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AttitudesandBeliefsAboutChronicPainAmongNursesBiomedicalorBehavioral?ACrosssectionalSurvey

IndianJPalliatCare.2011SepDec17(3):227234.

PMCID:PMC3276821

doi:10.4103/09731075.92341

AttitudesandBeliefsAboutChronicPainAmongNursesBiomedicalorBehavioral?
ACrosssectionalSurvey
VenkatesanPrem,HarikesavanKarvannan,RDChakravarthy, 1BBinukumar, 2SarojaJaykumar, 3andSenthilPKumar4
DepartmentofPhysiotherapy,ManipalCollegeofAlliedHealthSciences,(BangaloreCampus),Manipal,Karnataka,India
1
DepartmentofOrthopaedics,ManipalHospital,Bangalore,Karnataka,India
2
DepartmentofStatistics,ManipalUniversity,Manipal,Karnataka,India
3
ManipalCollegeofNursing,ManipalUniversity,Bangalore,India
4
DepartmentofPhysiotherapy,KasturbaMedicalCollege,ManipalUniversity,Mangalore,Karnataka,India
Addressforcorrespondence:SenthilPKumar,Email:senthil.kumar@manipal.edu
Copyright:IndianJournalofPalliativeCare
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,whichpermits
unrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
ThisarticlehasbeencitedbyotherarticlesinPMC.

Abstract

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Context:

Studieshavedocumentedthatnursesandotherhealthcareprofessionalsareinadequatelypreparedtocarefor
patientsinchronicpain.Severalreasonshavebeenidentifiedincludinginadequaciesinnursingeducation,absence
ofcurriculumcontentrelatedtopainmanagement,andattitudesandbeliefsrelatedtochronicpain.
Aims:

Theobjectiveofthispaperwastoassessthechronicpainrelatedattitudesandbeliefsamongnursingprofessionals
inordertoevaluatethebiomedicalandbehavioraldimensionsoftheirperceptionsonpain.
SettingsandDesign:

Crosssectionalsurveyof363nursesinamultispecialtyhospital.
MaterialsandMethods:

Thestudyutilizedaselfreportquestionnairepainattitudesandbeliefsscale(PABS)whichhad31items
(statementsaboutpain)foreachofwhichthepersonhadtoindicatethelevelatwhichheorsheagreedor
disagreedwitheachstatement.Factor1scoreindicatedabiomedicaldimensionwhilefactor2scoreindicateda
behavioraldimensiontopain.
StatisticalAnalysisUsed:

ComparisonsacrossindividualandprofessionalvariablesforbothdimensionsweredoneusingonewayANOVA
andcorrelationsweredoneusingtheKarlPearsoncoefficientusingSPSSversion11.5forWindows.
Results:

Theoverallfactor1scorewas52.9510.23andfactor2scorewas20.934.72(P=0.00).Thefemalenurses
hadahigherbehavioraldimensionscore(21.14.81)thantheirmalecounterparts(19.553.67)whichwas
significantatP<0.05level.
Conclusions:

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Nurseshadagreaterorientationtowardthebiomedicaldimensionofchronicpainthanthebehavioraldimension.
Thisdifferencewasmorepronouncedinfemalenursesandthosenurseswhoreportedverygoodgeneralhealth
hadhigherbehavioraldimensionscoresthanthosewhohadgoodgeneralhealth.Thestudyfindingshave
importantcurricularimplicationsfornursesandpracticalimplicationsinpalliativecare.
Keywords:Nursingeducation,Painassessment,Professionalbehavior,Professionalpsychology,Psychosocial
issues
INTRODUCTION

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Healthcareprofessionalsknowledge,attitudes,beliefs,andexperiencesdeterminenotonlytheirprocedurebut
alsotheirbehaviorduringtheevaluationandtreatmentofpatientswithchronicpain.[1]Painisthecommon
complaintandisoftenatopicofdiscussionbothbetweenpatientsandtheircaregivers,andbetweenphysiciansand
otherpalliativecareteammembers.[2]Afterphysicians,thenursesarethemostvaluablepalliativecareteam
memberswhoaddressthephysical,functional,social,andspiritualdimensionsofcare.[3]Fivepainmanagement
activitiesperformedbynursepractitionerswereidentified,includingassessingpain,prescribingpainmedications,
monitoringpainlevelsandsideeffectsofpainmedications,consultingandadvocatingforstaffandpatients,and
leadingandeducatingstaffrelatedtopainmanagement.[4]Studieshavealsodocumentedthatnursesandother
healthcareprofessionalsareinadequatelypreparedtocareforpatientsinchronicpain.Severalreasonshavebeen
identifiedincludinginadequaciesinnursingandmedicaleducation,absenceofcurriculumcontentrelatedtopain
management,andfacultyattitudesandbeliefsrelatedtochronicpain.[5]
Duringapatient'sstayinaward,nursesholdagreatdealofresponsibilityforpainmanagement,especiallywhen
analgesicsareprescribedonanasneededbasisforpatientswithchronicpain.Despitetheavailabilityofeffective
analgesicsandnewtechnologiesfordrugadministration,studiescontinuetodemonstratesuboptimalpain
management.[6]Accuratepainassessmentisvitalforgoodmedicalcare,andyettheliteratureindicatesthatnurses
oftenprovideinaccurateandbiasedestimatesoftheirpatientspain.[7]
Theknowledgeandunderstandingaboutchronicpainhadundergoneaparadigmshiftfromabiomedical
dimensiontoabehavioraldimension.[810]Inotherwords,ananatomicalorpathologicalunderstandingisnow
replacedwithbiopsychosocialperspectiveforpain.[11]Onesuchrecentbiopsychosocialexplanationofpainisthe
mechanismbasedclassification,usedbyphysicaltherapistsmanagementinpalliativecare.[12]Psychosocialissues
amongpatientsareoftenrecognizedinthefieldofpalliativecare.[13]Painisnotonlyreportedasacommon
complaintfrompatients,butalsoisacommonexperienceamonghumanbeingsingeneral.[14]
Previousstudiesevaluatednursesattitudestowardspaincontrol,[15]palliativesedation,[15,16]lifesustaining
treatment,[17]death,[18]endoflifereferrals,[19]caringforclientswithsexualhealthconcerns,[20,21]caringfor
peoplewithHIV/AIDS,[22]andcaringfordying.[18,23,24]
Thoughtherewerestudiesthatpreviouslyexaminednursesattitudestowardspain,manywereonquestionnaire
development,[2527]levelofeducation,[2831]practicepatterns,[32]andtypeofworksetting.[28,33]Noneofthe
studiesappropriatelyexaminedthetwodimensions,biomedicalandbehavioral,whichdeterminetheclinical
approachofthenursesinpainandpalliativecare.Anursewhohasapredominantlybiomedicalorientationtoward
painmaybemoreinclinednottogivefrequentanalgesicsinordertoavoidpatientaddictionwhileanursewitha
behavioralorientationmayprovideprescribedanalgesicstothepatientfrequentlywheneverindicatedsothatthe
patientmaydeservetohaveabetterqualityoflife.Whileabiomedicalnursemaybeinterestedinwhatthe
patientdoes,abehavioralnursemaybeinterestedinwhatthepatient"feels."Integratingthebehavioral
dimensioninunderstandingofpainisessentiallywarrantedinasituationsuchaspalliativecare.
Althougheffectivemeansforchronicpainmanagementhavelongbeenavailable,cancerpainremainswidely
undertreated.[34]Balfour[35]foundthatnursesdidnotalwaysadministeralltheanalgesiaprescribedtopatients,
eventhoughpatientsreportedsufferingpain.Surveysofmedicalpersonnelhaverevealedknowledgedeficitsand
attitudinalbarrierstochronicpainmanagement,buthavenotdeterminedwhysuchattitudespersistandhowthey
maybeaddressedinmedicalandnursingcurricula.[36]Theroleofnursesinpalliativecaresettingshadbeen
understoodinextensiveproportion,andinvariablytheirattitudesandbeliefsaboutchronicpainintermsof
biomedicaland/orbehavioraldimensionswouldhaveadirectimpactontheircommunicationbothwithpatients/
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caregiversandwithphysicians/otherteammembers.Knowingthepresentlevelsofprofessionalsattitudesand
beliefsfacilitateappropriatetrainingprograms[3740]toaddressidentifieddeficitsandtherebytoimprovethe
qualityofprovidedcare.Theobjectiveofthispaperwastoassessthechronicpainrelatedattitudesandbeliefs
amongnursingprofessionalsinordertoevaluatethebiomedicalandbehavioraldimensionsoftheirperceptionson
chronicpain.
MATERIALSANDMETHODS

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Thestudywasconductedinamultispecialtytertiarycarehospital,wheretheparticipantsincludedthosewho
attendedacontinuingprofessionaldevelopmentprogramexclusivelyforqualifiedstaffnurseswithaminimumof
Baccalaureatedegreeinnursing.Study'sethicalapprovalwasobtainedfromtheinstitutionalethicscommitteeand
allparticipantswererequiredtoprovidetheirwritteninformedconsentpriortotheirparticipation.Consented
participantswerethengiventhesurveyquestionnaire.
Thestudyutilizedaselfreportquestionnairewhichwasmodifiedfromitsoriginalversion,thepainattitudesand
beliefsscale(PABS)developedandvalidatedearlierbyOsteloetal.,[41]formeasuringhealthcareproviders
attitudesandbeliefstowardchroniclowbackpain.[42]Thetermchroniclowbackpainwasreplacedby
chronicpaininalltheitemsofthequestionnaire.Thescalehad31items(statementsaboutpain)foreachof
whichthepersonhadtoindicatethelevelonwhichheorsheagreedordisagreedwitheachstatement:1=totally
disagree,2=largelydisagree,3=disagreetosomeextent,4=agreetosomeextent,5=largelyagree,
and6=totallyagree.Tocalculatethescoreoffactor1,thescoresofitems4,5,9,10,13,14,20,22,23,24,25,
26,30,and31wereadded.Forfactor2,thescoresofitems3,6,7,11,12,and27wereadded.Forfactor1,the
rangewasfrom14through84,andfrom6through36forfactor2.
Thereceivedquestionnaireswerethenscreenedfortheirsuitabilityofresponsestogetthefinalnumberofincluded
participantsquestionnaires.Thus,wearrivedattheresponserateforoursurvey.
ComparisonsacrossindividualandprofessionalvariablesforbothdimensionsweredoneusingonewayANOVA
(posthocanalysisusingtheBonferonnitest)andcorrelationsweredoneusingtheKarlPearsoncoefficientusing
SPSSversion11.5forWindows(SPSSInc.,IL,USA).
RESULTS

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Outoftotal392questionnairesdistributedandcollected,363validquestionnaireswereincludedforanalysis,with
aresponserateof92.6%.TheoveralldescriptivedataofthestudyparticipantsareprovidedinTable1.
Table1
Overalldescriptivedataofstudyparticipants

ComparisonofPABSdimensionsbetweengenders

ThefemalenurseshadahigherbehavioraldimensionscorethantheirmalecounterpartswhichwassignificantatP
<0.05level.Thebiomedicaldimensionwasnotsignificantlydifferentbetweengenders[Table2andFigure1].
Table2
Comparisonofpainattitudesandbeliefsscaledimensionsbetweengenders
Figure1
Comparisonofpainattitudesandbeliefsscale(PABS)dimensionsbetween
genders
ComparisonofPABSdimensionsbetweenmaritalstatusescategories

Boththedimensionsdidnotdiffersignificantlybetweenthethreemaritalstatusesamongthenurses[Table3and
Figure2].
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Table3
Comparisonofpainattitudesandbeliefsscaledimensionsbetweenmarital
statuscategories
Figure2
Comparisonofpainattitudesandbeliefsscaledimensionsbetweenmarital
statuscategories
ComparisonofPABSdimensionsbetweenqualitiesofsleepcategories

Boththedimensionsdidnotdiffersignificantlybetweenthethreequalitiesofsleepcategoriesamongthenurses[
Table4andFigure3].
Table4
Comparisonofpainattitudesandbeliefsscaledimensionsbetweenqualities
ofsleepcategories
Figure3
Comparisonofpainattitudesandbeliefsscaledimensionsbetweenqualities
ofsleepcategories
ComparisonofPABSdimensionsbetweenphysicalactivitiescategories

Boththedimensionsdidnotdiffersignificantlybetweenthethreephysicalactivitycategoriesamongthenurses[
Table5andFigure4].
Table5
Comparisonofpainattitudesandbeliefsscaledimensionsbetweenphysical
activitycategories
Figure4
Comparisonofpainattitudesandbeliefsscaledimensionsbetweenphysical
activitycategories
ComparisonofPABSdimensionsbetweengeneralhealthcategories

Astatisticallysignificantoverallcomparisonwasfoundforbehavioraldimensionscoresbetweenthethreehealth
categorieswiththeposthoccomparisonbeingsignificantbetweenverygoodandgoodhealthcategories[
Table6andFigure5].
Table6
Comparisonofpainattitudesandbeliefsscaledimensionsbetweengeneral
healthcategories
Figure5
Comparisonofpainattitudesandbeliefsscaledimensionsbetweengeneral
healthcategories
ComparisonofPABSdimensionsbetweentypesofworksettings

Astatisticallysignificantoverallcomparisonwasfoundbothforbiomedicalandbehavioraldimensionscores
betweenthefourworksettingcategorieswiththeposthoccomparisonbeingnotsignificantbetweenany
categories[Table7andFigure6].
Table7
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Comparisonofpainattitudesandbeliefsscaledimensionsbetweentypesof
worksettings
Figure6
Comparisonofpainattitudesandbeliefsscaledimensionsbetweentypesof
worksettings
Secondaryanalysis

Age(r=0.033),bodyheight(r=0.004),bodyweight(r=0.020),BMI(r=0.023),workexperienceinthe
presentjob(r=0.058),andtotalworkexperience(r=0.004)werenotsignificantlyassociatedwiththefactor1
biomedicaldimensionsubscoreofPABS.
Age(r=0.001),bodyheight(r=0.024),bodyweight(r=0.033),BMI(r=0.046),workexperienceinthe
presentjob(r=0.088),andtotalworkexperience(r=0.008)werenotsignificantlyassociatedwiththefactor2
behavioraldimensionsubscoreofPABS.
Thefactor1subscorehadamoderatepositivecorrelation(r=0.445)thanthefactor2subscoreofPABSwhich
wasstatisticallysignificantatP<0.01.Inallanalyses,thebiomedicaldimensionscorewassignificantlygreater
thanthebehavioraldimensionscoreforallcategoriesandsubcategories.
DISCUSSION

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Nursingpainassessmentsareinfluencedbythelengthofavailabletools,patientcharacteristics,patientpathology,
concernaboutaddictivebehavior,andcharacteristicsofthenurse.[43]Painbydefinitionisamultifactorial
phenomenonforwhichbiomedicalfactorsinteractwithawebofpsychosocialandbehavioralfactors.Behavioral
medicineapproachesforpaingenerallyaddressspecificcognitiveandbehavioralfactorsrelevanttochronicpain,
therebyaimingtomodifytheoverallpainexperienceandhelprestorefunctioningandqualityoflifeinpain
patients.Behavioralmedicinefocusesonpatientsmotivationtocomplywitharehabilitativeregimen,particularly
thosewithchronic,disablingpain.Sincepatientsowncommitmentandactiveparticipationinatherapeutic
programarecriticalforthesuccessfulrehabilitation,therolethatbehavioralmedicinecanplayinpainandpalliative
careissignificant.[44]
Thisstudyincludedbiopsychosocialfactorsrelatedtonursingstaffsuchasage,gender,height,weight,andBMI
qualityofsleepandgeneralhealthandphysicalactivityandworksetting.Weconsideredtheabovementioned
individualrelatedvariablessuchasage,height,weight,andBMIwithrespecttochronicpainrelatedattitudesand
beliefssincetheseanthropometricfactorswereshowntoberelatedtothedevelopmentofpain.[45]Previous
studiesreportedbiopsychosocialriskfactors[4648]forthedevelopmentofchronicpainamongnursesandthey
foundasignificantinfluenceofageandgenderonnursesattitudestowardnotonlypainassessmentand
managementbutalsoonpain[49]andpatientspainidentitiesperse.[50]Otherpsychosocialfactors,bothwork
related[51]andhealthrelated,[52]werestudiedasinfluencingheathbehaviorsinthedevelopmentofchronicpain
amongnurses.Personalexperienceinchronicpainwouldinfluenceattitudesandbeliefstoagreaterextentthan
knowledgeacquiredthroughformaltraining.
Inadequaciesinthepainmanagementprocessmaynotbetiedtomythsandbiasesoriginatingfromgeneralattitudes
andbeliefs,butmayreflectinadequatepainknowledge.[53]Futurestudiesmayassesssuchrelationshipsbetween
knowledge,attitudes,beliefs,andbehaviorsofnursesinreallifepalliativecaresituations.Thestudyfindingsareof
utmostsignificancesinceindividualattitudesandbeliefslargelydeterminetheinterindividualandinterdisciplinary
communicationinamultidisciplinarycareframeworkforpainandpalliativecare.[54]Attitudestogetherwith
subjectivenormsandperceivedcontrolinfluencenursesintentiontoperformcomprehensivepainassessments.[55]
Patientswhodonotreportpainandhealthcareproviderswhofailtoassessforpainaremajorbarrierstotherelief
ofchronicpain.Usingpainasthefifthvitalsignandbeingknowledgeableaboutpainassessmentandmanagement
canhelpnursesandotherhealthcareprovidersovercomemanyofthebarrierstosuccessfulpaincontrol.A
successfulpaincontrolplanincludesestablishingthepaindiagnosis,treatingthecauseofthechronicpainwhen
possible,optimizinganalgesicuse,implementingnonpharmacologicalinterventionstomaximizephysicaland
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psychologicalcomfortandfunction,andreferringthepatientforinvasivepainmanagementoptionswhen
indicated.[56]
Thefindingsalsosuggestthatafurtherstudyisneededconcerningtherelationshipbetweenpersonalbeliefsand
experiencesandtheassessmentandmanagementofchronicpain.Membershipinprofessionalorganizations
appearstobeassociatedwithcomprehensiveapproachestotheassessmentandmanagementofpainandshouldbe
assessedinfurtherresearch.[43]
CONCLUSION

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Nurseshadagreaterorientationtowardthebiomedicaldimensioninchronicpainthanthebehavioraldimension.
Thisdifferencewasmorepronouncedinfemalenursesandthosenurseswhoreportedverygoodgeneralhealth
hadhigherbehavioraldimensionscoresthanthosewhohadgoodgeneralhealth.Thestudyfindingshave
importantcurricularimplicationsfornursesandpracticalimplicationsinpalliativecare.
ACKNOWLEDGMENT

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Theauthorswishtothanknurseswhoparticipatedinthestudyfortakingouttheirvaluabletimeandsharingtheir
viewsandopinionsinthesurvey.
Footnotes

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SourceofSupport:Nil
ConflictofInterest:Nonedeclared.

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