Original Article
An Educational
From the *Department of Pediatrics,
Narayana Multispeciality Hospital,
Rakhial, Ahmedabad, Gujarat, India;
†
Department of Pediatrics,
Pramukhswami Medical College,
Karamsad, India; ‡Central Research
Services, Charutar Arogya Mandal,
Karamsad, India; § Department of
Physiology, Pramukhswami Medical
College, Karamsad, India.
Address correspondence to
Somashekhar M. Nimbalkar, MD,
Pramukhswami Medical College,
Karamsad, Anand, Gujarat,
India 388325. E-mail: somu_somu@
yahoo.com
Received February 21, 2016;
Revised September 16, 2016;
Accepted October 4, 2016.
No external funding was sought for
the study.
1524-9042/$36.00
Ó 2016 by the American Society for
Pain Management Nursing
http://dx.doi.org/10.1016/
j.pmn.2016.10.003
Intervention to Improve
Nurses’ Understanding
of Pain in Children in
Western India
Ashish R. Dongara, MD,*,†
---
Somashekhar M. Nimbalkar, MD,†,‡ Ajay G. Phatak, MPH,‡
Dipen V. Patel, MD,† and Archana S. Nimbalkar, DCh§
- ABSTRACT:
Accurate assessment of pain and its management is a challenging
aspect of pediatric care. Nurses, usually the primary caregivers,
showed inadequate knowledge and restrictive attitudes toward pain
assessment. We evaluated an educational intervention to improve
nurses’ assessment of pain in a teaching hospital in India. A conve-
nient sample of nurses working in the neonatal intensive care unit,
pediatric ward, pediatric intensive care unit, and pediatric cardiac
intensive care unit were included in the study. Workshops to improve
understanding of pain, its assessment, and management strategies
were conducted. A modified and consensually validated Knowledge
and Attitudes Survey Regarding Pain questionnaire-2008 consisting of
25 true/false questions, eight multiple choice questions, and two case
scenarios was administered before, immediately after, and 3 months
after the workshops to evaluate impact of the intervention. Eighty-
seven nurses participated. Mean (standard deviation) experience was
4.04 (5.9) years. Thirty-seven percent felt that they could assess pain
without pain scales. About half (49.4%) of the nurses had not previ-
ously heard of pain scales, while 47.1% reported using a pain scale in
their routine practice. Significant improvement was observed be-
tween pretest and post-test total scores (15.69 [2.94] vs. 17.51 [3.47],
p < .001) as well as the pretest and retention score (15.69 [2.94] vs.
19.40 [4.6], p < .001). Albeit the study site and sampling frame may
limit the reliability of the findings, the educational intervention was
successful, and better retention test scores suggest a cascading effect.
Pain assessment and management education of children should be
incorporated in the nursing curriculum and should be reinforced in
all pediatric units.
Ó 2016 by the American Society for Pain Management Nursing
Pain Management Nursing, Vol -, No - (--), 2016: pp 1-9
2 Dongara et al.
Pain is the most common side effect of hospitalization.
There have been reports that almost 80% of perioper-
ated hospitalized children experience moderate to se-
vere pain (Polkki, Pietila, & Vehvilainen-Julkunen,
2003). Untreated or mismanaged pain is found to
adversely affect the cardiovascular, respiratory, and
gastrointestinal system as well as immunological func-
tion, and hence indirectly delays recovery, prolongs
hospitalization, or worsens illness (Al-Atiyyat, 2008;
Schechter, Berde, & Yaster, 2003). Despite such
serious implications, suboptimal pain management is
common (Breivik et al., 2009).
Multiple reports testify to a lack of sufficient
knowledge in tackling pain among health care pro-
viders—both nursing staff and doctors (Al Qadire &
Al Khalaileh, 2014; Latchman, 2014; Lui, So, & Fong,
2008; Schultz, Loughran-Fowlds, & Spence, 2010).
Pain in children is even more a complex issue. There
are multiple misconceptions and beliefs that impair a
health care provider’s ability to identify and treat
pain, especially in children (Dongara, Shah,
Nimbalkar, Phatak, & Nimbalkar, 2015; Helgadottir &
Wilson, 2004; Manworren, 2000; Nimbalkar,
Dongara, Ganjiwale, & Nimbalkar, 2013; Nimbalkar,
Dongara, Phatak, & Nimbalkar, 2014).
Previous studies conducted at our medical center
have demonstrated a deficit in knowledge and
improper attitudes pertaining to pain in pediatric pa-
tients (Dongara et al., 2015; Nimbalkar et al., 2013;
Nimbalkar et al., 2014). Education and training has
showed an improvement in the knowledge and
attitudes regarding pain and also improved pain
management practices among the nursing staff
(Huth, Gregg, & Lin, 2010; Pederson, 1996;
Treadwell, Franck, & Vichinsky, 2002). As a starting
point, a workshop-based module was designed and
tested for educating the nursing staff about identifica-
tion and management of pain in pediatric patients.
LITERATURE REVIEW
Various educational methods to improve identification
and management of pain by nurses have been tried.
Unfortunately, the literature from developing econo-
mies is scarce. Pederson (1996) conducted a study in
which a cohort of 35 nurses underwent a 2-hour
training program and showed improved knowledge
about pain and nonpharmacological interventions as
well as increased application in day-to-day usage. In
the study conducted by Knoblauch & Wilson (1999),
nurses were monitored before and after training as
they administered analgesics using chart audits of a
convenience sampling of children who had undergone
tonsillectomies during the study period. Surprisingly,
this study showed a delay in administration of first
dose of analgesic and increased interval between sub-
sequent doses.
De Rond et al. (2000) conducted a study wherein
a pain monitoring program consisting of two compo-
nents, education and implementation of daily pain
assessment, showed an increase in pain knowledge
questionnaire scores from 69.1% to 75.8%. Johnston
et al. (2007) conducted a study wherein one-on-one
coaching of the nursing staff across six pediatric hospi-
tals was performed. Though a significant site-to-site
variation was noted, an overall improvement in nurses’
knowledge, frequency of assessing pain, and usage of
nonpharmacological interventions was observed.
Huth et al. (2010) reported positive influence of a dedi-
cated educational intervention focusing on pediatric
pain on knowledge and attitudes of Mexican nurses.
A study by Vael & Whitted (2014) deduced that educa-
tion altered nursing practices about pain assessment
and increased frequency of pain assessment.
Evans & Mixon (2015) tried high-fidelity simula-
tion, including case study and roleplay, incorporated
in undergraduate nursing students’ curriculum. Albeit
a concurrent control group was not included, compar-
ison with historical control groups suggested better
performance of nurses in the simulation group with
respect to the Knowledge and Attitudes of Survey
Regarding Pain. Shen & El-Chaar (2015) conducted a
three-phase study in a neonatal intensive care unit. A
preintervention pain analysis of heel lancing in 25 ne-
onates was assessed in the first phase using the
Neonatal Pain Agitation and Sedation Scale. In the sec-
ond phase, the nursing staff and physicians were
educated about oral sucrose. A repeat analysis of
severity of pain during heel lancing of 25 neonates
was performed, which showed a decrease in pain
following the education intervention.
METHODS
Setting
The study was conducted at a tertiary-level teaching
hospital located in the rural part of western India
from December 2013 through March 2014. The study
was approved by the institutional ethics committee.
Sample
All the nurses working in the neonatal intensive care
unit, pediatric ward, pediatric intensive care unit,
and pediatric cardiac unit of the hospital were eligible
to be included in the study. All the nurses were
exposed to pediatric patients on a daily basis. All
eligible nurses were invited for the training program
and explained about the study. The nurses were
 Intervention Improving Nurses’ Understanding of Pain 3

included in the study after obtaining written informed

consent. TABLE 1.
Baseline Sociodemographic Characteristics and
Instrument Perceptions about Pain of the Study Participants
The investigators had used a Knowledge and Attitudes
Sociodemographic
Survey Regarding Pain questionnaire (Ferrell & Characteristics and
McCaffery, 2008) that was modified, validated, and uti- Perceptions of Pain Frequency (%) (N ¼ 87)
lized by the authors in previous studies (Nimbalkar
et al., 2013; Nimbalkar et al., 2014). This questionnaire Sociodemographic characteristics
was developed in 1987 by Ferrell and McCaffery. An Ward
updated version was released in April 2008 (Ferrell & Neonatal 27 (31.0)
Cardiac 38 (43.7)
McCaffery, 2008). The questionnaire has 25 true/false Pediatric 22 (25.3)
questions, eight multiple-choice questions (MCQs), and Marital status
two case-based scenarios. The questionnaire was modi- Married 37 (42.5)
fied to suit our setup. This modified questionnaire was Unmarried 50 (57.5)
consensually validated, pretested on 10 randomly Experience
<1 year 34 (39.1)
selected nurses outside the study sample. The question- 5 years 34 (39.1)
naire had a Cronbach a > 0.70 for attitude and knowl- >5 years 19 (21.8)
edge. Higher scores reflected better knowledge (Ferrell Children
& McCaffery, 2008). 0 65 (74.7)
1 21 (24.1)
2 1 (1.2)
Training and Assessment Age
A 3-hour workshop session was designed consensually 20-25 years 47 (54.0)
by the investigators to educate the nursing staff 26-30 years 22 (25.3)
regarding the physiology of pain, its assessment, and 31-40 years 13 (14.9)
management strategies. Three separate sessions were >40 years 5 (5.8)
Mean (SD): 27.36 (6.254)
conducted to cover all of the 104 nurses. A modified Perceptions about pain assessment tools
and consensually validated Knowledge and Attitudes Have you previously heard of pain assessment tools
Survey Regarding Pain questionnaire-2008 was admin- Yes 44 (50.6)
istered before, immediately after, and 3 months after No 43 (49.4)
the workshops to evaluate the impact of the interven- Are they useful
Yes 41 (47.1)
tion. No time limit was imposed on them. No 46 (52.9)
Will you like to use these scales in ward
Statistical Analysis Yes 33 (37.9)
Descriptive statistics (mean [standard deviation, (SD)], No 54 (62.1)
and frequency [%]) were used to portray the profile of Are you currently using any sort of assessment tool
Yes 46 (52.9)
the study population. Analysis of variance/Chi-square No 41 (47.1)
test/correlation coefficient were used to determine as-
sociations depending on variable type. The analysis
was performed using STATA 14.
reluctant to use such scales in the wards (54 [62.1%]),
although most (57 [65.5%]) agreed on the importance
RESULTS of these tools in reliably assessing pain and more than
Out of 104 eligible nurses, 94 (90.38%) completed the half (46 [52.9%]) reported using some pain assessment
first assessment and training, 90 (86.54%) completed tool in the ward, as mentioned in Table 1.
post-training assessment, and 87 (83.7%) completed A statistically significant improvement was
the 3-month retention assessment. All of the nurses observed in mean (SD) total post-test score pertaining
were women. Most of them were cardiac ward nurses to true/false questions as compared to the pretest score
who were unmarried, young, without any children, (12.47 [2.30] vs. 13.64 [3.00], p ¼ .005). The mean (SD)
and less experienced, as shown in Table 1. The mean total post-test score improved significantly over the next
(SD) age of the nurses was 27.36 (6.25; range: 23-50) 3 months (13.64 [3.00] vs. 14.98 [3.61], p ¼ .003). A sta-
years. Forty-three (49.4%) nurses had not heard of tistically significant improvement was observed in the
pain assessment tools and 46 (52.9%) perceived that mean (SD) total post-test score pertaining to MCQs as
these tools may not be useful. Most of them were compared to the pretest score (3.22 [1.48] vs. 3.86
 4
TABLE 2.
Performance in True/False Questions and Multiple-Choice Questions
Pretest Post-test Retention Test
Questions Frequency (%) Frequency (%) Frequency
(Frequency [%] of Correct Answers) (N ¼ 87) (N ¼ 87) (%) (N ¼ 87)

True/false questions
1 Vital signs are always reliable indicators of the intensity of a patient’s pain. 10 (11.5) 10 (11.5) 38 (43.7)
2 Because their nervous system is underdeveloped, children under two years 45 (51.7) 59 (67.8) 63 (72.4)
of age have decreased pain sensitivity and limited memory of painful
experiences.
3 Patients who can be distracted from pain usually do not have severe pain. 31 (35.6) 27 (31.0) 23 (26.4)
4 Patients may sleep in spite of severe pain. 12 (13.8) 31 (35.6) 49 (56.3)
5 Combining analgesics that work by different mechanisms may result in 46 (52.9) 60 (69.0) 67 (77.0)
better pain control with fewer side effects than using a single analgesics
agent.
6 The usual duration of analgesia of 1-2 mg fentanyl IV is 4-5 hr. 43 (49.4) 39 (44.8) 37 (42.5)
7 Opioids should not be used in patients with history of substance abuse. 26 (29.9) 26 (29.9) 27 (31.0)
8 Patients should be encouraged to endure as much pain as possible before 35 (40.2) 53 (60.9) 44 (50.6)

Dongara et al.
using an opioid.
9 Children younger than 11 years cannot reliably report pain, so clinicians 23 (26.4) 38 (43.7) 50 (57.5)
should rely solely on the parents’ assessment of the child’s pain intensity.
10 Patients’ spiritual beliefs may lead them to think pain and suffering are 46 (52.9) 57 (65.5) 64 (73.6)
necessary.
11 After an initial dose of opioid analgesic is given, subsequent doses should be 62 (71.3) 57 (65.5) 75 (86.2)
adjusted in accordance with an individual patient’s response.
12 Lack of pain expression does not necessarily mean absence of pain. 47 (54.0) 58 (66.7) 76 (87.4)
13 Patients should be maintained in a pain-free state. 53 (60.9) 50 (57.5) 59 (67.8)
14 If a patient reports pain relief and euphoria, he or she should be given a lower 44 (50.6) 46 (52.9) 41 (47.1)
dose of the analgesic.
15 Patients can tolerate high doses of opioids without sedation or respiratory 45 (51.7) 48 (55.2) 44 (50.6)
depression.
16 Estimated pain by an MD or RN is a more valid measure of pain than the 41 (47.1) 38 (43.7) 28 (32.2)
patient self-report.
17 Patients may be hesitant to ask for pain medications due to their fears about 47 (54.0) 61 (70.1) 56 (64.4)
use of opioids.
18 Patients have the right to expect total pain relief as the goal of treatment. 77 (88.5) 73 (83.9) 72 (82.8)
19 Continuous assessment of pain and medication effectiveness is necessary 71 (81.6) 70 (80.5) 73 (83.9)
for good pain management.
20 Giving opioids on a regular basis is preferred over a PRN schedule for 53 (60.9) 61 (70.1) 69 (79.3)
continuous pain.
21 A patient should experience discomfort before giving the next dose of pain 39 (44.8) 35 (40.2) 45 (51.7)
medication.
22 Comparable stimuli in different people produce the same intensity of pain. 42 (48.3) 43 (49.4) 55 (63.2)
 23 Nondrug interventions (heat, music, imagery, etc.) are very effective for mild 26 (29.9) 23 (26.4) 19 (21.8)
to moderate pain control but rarely helpful for more severe pain.
24 Beyond a certain dosage of morphine, increases in dose will not increase 48 (55.2) 58 (66.7) 47 (54.0)
pain relief.
25 In order to be effective, heat and cold should only be applied to the painful 73 (83.9) 66 (75.9) 82 (94.3)
areas.

Total score (True/false questions) Mean (SD)

12.47 (2.3) 13.64 (3.00) 14.97 (3.61)

MCQs
1 Recommended route of administration of opioid analgesics to patient with 64 (73.6) 74 (85.1) 80 (92.0)

Intervention Improving Nurses’ Understanding of Pain

post of pain
2 Which of the following analgesics medications is considered as a drug of 32 (36.8) 44 (50.6) 53 (60.9)
choice for the treatment of prolonged moderate to severe pain for post op
3 Analgesics for post op pain should initially be given 74 (85.1) 69 (79.3) 66 (75.9)
4 Most likely explanation for why patient with pain would request increased 36 (41.4) 59 (67.8) 35 (40.2)
doses of pain medication is
5 The most accurate judge of the intensity of the patients pain is 28 (32.2) 26 (29.9) 60 (69.0)
6 Narcotic/opioid addiction is defined as psychological dependence 0 12 (13.8) 44 (50.6)
accompanied by overwhelming concern with obtaining and using
narcotics for psychic effect, not for medical reasons. It may occur with or
without psychological changes of tolerance to analgesia and physical
dependence (withdrawal).
Using this definition, how likely is that opioid addiction will occur as a result
of treating pain with opioid analgesics
7 The time to peak effect for fentanyl is 24 (27.6) 21 (24.1) 24 (27.6)
8 The time to peak effect of PCM given orally is 22 (25.3) 31 (35.6) 23 (26.4)

Total score (MCQs) Mean (SD)

3.21 (1.4) 3.86 (1.45) 4.42 (1.74)

Total score (True/false questions þMCQs) 15.69 (2.94) 17.51 (3.47) 19.40 (4.61)

Case scenarios Pretest frequency Post-test Frequency Retention test

underestimating/ underestimating/ Frequency
undertreating undertreating underestimating/
pain (%) pain (%) undertreating
(N ¼ 87) (N ¼ 87) pain (%)
(N ¼ 87)

1A Rahul is 16 years old and this is his first day following cardiac surgery. As you 81 (93.1) 81 (93.1) 80 (92.0)
enter his room, he smiles at you and continues talking and joking with
(Continued )

5
 6
TABLE 2.
Continued
Pretest Post-test Retention Test
Questions Frequency (%) Frequency (%) Frequency
(Frequency [%] of Correct Answers) (N ¼ 87) (N ¼ 87) (%) (N ¼ 87)

his visitor. Your assessment reveals the following information—BP:

120/80, HR: 80, RR: 18. On a scale of 1-10, he rates his pain 8. On the
patients chart you must mark his pain as ___?
1B He has received PCM 2 hours before the assessment. Serial pain 68 (78.2) 66 (75.9) 74 (85.1)
assessments reveal a score range of 6-8. He has identified 2 as an
acceptable level of pain relief. Fentanyl is to be given as required. What
will be your next step?
2A Niraj is 16 years old and this is his first day following cardiac surgery. As you 56 (64.4) 68 (78.2) 61 (70.1)
enter his room, he is lying quietly and grimaces as he turns in bed. Your
assessment reveals the following information—BP: 120/80, HR: 80,
RR: 18. On a scale of 1-10, he rates his pain 8. On the patients chart you
must mark his pain as ___?
2B He has received PCM 2 hours before the assessment. Serial pain 70 (80.5) 50 (57.5) 45 (51.7)

Dongara et al.
assessments reveal a score range of 6-8. He has identified 2 as an
acceptable level of pain relief. Fentanyl is to be given as required. What
will be your next step?
MCQ ¼ multiple-choice questions; PCM ¼ paracetamol; BP ¼ blood pressure; HR ¼ heart rate; RR ¼ respiratory rate.
 Intervention Improving Nurses’ Understanding of Pain
FIGURE 1. - Box plots depicting comparison of pre, post,
and retain scores.
[1.45], p ¼ .001). The mean (SD) total post-test score of
MCQs improved significantly over the next 3 months
(3.86 [1.45] vs. 4.42 [1.74], p ¼ .006), as shown in
Table 2 and Figure 1.
The mean (SD) improvement (post/pre) in total
score (true/false þ MCQs) was not associated with be-
ing married (2.08 [3.93] vs. 1.62 [4.08], p ¼ .60) or hav-
ing children (2.27 [4.31] vs. 1.66 [3.91], p ¼ .54). The
improvement was neither associated with age (correla-
tion coefficient [r] ¼ 0.12, p ¼ .28) nor with experi-
ence (correlation coefficient [r] ¼ 0.12, p ¼ .25).
However, the improvement was significantly higher
in pediatric units as compared to neonatal units
(p ¼ .007) and cardiac units (p ¼ .006).
Despite some improvement in knowledge, the
nurses not only underestimated the pain but also
were hesitant to administer proper drugs for the man-
agement of pain. In case scenario 1, 81 (93.1%), 81
(93.1%), and 80 (92.0%) of the nurses underestimated
the pain during pre, post, and retain evaluation. Further-
more, only 19 (21.8%), 21 (24.1%), and 13 (14.9%)
correctly identified line of treatment during pre, post,
and retain evaluation pertaining to pain level in case sce-
nario 1. In case scenario 2, 56 (64.4%), 68 (78.2%), and
61 (70.1%) nurses underestimated pain during pre,
post, and retain evaluation. Surprisingly, significantly
more nurses correctly identified line of treatment in
post (17 [19.5%] vs. 37 [42.5%], p ¼ .002) and retain
(17 [19.5%] vs. 42 [48.3%], p < .001) evaluation as
compared to baseline (pre) evaluation.
DISCUSSION
The nurses were relatively young with a mean age of
27.36 years. Most of the nurses had experience of
7
<5 years, were unmarried, and did not have children.
Their initial perceptions about pain assessment tools
were a reason to worry. More than half of them had
heard of pain scales and were using them in practice,
but most of them felt that these pain assessment tools
were not useful and they would not like to use the
scales to assess pain in children in the wards.
There was a statistically significant improvement
in the score of true/false questions and MCQs of the
nursing staff in the pretest, post-test, and 3-month
retention test. This signifies an improvement in knowl-
edge about pain in children after training. Similar
improvement in knowledge was also observed by
Johnston et al. (2007) and Huth et al. (2010). We do
not know whether this improvement in scores would
reflect as better pain management in patients.
The improved knowledge could be a reflection
of increasing frequency of pain assessment and atten-
tion to patients’ complaints as noted by Johnston
et al. (2007) and de Rond et al. (2000), increase in in-
terventions as noted by Pederson (1996), or as
improvement in both patient and staff satisfaction
as noted by Treadwell et al. (2002). A study by
Knoblauch and Wilson (1999) noted a paradoxical
deterioration after training. However, this deteriora-
tion was gauged as time to administration of first
analgesic and interval between two doses of analge-
sics, so it cannot be considered a reflection of pain
management as a whole entity.
The improvement was not associated with age,
experience, marital status, or whether the nurses had
children. These findings are not surprising considering
the composition of this study group. The ward where
they are working has a significant impact on the
improvement with nurses from the cardiac ward hav-
ing very limited improvement. With the training pro-
grams and nurses’ backgrounds being similar, this
probably indicates an area to focus and conduct rein-
forcement sessions.
The nurses scored lower and showed less
improvement in questions that were related to phar-
macology and dosages of analgesic medications, espe-
cially opioids. This finding was observed despite the
fact that the original questionnaire was edited to re-
move difficult questions regarding pharmacodynamics
of drugs and dosages, keeping only questions related to
routinely used medications. This highlights another
area to focus on in training programs.
A very important finding of this study is the signif-
icant improvement that is noted not only between the
pretest and post-test but also between the post-test and
3-month retention test. This finding suggests that the
training triggered some sort of snowball effect, encour-
aging the nursing staff to educate themselves and
8 Dongara et al.
improve their knowledge, as depicted by higher reten-
tion test scores.
Limitations
One of the shortcomings of this study is that the inves-
tigators have not yet conducted a repeat survey to
ascertain long-term retention of knowledge. Further,
the translation of knowledge into practice was not
evaluated. Although a convenient sample was drawn,
87 (83.7%) of all eligible nurses participated; hence,
the findings are quite reliable in this aspect. However,
this study was conducted at an academic hospital, and
generalizability of the results in nonacademic settings
may be limited.
Implications for Nurses’ Education, Practice,
and Research
The nurses’ training module in the United Kingdom is
reported to lack basic training about pain, its assess-
ment, and management strategies (Twycross, 2000).
Pediatric pain is still a neglected area. Nursing educa-
tion in India propagates a generalist approach, and
most nurses working in India possess some kind of
diploma. Most of the nurses learn specific aspects of
care by experience, as there is no subspecialty in
nursing education. The authors feel that it is time to in-
crease the availability of subspecialty certificate
courses, such as primary care, emergency care, and
intensive care unit care, in nursing education.
With respect to pediatric specialties, there is a
need to introduce certificate courses, such as pediatric
intensive care nursing, neonatal intensive care nursing,
emergency pediatric care, and pediatric cardiac critical
care, which would include modules on standardized
pain management. The curriculum relating to pain
management would need to have standardized infant
and pediatric pain instruments training, pharmacolog-
ical, and nonpharmacological approaches as well as
quality improvement training to improve care.
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The educational intervention was successful, and bet-
ter retention test scores suggest a cascading effect.
Pain assessment and management in children should
be incorporated in the nursing curriculum and should
be reinforced in all pediatric units.
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