Nurses' Knowledge and Attitudes About Pain

Personal and Professional Characteristics and Patient Reported Pain Satisfaction

Jeannine M. Brant, PhD, APRN, AOCN, FAAN; Carla Mohr, RN, BSN, PCCN; Nicholas C. Coombs, MS; Susan Finn, MN, RN, CEN, CCRN; Estella Wilmarth, BSN


Pain Manag Nurs. 2017;18(4):214-223. 

In This Article

Abstract and Introduction


Pain is a nursing sensitive indicator and yet pain is often not well managed in both hospital and ambulatory settings. Improving nurse knowledge and attitudes about pain may translate to improved patient outcomes. The objective of this study was to investigate knowledge and attitudes about pain (KAP) in nurses who work in diverse settings, professional and personal characteristics that predict KAP, and whether KAP correlated with patient satisfaction according to Hospital Consumer Assessment of Healthcare Providers (HCAHPS). Descriptive, cross-sectional, correlational study. A large integrated health care facility in the northwest. A total of 217 registered nurses working in acute, ambulatory, and long-term care. A Pain Knowledge and Attitudes Survey was administered to registered nurses in diverse settings. Scores were examined for personal and professional predictors of KAP and correlated with HCAHPS patient satisfaction surveys. Nurses scored an average of 72%; nurses in long-term care scored the highest. Having more than 5 years of nursing experience, being a certified nurse, and receiving pain education in the last year were predictive of a higher score on the KAP survey, which explained only 9.8% of the variance. Unit mean KAP scores were highly correlated with unit-based HCAHPS scores (r = 0.917, p = .01). Certified nurses scored higher on the KAP survey, consistent with other studies. This study suggests that having more knowledge and better attitudes about pain may improve patient satisfaction of pain. Further studies are needed that link knowledge and attitudes about pain to patient outcomes.


Appropriate pain assessment and management are key indicators of pain care quality and patient satisfaction, regardless of health care setting—the hospital, ambulatory setting, and long-term care (Beck et al., 2010, Pett et al., 2013, Topolovec-Vranic et al., 2010). Approximately 50%-80% of hospitalized patients experience pain at some time during their hospitalization as a result of procedures, surgical interventions, and disease states (Coker et al., 2008, Goldberg and Morrison, 2007, Gregory and McGowan, 2016). Additionally, 100 million adults suffer from chronic pain in the United States. These patients receive care in all health care settings (Institute of Medicine, 2011).

Pain is a nursing sensitive indicator; therefore nurses have a pivotal role in the assessment and management of pain. Unfortunately, the treatment of pain is highly inadequate because of social stigma about pain, fears of addiction, and inadequate clinician knowledge about the best ways to manage pain (Institute of Medicine, 2011, Meeker et al., 2011, Oliver et al., 2012). Although clinician knowledge about pain is known to be insufficient, studies are lacking that identify whether improving knowledge and attitudes about pain can influence outcomes (Beck et al., 2016).

Some evidence exists that pain resource nurse (PRN) programs have been instrumental in improving pain care quality (Ferrell, Grant, Ritchey, Ropchan, & Rivera, 1993). A recent systematic review indicated successful elements of PRN programs, including leadership commitment, an embedded culture of effective pain management throughout the organization, recognizing pain management barriers, identifying strategies to overcome these barriers, and collaborative multidisciplinary teamwork and communication (Crawford, Boller, Jadalla, & Cuenca, 2016). This organization launched a PRN program to improve pain care quality, and this study was a collaborative effort of the PRN nurses of this organization.

This purpose of this study was to (1) examine nurse knowledge and attitudes about pain (KAP) among nurses who work in diverse settings; (2) identify professional (certification status, experience, degree, area of practice, being a PRN) and personal characteristics (age, gender, personal or family history of pain or substance abuse) that predict KAP, and (3) examine whether KAP correlates with patient satisfaction according to Hospital Consumer Assessment of Healthcare Providers (HCAHPS). It was hypothesized that KAP would be higher in certified nurses and in those with a personal or family history of pain or substance abuse, and that patients would be more satisfied when cared for on nursing units where nurses scored the highest; that is, who had more knowledge and better attitudes about pain.

Literature Review

The literature is replete with decades of research describing inadequate knowledge and attitudes about pain and suboptimal pain management practices among health professionals, including nurses. Ignorance regarding the use of opioids has fueled fears related to addiction despite care recommendations by the American Society of Pain Management Nurses and others (Oliver et al., 2012, van Boekel et al., 2015). Fear related to side effects such as respiratory depression is warranted, but opioids can be delivered safely with adequate knowledge (Jarzyna et al., 2011). Misconceptions exist regarding prevalence and inevitability of pain, especially in older adults; mistaken beliefs about pain assessment; and inadequate knowledge of opioid pharmacology (Lewthwaite et al., 2011, Swafford et al., 2014). Some clinicians find it difficult to believe a patient's report of pain, which can affect pain management practices (Briggs et al., 2013, Niemi-Murola et al., 2007), and the high incidence of addiction in society complicates this issue (Institute of Medicine, 2011, Paice et al., 2016). Physicians and nurses have also been known to rely on personal experiences when assessing another individual's pain (Vaismoradi, Skar, Soderberg, & Bondas, 2016). Studies examining a personal experience of pain and its influence on pain knowledge and attitudes are limited. Studies are also lacking on the relationship between a personal or family history of substance abuse and knowledge and attitudes about pain and addiction. This study descriptively examines these potential relationships.

Some data exist regarding which nurses have more knowledge and better attitudes about pain and whether or not this knowledge translates to improved patient outcomes. For example, some studies report that a higher education level results in increased knowledge (Brunier et al., 1995, Lewthwaite et al., 2011), but other studies found no difference (Brown et al., 1999, Matthews and Malcolm, 2007). The influence of nursing certification on pain knowledge and attitudes has been investigated in a handful of studies. Beck and colleagues recently found that oncology-certified nurses scored significantly higher than noncertified nurses (Beck et al., 2016); additional studies concurred (Coleman et al., 2010, Frank-Stromborg et al., 2002). Although there may be knowledge differences, more knowledge and better attitudes about pain has not necessarily translated to improved pain management outcomes, and further investigation is needed (Beck et al., 2016, Coleman et al., 2010, Frank-Stromborg et al., 2002).

Patient satisfaction about pain has received increased interest with the advent of HCAHPS, a national initiative that measures patients' perspectives on hospital care, including pain. HCAHPS provides a national standard for collecting and publicly reporting patients' perspectives of care information that enables valid comparisons to be made across all hospitals. In May 2005, the National Quality Forum, an organization established to standardize health care quality measurement and reporting, formally endorsed the HCAHPS Hospital Survey (Keller et al., 2005, O'Malley et al., 2005). The National Quality Forum endorsement represents the consensus of health care providers, consumer groups, professional associations, purchasers, federal agencies, and research and quality organizations. Surveys are sent to patients after discharge from an inpatient visit. Patients are asked to rate responses according to the nursing unit they were discharged from. Data are released per hospital and per hospital unit. Hospitals and units are scored positively on the indicator only if the patient answers "Always" on the survey. Hospital reimbursement is awarded based on positive scores, triggering interest in patient satisfaction. Although these data provide a mechanism to benchmark pain satisfaction with other organizations, this team of investigators is unaware of any study that reported a relationship between KAP and HCAHPS scores.