only 54 of more than 22,000 pages in physicians textbooks 16 and in only 248 of 45,683 pages in nurses textbooks. 17 Oncologists consider that their medical school training in cancer pain was poor. 18 The information gathered in the present survey is useful for planning the educational strategies because the least correctly responded items should guide the choice of the educational areas to address with priority, i.e., the pharmacological management of pain and the management of pediatric pain. Cronbach s alpha was not excellent, but this is anyway an important finding as the questionnaire of Lebovits survey has not been yet psychometrically evaluated. One explanation of this not very high internal consistency could be the presence of different dimensions of the questionnaire that can be investigated in future studies. The objective of this survey was to assess the general and specific shortcomings in the various departments in order to plan training programs regarding the approach and treatment of patients in pain. The project Towards a Pain-Free Hospital has been undertaken at Vicenza Hospital as an experiment, but will be introduced into Italian hospitals in general. The questionnaire will, therefore, need revising and perfecting before presenting it to other hospitals. A survey conducted in various hospitals nationwide, using the same questionnaire, will provide highly significant future data. To conclude, the results of this survey reveal that the lack of training and inappropriate attitudes of caregivers are relevant, even in a hospital where pain therapy has been dealt with for many years. As a result, projects such as Towards a Pain-Free Hospital, which aim to bring together the needs of the population and the hopes of the caregivers, are probably necessary to reach the goal of an improved assessment and treatment of pain. Both citizens and medical staff must, therefore, be made more aware of the questions. Correct training is necessary. Surveys such as ours, although they need to be improved from a methodological point of view, may prove useful in the planning of training programs for medical staff. Acknowledgments We would like to thank all the staff of S. Bortolo Hospital of Vicenza for their cooperation in performing the survey. References 1. Marks RM, Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med 1973;78: Melzack R. The tragedy of needless pain: a call for social action. In: R Dubner, GF Gebhart, MR Bond, eds. Proceedings of the 5th World Congress on Pain. New York: Elsevier, 1988: Grossman SA. Undertreatment of cancer pain: barriers and remedies. Support Care Cancer 1993;1: Hamilton J, Edgar L. A survey examining nurses knowledge of pain control. J Pain Symptom Manage 1992;7: Elliott TE, Murray DM, Elliott BA, et al. Physician knowledge and attitudes about cancer pain management: a survey from the Minnesota Cancer Pain Project. J Pain Symptom Manage 1995;10: Clarke EB, French B, Bilodeau ML, et al. Pain management knowledge, attitudes and clinical practice: the impact of nurses characteristics and education. J Pain Symptom Manage 1996;11: Lebovits AH, Florence I, Bathina R, et al. Pain knowledge and attitudes of healthcare providers: practice characteristics differences. Clin J Pain 1997; 13: Levin ML, Berry JI, Leiter J. Management of pain in terminally ill patients: physician reports of knowledge, attitudes, and behavior. J Pain Symptom Manage 1998;15: Drayer RA, Henderson J, Reidenberg M. Barriers to better control in hospitalized patients. J Pain Symptom Manage 1999;17: Salanterä S, Lauri S, Salmi TT, Helenius H. Nurses knowledge about pharmacological and nonpharmacological pain management in children. J Pain Symptom Manage 1999;18: Besner G, Rapin CH. The hospital. Creating a pain-free environment: a program to improve pain control in hospitalized patients. J Palliative Care 1993;9: Visentin M. Verso un ospedale senza dolore. Un progetto ed una campagna per il miglioramento dell assistenza sanitaria. Recenti Progressi in Medicina 1999;90(6):

6 930 Visentin et al. Vol. 22 No. 5 November Broome ME, Richtmeir A, Maikler V, Alexander MA. Pediatric pain practices: a national survey of health professionals. J Pain Symptom Manage 1996; 5: Pederson C, Matthies D, McDonald S. A survey of pediatric critical care nurses knowledge of pain management. Am J Crit Care 1997;6: Ferrell BR, Grant A, Ritchey KJ, Ropchan R, Rivera LM. The pain resource nurse training program: a unique approach to pain management. J Pain Symptom Manage 1993;8: Bonica JJ. Pain research and therapy: achievements of the past and challenges of the future. In: JJ Bonica, U Lindblom, A Iggo, eds. Proeedings of the Third World Congress on Pain. Advances in Pain Research and Therapy, Vol. 5. New York: Raven Press, 1983: Ferrell B, Virani R, Grant M, Vallerand A, Mc- Caffery M. Analysis of pain content in nursing textbooks. J Pain Symptom Manage 2000;19: Van Roenn JH, Cleeland CS, Gonin R, Hatfield AK, Pandya KJ. Physician attitudes and practice in cancer pain management. Ann Intern Med 1993; 119: