Nurse Education Today 31 (2011) 117–121

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Nurse Education Today

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t

Re-thinking pain educational strategies: Pain a new model using e-learning and PBL
Donna Keyte ⁎, Cliff Richardson ⁎
University of Manchester, School of Nursing, Midwifery and Social Work, Jean MacFarlane Building, University Place, Oxford Road, Manchester, M13 9PL, UK

a r t i c l e i n f o s u m m a r y

Article history: Despite some high profile reorganisation including the introduction of acute pain teams, many patients still
Accepted 4 May 2010 experience unnecessary pain. Traditional teaching and learning strategies seem to have made little impact in
clinical practice. This paper explores the possible reasons for this and identifies the need to help
Keywords: postregistration students transfer (re-contextualise) what they are learning to practice. A new, more flexible
Blended learning
pain management module utilising a blended face to face/e-learning approach within a problem-based
PBL
e-learning
learning philosophy was introduced to increase knowledge in pain management whilst also attempting to
Pain overcome the barriers to knowledge transfer into practice. This is done by challenging attitudes and
encouraging students to explore their clinical practice alongside theoretical concepts.
© 2010 Elsevier Ltd. All rights reserved.

Background (Simons, 2002; Twycross, 2002; Goodrich, 2006; McCluskey and

Pain is a common consequence of ill health. In cancer care, pain is
recognised as impacting on all aspects of quality of life (Sun et al.,
2007) whilst in Britain 17% of adults suffer long-term chronic pain
from non-malignant causes (Breivik et al., 2006). Additionally acute
pain can complicate surgical recovery, extend length of hospital stay
and increase the risk of long-term pain (Watt-Watson et al., 2001;
Macrae, 2001). Such details show that there is a health care
imperative to manage pain appropriately with nurses having a unique
role given that, of all the health professionals, they spend the most
time with patients in pain (Carr and Thomas, 1997; Zhang et al.,
2008). Despite advances in the understanding of the physiology of
pain and improved treatment strategies however, it is clear that pain
still goes unrecognised and under treated (Carr and Thomas, 1997;
Watt-Watson et al., 2001; Cheung et al., 2009).
One of the potential causes for this incongruence between theory
and practice was that nurses do not give pain management a high
priority (Twycross, 2002, Manias and Bucknall, 2005). However,
recent studies disagree, finding that nurses are ‘not complacent’ about
pain management (Simons, 2002) and experience ‘real distress’ when
they are not able to achieve good pain relief for their patients
(Richards and Hubbert, 2007; Blondal and Halldorsdottir, 2009). This
all suggests that there may be inadequacies in current pain education
strategies in terms of preparing nurses to manage pain, and also in
helping them to deal with real clinical situations (Twycross, 2002).
Education of pain management using traditional learning and
teaching methods has been found to increase knowledge and
motivation but does not always change attitude, behaviour or practice
⁎ Corresponding authors. Tel.: + 44 161 306 7638 9; fax: + 44 161 306 7707.
E-mail addresses: Donna.j.keyte@manchester.ac.uk (D. Keyte),
Clifford.richardson@manchester.ac.uk (C. Richardson).
Lovarini, 2005; Greenberger et al., 2006; Zhang et al., 2008). In order
to try to improve nurse education in the field of pain management, it
is necessary therefore to have knowledge of how nurses learn about
pain management and how to help them incorporate it and transfer it
into their clinical practice.
What can be learnt from focused pain education programmes?
Using a Pain Activities Questionnaire, Dalton et al. (1995)
monitored nurses pain-related opportunities with weekly placements
in a community based hospital. Additional seminar discussions and
participation in ward rounds with medical and pharmacy staff
reinforced skills utilisation. Each nurse on the course (n = 29) was
asked to collect and complete inventories of their knowledge,
attitudes and behaviour and their expectations of change in practice,
immediately prior to starting and also 10 weeks after the course. Six-
month follow up showed an improvement in documentation and the
nurses reflected on the great value of what they had learned but the
effect on practice was not easily measured. The researchers concluded
that although results were extremely favourable, further evaluation
was required.
In a second study Adriaansen et al. (2005) set specific pain-related
practical projects aimed at care improvement. Two measurement
tools were used pre and posteducation to test for change in attitude
towards pain management. The self-efficacy instrument (SEP)
measured the belief of the nurse to perform at a desired level whilst
the expertise and insight test (C-PCQN) identified knowledge of pain
management. The results of the SEP and C-PCQN (n = 38) showed
increased competency related to both pain and symptom manage-
ment, although this was not statistically significant. Change in practice
was implied but could not be measured.

0260-6917/$ – see front matter © 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2010.05.001
118 D. Keyte, C. Richardson / Nurse Education Today 31 (2011) 117–121
Francke et al. (1997) provided 3 h of pain education per week for
8 weeks to five ward teams of surgical nurses. Four months later 2
nurses from each team were interviewed. Individual views of pain
management, the social aspects of teams and the creativity of the
manager were found to be important aspects for change in pain
management to occur. Interestingly the findings were not persuasive of
blanket education across a whole team and may suggest targeting key
individuals as change agents. A feature also identified by Simons (2002).
Although MacLellan (2004) found a small improvement in patient
pain scores (n = 400 pre and post) following an education programme it
was clear that nurses did not use their knowledge in daily practice to
manage pain. It was suggested that education needed to include a
strategy to assist nurses actively to transfer their knowledge to practice.
The next step therefore is to see how nurses perform in practice.
Pain management in practice
Before deciding the best way to educate nurses on pain
management it is important to understand how they work and
what the influences are in practice. Richards and Hubbert (2007)
conducted a pilot study of 3 ‘expert’ nurses caring for postoperative
patients in pain using qualitative semi-structured interviews. Four
main themes emerged. In the first theme ‘considering the whole
person’ the participants started with pain assessment viewing the
patient holistically and reflected upon what other factors may be
influencing the patient. This included psychological, physiological and
behavioural aspects to gain a holistic view. The participants
emphasised that the patients self-report was the most reliable
indicator of pain and in the theme ‘accepting what the patient says’
this was considered to be important for the benefit of the patient. In
contrast Brockopp et al. (2004) found that the subjectivity and
complexity of pain allows individual nurses' decision-making to be
biased by pre-conceived ideas or stereotyping about patient groups,
Richards and Hubbert (2007) found that expert nurses could put aside
their own biases and suggested that this was what distinguished
expert nurses from novices in pain management.
Richards and Hubbert's third theme addressed the management of
pain, where the participants identified the need for a balanced analgesic
approach that incorporated pharmacological and non-pharmacological
strategies. Whilst in the final theme ‘commitment to surgical nursing’ all
the participants commented that they valued and got reward from being
able to impact positively on patient outcomes.
In their study Brockopp et al. (2004) asked 157 practicing nurses
and 265 student nurses to complete a questionnaire asking them how
much time and energy they would spend managing different patients'
pain using vignettes of 12 pain patient groupings including cancer,
substance abuse, a suicide attempt, general surgery and chronic pain.
Small group (3–4 in size) sessions followed where the participants
were encouraged to discuss their own beliefs and pre-conceived ideas.
Following the group work the questionnaire was completed again. A
small increase in the amount of time and energy nurses would be
willing to spend with certain groups was found alongside slightly
improved documentation.
In a recent qualitative study by Blondal and Halldorsdottir (2009)
nurses' experiences of working with patients in pain were explored. Ten
experienced nurses working in medical and surgical wards were
interviewed. Several previously unidentified contributory factors to
nurses' pain management strategy were found to motivate nurses to
advocate and manage a patient's pain. These included moral obligation
or sense of duty, clinical experience, self-confidence and conviction to
drive the management forward. Doctors were often seen as ‘gate
keepers’, for analgesia with nurses having to negotiate and sometimes
bypass them if the patient need required them to do so (Blondal and
Halldorsdottir, 2009). Simons (2002) also identified the frustration that
the nurses felt with medical staff in relation to pain management. It was
strongly suggested that pain education use a more holistic perspective
to patient management including personal and ethical knowledge
alongside negotiation and assertiveness training.
Learning the lessons
Barriers to successful pain management for nurses are not
therefore simply related to knowledge but also linked to factors
such as the complexity and subjectivity of pain, lack of accountability,
organisational issues and culture. In health care environments the
accountability and responsibility for pain management is often
blurred. This was highlighted in the seminal report in the UK by the
Royal College of Surgeons and Anaeasthetists (1990) who recom-
mended the organisation of acute pain teams to take responsibility for
ensuring adequate pain management. Nursing culture needs to be
supportive to enable nurses to feel confident to make decisions and
suggest improvements in care related to pain. Additionally within
pain management there are complex individual cultural factors
related to the patient and those of the staff where there may be a
mismatch of expectations and pain-related behaviours. Until these
elements are included and discussed in pain education it is unlikely to
lead to improvements in practice, indeed it has been suggested that
many pain education initiatives may compound poor pain manage-
ment practices rather than improve them (Francke et al., 1997;
Twycross, 2002). Closer exploration and understanding of organisa-
tion and drivers in the health care environment, pain-related activities
and how nurses make decisions related to pain management in the
clinical environment are as important as knowledge and should be
included in educational efforts.
A key to the successful educational initiatives identified from the
literature was the concept of student centeredness with the content
being driven by their needs; hence educationalists need to be flexible
enough to adapt to the particular needs of the student (Simons, 2002).
This flexibility may include the need to offer support over a period of
time for change to happen and then to be sustained (Dalton et al.,
1995). In an attempt to improve provision of pain education including
these important factors, a new pain management module was created.
This used problem-based learning and e-learning as the foundation to
be able to improve knowledge but also to challenge existing beliefs,
values and attitudes and to enable exploration of issues associated
with the complexity of healthcare workplaces.
The new pain module
Having identified the potential to improve learning and affect
practice the new pain management module was created and under-
pinned by humanistic and adult learning philosophies. Problem-based
learning (PBL) is an educational strategy that aims to link theory to
practice by facilitating the synthesis of knowledge and skills, and
developing critical thinking (Andrews and Reece Jones, 1994; Creedy
and Hand, 1994). It embodies a socio-constructivist educational
approach (Wozniak et al., 2005), which is student centred, encourages
participation, promotes self-directed learning, and develops problem
solving skills (Savin-Baden, 2003; Wilkie and Burns, 2003). Student's
experiences are recognised and valued enabling them to explore and
learn together to apply existing knowledge to less familiar areas
(Haith-Cooper, 2000). This allows individuals to consider what is
most relevant to their own practice hence promoting a desire to learn.
In nursing this is particularly relevant for postregistration learners.
With experienced staff and careful induction of students, PBL has
the potential to be an effective learning philosophy (Biley and Smith,
1999), as it is possible to simulate and explore real life pain problems
within a safe learning environment where students use their
experience, research and debate with fellow students and facilitators,
and reflect on how this impacts on their clinical area. It was proposed
that this should assist with transference of knowledge into practice by
taking cognisance of students' knowledge and previous experiences
 D. Keyte, C. Richardson / Nurse Education Today 31 (2011) 117–121
thus helping to link theory to practice. It was felt that if the course was
structured to encourage participants to draw on their clinical
experience, explore areas of interest to them, with reflection and
application to their practice, then transference of knowledge would be
more likely to take place.
To create an environment conducive for PBL and discussion
amongst the course participants' computer based technologies were
incorporated. Previously it had been found that student learning
online is enhanced with involvement in activities through interac-
tions with others (Wilhelm et al., 2003). PBL provides the platform for
this discussion and can be bolstered using the engagement theory of
Kearsley and Schneiderman (1998) which provides a constructivist
and experiential framework for online-based learning. This ‘triangular
framework’ includes relating or collaborating with others, creating a
project based content and practical contribution of the participants.
Similarly Salmon (2003) developed a 5-stage model of teaching and
learning online, which incorporates the engagement model and
further extends it to include the role of the e-moderator. She suggests
that in stages 1 and 2 students need to become familiar with the
online environment, develop their online socialisation skills and use
the discussion boards. In stage 3 students begin to interact with the
information available online and exchange this information with each
other working independently. By stage 4 the students are beginning to
interact with each other in a more participative way. They are able to
widen their own viewpoint and engage in active learning. Enhanced
through discussion and debate by stage 5 the students should begin to
grasp concepts and theories, reflect on learning and be relating them
to practice.
The importance of the role of the e-moderator to the learning process
has been highlighted. In a qualitative study Wilhelm et al. (2003)
explored nursing students, (n = 10) perceptions of online discussion the
students identified that having more teacher input during the process
was helpful. Others believe the role of the e-moderator is integral to
creating a successful online learning environment through creating
opportunities for socialisation, inviting students into discussion
and providing motivating feedback (Goodyear, 2001; Salmon,
2003; MacDonald, 2004). Salmon (2003) adds that it is useful for
the e-moderator to summarise discussion as this can stimulate new
strands or topics for discussion and close down less productive ones. The
e-moderator encourages discussions using a technique known as
weaving. Weaving acknowledges contributions and assists in assimi-
lating all points into the overall discussion, rather than just picking main
points (Salmon, 2003; Goodyear, 2001). It may also be necessary to
monitor participation and to email less active students if needed.
Online learning in nursing education is gradually increasing
(Thurmond, 2002), and Schmitt et al., (2004) recently designed and
evaluated an online continuing education course in acute pain
management for nurses working with older adults. The course included
evidence-based practice guidelines supplemented with literature
related to aging, pain assessment and pain management. Sixteen
feedback quizzes linked to each section of the course were included to
assist the learning process. Following a pilot it was estimated that the
course would take approximately 4 h to complete however only 4
nurses (3%) out of 124 nurses completed the online course. Supple-
mental paper copies of the course had to be supplied to ensure
participation. On evaluation it was found that many nurses were
unwilling to take the course online despite being given clear directions
in the use of the materials. Reasons given included the time consuming
nature of the course and technological difficulties at home including a
lack of comfort with the technology (Schmitt et al., 2004). This was
surprising as all the nurses used computers in their daily work.
Perhaps the most likely reason for the problems was the lack of
interaction, with the content, other participants, and with the teacher
(Hardin, 2003) which led to isolation and frustration. The resources
themselves also play a role and need to be user-friendly (Koeckeritz
et al., 2002). It is also possible that Schmitt et al. (2004) set up their
119
programme before the participants were ready. With the more recent
explosion of the use of chat rooms and email, online communication has
become a more integral part of life (Jacobs et al., 2003) so newer
initiatives may have fewer problems. A further potential advantage for
online learning is the reduced need for students to attend university,
particularly for students working in busy clinical environments who
traditionally found it difficult to negotiate time away for study.
Potentially the market for student participation is widened not only to
more nurses but could also include other health-related disciplines due
to the flexibility for access to the materials across the 24-hour period.
In order to overcome some of the potential pitfalls with e-learning
and to try to encourage student participation and consolidation of
learning the new module was created on a blended learning template
of 50% face to face and 50% online. Alongside this a new model was
created to assist in a methodical approach to all aspects of pain and
pain management. The students are divided into small groups and are
encouraged to interact online and face to face. Student groups of 8 to
15 are considered ideal for asynchronous discussions. The number is
small enough to allow everyone the opportunity to contribute easily
and it enhances participants' awareness of each other, helping them to
develop relationships. It is also possible to summarise and provide
feedback, and if 2 or 3 people are unable to participate there are still
enough students left to have a discussion (MacDonald, 2004; Salmon,
2003).
PAIN a new model for learning about pain
The management of pain can be divided into 4 areas, Preparation,
Assessment, Intervention and Normalisation. Preparation is a multi-
faceted complex concept which includes the groundwork required
prior to a painful event and all aspects of interaction prior to the
formalised assessment of pain. Depending upon the person, the
context and the type of pain, preparation could target the individual
suffering the pain or the healthcare professional trying to manage it.
Preoperative information giving would be one area of preparation but
understanding individual and collective attitudes, beliefs and cultures
associated with practical environments is also crucial to this area.
Assessment covers all aspects of the formal biopsychosociocultural
assessment of the pain, which is essential prior to managing or
intervening. Pain intervention includes psychological and social
techniques as well as pharmacological and non-pharmacological
management. Focus is given to how these may work in relation to the
knowledge of the theories of how and why we feel pain which were
introduced at the preparation stage. The final stage of the model is
normalisation and covers all aspects of returning the pain sufferer
back to their normal or optimal state. Fig. 1 shows the overlapping
relationship between the four areas.
The model is applied to case histories of three patients suffering
from common pain conditions. In order to cover a broad cross-section
of pain issues each of the patients has a different form of pain. The first
(acute pain) undergoes abdominal surgery, the second (chronic non-
malignant pain) is suffering low back pain and the third (chronic
malignant pain) has pain from metastatic breast cancer. The students
are allocated to action learning groups with a maximum of 15
students per group. Each week the students are delivered an online
trigger from one of the patient case histories. The first 4 weeks
concentrate on preparation the next four on assessment and so on. At
the end of the week for the first 3 weeks of each aspect of the model a
nominated scribe for the group produces a summary of that week's
discussion and the fourth week is classroom based. The weekly
discussions are visible only to the individual groups but the final
summary is visible to every group in order to ensure that should a
group miss an area of information they have access through the other
groups. The scribe rotates each week so that every member takes the
role.
120 D. Keyte, C. Richardson / Nurse Education Today 31 (2011) 117–121
Fig. 1. PAIN model showing how the four concepts overlap and integrate into each other.
In class the students consolidate learning from the previous 3 weeks
and are encouraged to explore issues which could be taken to their own
practice area. Particular emphasis is placed on learning how to overcome
potential barriers to implementation of good pain management.
Conclusions
For education to be effective the best approaches for the particular
student group need to be identified. Within the present study an
androgogical approach was taken to encourage the students to use
enquiry and be autonomous. They are encouraged to use their
expertise and draw on that of others to see new perspectives and
challenge their own views and biases so that they can manage pain
effectively (Brockopp et al., 2004; Richards and Hubbert, 2007).
Regular classroom sessions where the participants are encouraged to
reflect and identify problems in their workplace and how they might
be addressed, based on what they have learned from the online
discussion, may also help them to see pain management from
different perspectives and provide tools for managing certain
situations better. In this way rather than just providing knowledge
this self-directed, more active learning style of education helps the
participants to develop the pain skills necessary to manage pain
appropriately in a variety of circumstances. As the module is open to
all health care professionals it may also help to provide a network for
people to call on in the future.
The future
Early anecdotal evaluation suggests that the students believe that
they know more and understand the complexities existent within the
area of pain and pain management. It remains to be seen however if
this new approach has an effect on practice, but formal and robust
evaluation is under way commencing with the measurement of the
confidence that practitioners have to carry out pain management
activity. Further modification to take account of how less experienced
nurses learn (Dalton et al., 1995) and how to target key personnel
(Brockopp et al., 2004) alongside the identification of the most
appropriate form of assessment are currently being explored.
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