Original Article
Knowledge and Beliefs
From the *Department of Nursing,
Universit
e du Qu
ebec a Rimouski,
Rimouski, Quebec, Canada; †School
of Nursing, Universit
e de Sherbrooke,
Sherbrooke, Quebec, Canada.
Address correspondence to Dave A.
Bergeron, MSc, RN, Department of

Nursing, Universit
e du Qu
ebec a
Rimouski, 300 all
ee des Ursulines,
Rimouski, Qu
ebec G5L 3A1, Canada.
E-mail: dave.a.bergeron@
usherbrooke.ca
Received June 26, 2015;
Revised September 28, 2015;
Accepted September 30, 2015.
1524-9042/$36.00
Ó 2015 by the American Society for
Pain Management Nursing
http://dx.doi.org/10.1016/
j.pmn.2015.09.001
about Chronic Non
Cancer Pain Management
for Family Medicine
Group Nurses
--- Dave A. Bergeron, MSc, RN,*
Patricia Bourgault, PhD, RN,†
and Frances Gallagher, PhD, RN†
- ABSTRACT:
To provide effective care for chronic pain sufferers, nurses must have
a knowledge of chronic pain management. In Quebec, nurses working
in Family Medicine Groups (FMGs) could play a major role in helping
patients with chronic noncancer pain (CNCP); however, the extent of
their knowledge about CNCP management is unknown. The primary
goal of this study was to explore the knowledge and beliefs of FMG
nurses about CNCP management. The secondary goal was to explore
the obstacles seen by these nurses as preventing them from per-
forming CNCP management. We used a mixed-methods design with
quantitative preponderance. Fifty-three FMG nurses answered a self-
administered mail-in questionnaire. A rigorous data collection
method was used. FMG nurses have suboptimal knowledge about
CNCP management. They identify their lack of training and lack of
knowledge as major obstacles to conducting pain management inter-
ventions. There is a need for pain management training specifically
designed around the realities of FMG nursing.
Ó 2015 by the American Society for Pain Management Nursing
BACKGROUND
To provide effective care for chronic pain sufferers, nurses must have knowledge
of chronic pain management (Registered Nurses Association of Ontario [RNAO],
2013). Several studies detail the inadequate knowledge, inaccurate beliefs, and
challenges faced by nurses in providing care for patients with acute
pain (Abdalrahim, Majali, Stomberg, & Bergbom, 2011; Al-Shaer, Hill, &
Anderson, 2011; Broekmans, Vanderschueren, Morlion, Kumar, & Evers, 2004;
Coulling, 2005; Layman Young, Horton, & Davidhizar, 2006; Manias, 2003;
Manias, Bucknall, & Botti, 2004). However, there is little evidence regarding
the knowledge, beliefs, and challenges faced by nurses regarding chronic
noncancer pain (CNCP) management.
Currently, CNCP treatment and management are often inadequate (Gilron &
Johnson, 2010). The recommended way to ensure the best possible care is to
Pain Management Nursing, Vol 16, No 6 (December), 2015: pp 951-958
952 Bergeron, Bourgault, and Gallagher
make an early diagnosis, provide optimal treatment
and primary care management, and work in interdisci-
plinary teams (Debar et al., 2012; Steglitz, Buscemi, &
Ferguson, 2012). As part of such teams, nurses can
make practical interventions to optimize pain relief
for people suffering from CNCP (American Society of
Pain Management Nurses [ASPMN], 2010). More spe-
cifically, and in collaboration with general practi-
tioners, they can conduct interventions such as
detection, assessment, follow-up care, and CNCP-
related education (RNAO, 2013; Veterans Health
Administration, 2009).
Primary care for CNCP patients is suboptimal in
Quebec (Jouini et al., 2014). The introduction of the
Family Medicine Group (FMG) model could optimize
CNCP management in primary care (Lalonde et al.,
2014). An FMG consists of several family physicians
working in close collaboration with nurses to provide
integrated care and care continuity, especially for
vulnerable groups, such as patients with chronic con-
ditions (Pomey, Martin, & Forest, 2009). Given the
high prevalence of CNCP, its association with the
chronic health issues seen in FMGs (diabetes, chronic
obstructive pulmonary disease, etc.; ASPMN, 2010),
and its even greater prevalence in cases of multimor-
bidity (Ramage-Morin & Gilmour, 2010), many FMG pa-
tients may be suffering from CNCP.
To intervene adequately, nurses must possess suf-
ficient knowledge and appropriate beliefs about pain
management (Patiraki-Kourbani, Tafas, McDonald,
Papathanassoglou, Katsaragakis, & Lemonidou, 2004;
RNAO, 2013). The challenges they face in conducting
pain management must also be understood (Pellico,
Gilliam, Lee, & Kerns, 2014; Siedlecki, Modic,
Bernhofer, Sorrell, Strumble, & Kato, 2014) and
addressed. Those challenges, and the knowledge and
beliefs of FMG nurses about CNCP, have not yet been
documented.
Goals
The primary goal of this study was to evaluate the
knowledge and beliefs of FMG nurses about CNCP
management. The secondary goal was to explore the
barriers identified by nurses as preventing them from
performing CNCP management.
Conceptual Framework
The research presented in this paper is based on the
model of Patiraki–Kourbani et al. (2004), which was
developed after a review of the literature on how the
personal and professional experiences of nurses with
pain affected their knowledge and skills in pain man-
agement. We chose this model because it provides a
way to analyze the different barriers associated with
effective pain management by nurses. The factors
considered for this study were pain-related training,
professional experience with pain, theoretical knowl-
edge about pain, the characteristics of individual
nurses, and effective pain management.
MATERIAL AND METHODS
Participants
We used a mixed-methods design with quantitative
preponderance (cross-sectional mail survey; Dillman,
2007; Doyle, Brady, & Byrne, 2009; Grove, Burns, &
Gray, 2013). The accessible population for the study
consisted of nurses on a list of Ordre des infirmieres
et infirmiers du Qu
ebec (OIIQ) members working in
FMGs. Of the 430 FMG nurses, 195 agreed to be
contacted at home for research purposes. An
exhaustive sampling of those nurses was performed.
Each participant in the study had to be an OIIQ
member and able to read, understand, and answer
questionnaires written in French.
Procedure
The study was approved by an institutional ethics com-
mittee. Data collection by mail was performed using
the Dillman strategy (2007) to maximize response
rate. The mailing contained a letter of explanation
with the researchers’ contact information, two copies
of the consent form, the questionnaire, and two
postage-paid return envelopes. Nurses who agreed to
participate had to sign and date one copy of the infor-
mation and consent form, returning it and the ques-
tionnaire in separate postage-paid envelopes. This
procedure ensured anonymity and reduced the possi-
bility of social desirability bias.
Reminder mailings were sent 1 and 3 weeks after
the initial mailing. To guarantee anonymity, we did not
proceed to a second mailing of questionnaires for
nurses who did not respond to the first reminder. To
maximize response rate, all letters (including re-
minders) were personalized and signed by the
researchers.
Variables
The first variable was knowledge about best practices
in CNCP management, which refers to facts based on
empirical data that are published and widely available
(Watt-Watson, Stevens, Garfinkel, Streiner, & Gallop,
2001). The second variable was beliefs about CNCP
management, which refers to statements that are
believed to be true but have no scientific basis (Watt-
Watson et al., 2001). The final variable was the barriers
preventing from performing CNCP management ac-
tions, defined as personal or organizational factors
 Noncancer Pain Management Beliefs
that hamper or discourage CNCP management initia-
tives (Carroll et al, 1997; Hanks, 2007). The following
sociodemographic variables were also collected: age,
gender, type of FMG, academic training, work
experience as a nurse, work experience in an FMG,
academic training on pain management, and
continuing education on pain management. These
sociodemographic variables reflect those in the
model of Patiraki–Kourbani et al. (2004), the concep-
tual framework on which the study was based.
Questionnaire
The French version of the Toronto Pain Management
Index (the Questionnaire Toronto sur la gestion de la
douleur), was used for this study. The original version
uses visual analog scales (VAS) to evaluate, in the post-
operative context, the knowledge and beliefs of nurses
about pain management, including those regarding
analgesia, a person’s experience of pain, and a person’s
reaction to pain. The questionnaire includes a few
open questions to facilitate data triangulation and
represent the qualitative portion of this mixed-
methods design. The face and content validity of the
original version of the questionnaire were established
by nine nurses and medical experts on pain manage-
ment (Watt-Watson, Garfinkel, Gallop, Stevens, &
Streiner, 2000).
To assess the questionnaire’s reliability coeffi-
cient, the original author conducted an intraobserver
test–retest over a 2-week period on 33 nurses in a post-
operative setting. The intraclass coefficient of variation
is 0.81 (Watt-Watson et al., 2000). The questionnaire
was translated into French by Bourgault, Michaud,
Bolduc, & Lapr
e (2009) following the seven steps of
translation developed by Vallerand (1989). After an in-
traobserver test–retest on 80 nurses, the intraclass co-
efficient of variation for the French version was found
to be 0.80 (Bourgault et al., 2009).
To account for the specific nature of CNCP and
primary care, a few changes were made to the French
version of the questionnaire. This was done in collabo-
ration with an expert in CNCP management and an
expert in community health. Thus, for the purposes
of this study, four questions were removed that had
no relevance in the context of primary care. We added
a visual analog scale for the degree of interest in
playing a greater role in chronic pain management. Vo-
cabulary specific to the postoperative setting was re-
viewed, and we modified 14 questions and three
open questions to focus on the particularities of
CNCP in primary care. A graphic designer reviewed
the layout of the questionnaire to improve its visual
presentation. To ensure the quality of question content
and the items we wished to measure, the face validity
953
and construct validity of our modified version were
verified by six healthcare professionals, all pain man-
agement experts. The modified questionnaire was
also pretested on four FMG nurses who did not partic-
ipate in the study.
Statistical Analysis
We performed a descriptive analysis of our variables.
Discrete and continuous quantitative data with a
normal distribution were presented in average and
standard deviation form, whereas abnormally distrib-
uted quantitative data were presented using mean
and interquartile range. Spearman correlations were
done to check for associations between the factors
being studied (Howell, 2009). Statistical analysis was
done using PASW Statistics 18 (Armonk, NY: IBM
Corp.), with the significance level set at p < .05. An-
swers to open questions were transcribed into an
Excel file, then organized and coded manually to facil-
itate triangulation between quantitative and qualitative
data (Doyle et al., 2009; Miles, Huberman, & Salda~ na,
2013).
RESULTS
Sociodemographic Characteristics of
Participants
Of the 195 questionnaires mailed, 16 were returned
without being completed, and 53 were returned
completed, giving a response rate of 30%. One of the
53 was not completed correctly, so only the answers
to the open questions were included in our analysis.
Of the 16 nurses who did not complete the question-
naire, nine said they were not involved in CNCP
management, five said they no longer worked in an
FMG, and two said they were on an extended leave
of absence. Table 1 presents the participants’ sociode-
mographic characteristics.
Knowledge and Beliefs of Participants
Regarding CNCP Management
The results pertaining to knowledge are presented
in Table 2. For the questionnaire as a whole, the
average weighted total score was 1,229.56 (stan-
dard deviation [SD] 153.3) out of a maximum of
2,000, for a success rate of 61.5%. Isolating the sec-
tion on nurse beliefs about the patient’s experience
of pain and the nurse’s knowledge of pain assess-
ment and management, the weighted average was
516.5 (SD 91.7) out of 800, for a success rate of
64.6%. The weighted average for results regarding
beliefs and knowledge about opioids and their
delivery was 357.4 (SD 64.7) out of 700, for a suc-
cess rate of 51.1%. For the section covering multiple
954 Bergeron, Bourgault, and Gallagher

TABLE 1. TABLE 2.
Sociodemographic Characteristics Knowledge and Beliefs of Nurses About CNCP
Management
Sample
Characteristics (N ¼ 53) Score n Average (SD)
Age (years) – average (SD) 38.7 (9.7) Weighted total score 51 1,229.56 (153.3)
Sex n (%) (out of 2,000)
Male 3 (5.7) Score in % 61.5 (7.7)
Female 50 (94.3) Section on beliefs about 51
Training completed n (%) patient experience of pain
College 1 (1.9) and pain management
University Certificate 4 (7.5) Weighted score (out of 800) 516.5 (91.7)
Bachelor’s Degree 45 (84.9) Score in % 64.6 (11.5)
Master’s Degree 3 (5.7) Section on beliefs about 50
Work experience n (%) opioid delivery and
0-5 years 5 (9.4) knowledge about opioids
6-10 years 14 (26.4) Weighted total score 357.4 (64.7)
11-20 years 20 (37.7) (out of 700)
21-30 years 11 (20.8) Score in % 50.2 (6.2)
31þ years 3 (5.7) Section on beliefs about peer 50
Work experience in FMGs n (%) support, common
Less than a year 2 (3.8) practice, and self-
1-2 years 23 (43.4) perception of
3-4 years 15 (28.3) competence
5þ years 13 (24.5) Weighted total score 286.3 (96.5)
Pain training n (%) (out of 500)
Continuing education 19 (35.8) Score in % 57.3 (19.3)
Number of hours – median (IQR) 6.0 (3.0-12.0) Degree of interest in playing a 51 72.0 (23.3)
Formal training 35 (66.0) greater role in CNCP
Number of hours – median (IQR) 9.0 (3.5-30.0) management (out of 100)
SD ¼ standard deviation; FMG ¼ Family Medicine Group; SD ¼ standard deviation.
IQR ¼ interquartile range.

dimensions (i.e., beliefs about peer support, the
nurse’s customary practice, and self-perception of
competence), the weighted average was 286.3 (SD
96.5) out of 500, giving an average result of
57.3%. On the other hand, the participants dis-
played a high level of interest (72.0 on a scale of
0 to 100) in playing a greater role in CNCP
management.
Analysis of results from the visual analog scales in
our version of the questionnaire (Table 3) shows that
the five best-answered questions had results ranging
from 78.5% to 85.5%. Four of these (Q12 [85.5%],
Q13 [80.4%], Q28 [79.2%], and Q11 [78.5%]) are in
the first section of the questionnaire, which concerns
beliefs about the patient’s experience of pain and the
nurse’s knowledge of pain assessment and manage-
ment. The other question in the top five (Q22
[81.0%]) is in the section on beliefs about opioid
delivery and knowledge about opioids. On the other
hand, for 6 of the 20 visual analog scale questions
the average result was under 50%. Those six are ques-
tions 23 (48.2%) and 20 (23.3%) on knowledge about
opioid use; questions 29 (40.0%) and 30 (39.1%) on
self-perception of competence; and questions 15
(41.4%) and 17 (33.3%) on perceptions about the pa-
tient’s experience of pain. Note that we found no asso-
ciation between the nurses’ sociodemographic
characteristics and their level of knowledge about
chronic pain management.
Perceptions of Barriers Preventing
Performance of CNCP Management
Four recurring themes stand out among answers to the
open questions on CNCP management: foremost, the
limited time available to health professionals for
providing care to patients with CNCP. Next was the
lack of knowledge among physicians and nurses about
CNCP management, followed by the need for ongoing
training to extend and refresh their knowledge. Lastly,
many nurses pointed out the subjective and complex
nature of CNCP assessment.
DISCUSSION
One of the first findings of our study concerned the
suboptimal knowledge and inappropriate beliefs
 Noncancer Pain Management Beliefs 955

TABLE 3.
Scores, From Highest to Lowest Percentage, for Each Visual Analog Scale in Our Modified French
Version of the Toronto Pain Management Index
Questions (Q) n Average % (SD)

1. Q12: With effective relief, what pain rating (from 0 to 100) should patients experience?* 50 85.3 (21.0)
2. Q22: How often should you use a combination of pharmacological and non- 49 81.0 (20.9)
pharmacological treatments to help a patient suffering from CNCP?
3. Q13: How often do patients overstate their pain?* 49 80.4 (17.2)
4. Q28: How often do you use a scale (e.g. 1 to 10) to assess a patient’s pain? 49 79.2 (26.6)
5. Q11: What percentage of your patients who take opioids (e.g. codeine, morphine) to 50 78.5 (20.0)
relieve their pain become addicted?*
6. Q19: What percentage of patients where you work say that they experience severe pain?* 51 76.9 (23.4)
7. Q14: How often do you agree with patients’ statements about their pain? 51 75.6 (20)
8. Q21: What pain rating (from 0 to 100) should patients have before they receive an 50 73.4 (15.5)
analgesic dose?*
9. Q26: To what degree do nurses where you work agree with your decisions about 42 69.2 (20.3)
managing a patient’s pain?
10. Q27: To what degree do physicians where you work agree with your decisions about 43 68.7 (22.1)
managing a patient’s pain?
11. Q18: What percentage of patients where you work say that they experience moderate 51 65.9 (19.4)
pain?*
12. Q16: How often do patients ask you voluntarily for an analgesic?* 51 58.7 (26.1)
13. Q24: Mrs. Nadeau’s morphine dose has been increased because of her unrelieved pain. 50 57.3 (30.1)
She has begun to experience nausea and is given an antiemetic. Your nursing colleague
suggests that you decrease the morphine dose. To what extent do you agree with her?*
14. Q25: Mr. Thivierge, despite receiving 10 mg of morphine every four hours, continues to 50 51.8 (31.0)
report moderate pain. Would you ask the physician for a higher dose?
15. Q23: A 45-year-old construction worker complains of severe chronic pain in the lumbar 49 48.2 (35.9)
region despite taking Tylenol every four hours. Would you suggest that he take the
prescribed morphine dose of 10 mg SC q4h?
16. Q15: How often do patients tell you without being asked that they are having pain? 50 41.4 (24.2)
17. Q29: To what degree do you feel that your current knowledge about pain management 52 40.0 (23.2)
(assessment and relief) is adequate?
18. Q30: To what degree do you feel competent to provide effective pain management to 52 39.1 (24.1)
patients?
19. Q17: What percentage of patients where you work say that they are experiencing light 51 33.3 (24.1)
pain?
20. Q20: What percentage of your patients take analgesics orally when other routes would 47 23.3 (24.0)
be more appropriate?
SD ¼ standard deviation; CNCP ¼ chronic non cancer pain.
*Reverse-score question.

among participating nurses. The second finding was
that, when asked about the challenges they face in
managing CNCP, the nurses identified a lack of
time and a lack of CNCP-specific training. Those
findings are consistent with the model of Patiraki-
Kourbani et al. (2004).
The knowledge and beliefs of nurses about
opioid administration, their customary practice,
and their self-perception of competence in
managing CNCP should be improved. These results
are in line with the principal shortcomings noted in
the literature, including ignorance of pharmacolog-
ical treatment options (Matthews & Malcolm,
2007); false beliefs about opioid use (Broekmans
et al., 2004); and awareness of limitations with
regard to knowledge, attitudes, and beliefs about
pain management (Coulling, 2005). On the whole,
however, the nurse participants have a positive atti-
tude toward taking on a greater role in the manage-
ment of chronic pain.
The suboptimal knowledge and beliefs of our
respondents can be explained by a number of
perceived barriers. First, given that chronic pain
syndrome was only recognized fairly recently
(Breen, 2002) and that over 60% of the participating
nurses had more than 10 years of experience,
chronic pain was probably not covered in depth
during their academic training. Indeed, 34% of the
participating nurses said they had received no aca-
demic training on pain. Furthermore, among those
956 Bergeron, Bourgault, and Gallagher
who had received such training, the median number
of hours received was 9. That figure contrasts
sharply with the average of 31 hours reported in a
study of nine Canadian nursing schools (Watt-
Watson et al., 2009). The same study also revealed
that academic training devoted little time to false
beliefs, pain assessment, and pain care. Thus, these
core concepts probably received little or no discus-
sion during our participants’ training.
Our second finding concerned the need to
develop ongoing training on pain management for
FMG staff, with a particular focus on the different
types of assessment tools. Results show that
on-the-job training about pain is positively associ-
ated with nursing activities in pain management
(Gregory & Haigh, 2008; Hansson, Fridlund, &
Hallstr€om, 2006; Patiraki et al., 2006). Other
results show that receiving continuing education
on the provision of care for chronic health
problems increases nurses’ professional autonomy,
notably in evaluating and documenting pain
(Courtenay & Carey, 2008; E
quipe d’
evaluation des
GMF, 2008). However, adequate knowledge and
appropriate beliefs alone do not guarantee a
change in nurse practices. Nurses must also have a
positive attitude toward playing a greater role in
pain management. The combination of proper
knowledge and beliefs with a positive attitude will
result in more effective pain management by
nurses (McMillan, Tittle, Hagan, & Small, 2005).
In this regard, the positive attitudes toward
playing a greater role in CNCP care found in our
participants lead us to believe that with improved
knowledge and beliefs, they would become able to
perform a wider variety of CNCP management ac-
tions. To maximize participation, training toward
that end should take an adult learning approach
(Lapr
e, Bolduc, & Bourgault, 2011). For optimal
pain management to be maintained subsequently,
follow-up training and feedback from peers should
also be provided on a regular basis (Warren
Stomberg, Lorentzen, Joelsson, Lindquist, &
Haljam€ae, 2003). As mentioned by the RNAO
(2013), healthcare facilities are also responsible
for providing pain care, and action plans should
be implemented to ensure that they do so
adequately. It is therefore crucial that nurses be
given the resources they need to perform optimal
pain management.
Limitations, Strengths, Benefits
This is the first study to document the knowledge of
nurses about CNCP management and the perceived
challenges they face in the FMG context, based on a
comprehensive sample of FMG nurses in Qu
ebec.
Though Dillman’s guidelines (2007) were re-
spected, the response rate and sample size (n ¼ 53)
were somewhat disappointing for a province-wide
study. In fact, when compared with the median
response rate of 50.0% (37.0-71.0) reported by a
meta-analysis of mail-in surveys of nurses (Cook,
Dickinson, & Eccles, 2009), our response rate of
29.8% is low.
This low response rate suggests the presence of
a favorable systematic bias in the answers (Grove
et al., 2013). The time required to complete the
survey could also explain our low rate. Neverthe-
less, the additional information generated from
longer mail-in questionnaires is considered to
compensate for the no-response risk (Lund &
Gram, 1998). It could also be that the nurses who
did not respond did not feel concerned by the ques-
tion of pain management. Finally, despite the prior
permission given by the nurses to contact them at
home for research purposes, this strategy is prob-
ably less effective than recruiting directly in their
working environment.
The results of this study will contribute to dis-
cussions of the contribution of nurses to CNCP
management in primary care, and to recognition
of the importance of developing FMG-nurse-
specific training (D’Amour et al., 2008). Such
discussion is especially important now in Quebec,
before creating an integrated structure for CNCP
management that would involve primary care
workers (Fr
echette & Bouchard, 2012).
CONCLUSION
Although the present study highlights the
suboptimal knowledge of FMG nurses, it also shows
that they are open to playing a larger role in the
management of chronic pain, an affliction suffered
by 16% of the population (Boulanger, Clark,
Squire, Cui, & Horbay, 2007). Through the collabo-
ration of nurses and family physicians, and by opti-
mizing the knowledge and contributions of nurses,
FMGs could become an important component in
the development and deployment of an integrated
structure for CNCP care in Quebec. People
suffering from CNCP would gain faster access to pri-
mary care professionals specializing in the clinical
assessment and treatment of their condition,
providing them with better care and, ultimately,
more effective pain relief.
 Noncancer Pain Management Beliefs
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