Original Articles

Association of the knowledge of nurses about the pain management with their attitude towards cancer patients

Nasreen Tufail1, Khalid Zaeem2, Mansoor Ghani3, Shamila Afshan4, Ayesha5

1Deputy Matron; 5Statistician, Combined Military Hospital, Jhelum (Pakistan)

2Classified Anesthesiologist, Military Hospital, Rawalpindi (Pakistan)

3Program Coordinator, University of Health Sciences, Lahore (Pakistan)

4Biostatistician, Punjab Institute of Cardiology, Lahore (Pakistan)

Correspondence: Lt Col Nasreen Tufail, Deputy Matron, Combined Military Hospital, Jhelum Cantt (Pakistan); Phone: +92 3088984478: E-mail: ntntufail@gmail.com


Objective: Proper training and knowledge about pain and pain management can help nurses during their task of active management to relieve pain, but it also builds positive attitude towards patients. We aimed to determine the association between knowledge and attitudes of the nurses about pain management of cancer patients and the relationship to different demographic and educational factors.

Methodology: This cross-sectional study was conducted in four hospitals of Lahore, (Pakistan) from 1st July 2013 to 1st July 2014. A self-administered questionnaire was used to collect data. 100 nurses working in cancer units (both medical and surgical oncology wards) were included in the study using convenient sampling technique. Nurses not working in cancer units, high positioned (head nurses) and nurses with higher education [e.g. MSc (N), post RN-BSc (N), other courses] were excluded from the study. Questionnaire used based upon the “Knowledge and Attitudes Survey Regarding Pain (KASRP)” for knowledge and attitude. Data was collected and analyzed using SPSS version 21.0.

Results: Out of one hundred nurses 90% were females while 10% were males. The mean age of participants was 30.88 ± 8.91 years. Majority of the nurses i.e., 59% had inadequate knowledge. Attitude score regarding the cancer pain management was 60%. Knowledge of pain management was significantly associated with nurses attitude towards pain management (p = .001).

Conclusion: There is positive association between the knowledge and attitude towards cancer pain management. Thus, by showing good attitude, the nurses, who spend most of their time with patients can help to minimize their pain. This is only possible if the nurses have proper knowledge and education in this field.

Key words: Pain; Knowledge; Attitude; Nurses; KASRP

Citation: Tufail N, Zaeem K, Ghani M, Afshan S, Ayesha. Association of the knowledge of nurses about the pain management with their attitude towards cancer patients. Anaesth Pain & Intensive Care 2017;21(2):166-169

Received: 21 Jan 2017, Reviewed: 18 Mar 2017, Corrected: 30 Apr 2017, Accepted: 5 May 2017


Cancer is the term to describe a pathological condition when cells of the body start uncontrolled growth. Cancer is a very ancient disease and records for the ailment are found throughout the history and it is also evidently found in fossil bones and Egyptian mummies.1

Approximately 6.6 million people died of cancer per year.2 According to WHO, the prevalence of cancer was found to be high in female gender i.e., females 51.8% and males 48.1%.3 The pain experienced by cancer patients is one of the most terrible one. Unmanaged pain has been identified as a major obstacle in the care of oncology patients.4 In fact, more than 70% of this population will experience chronic cancer-related pain at some point in the course of their disease with the majority receiving ineffective treatment.5 Cancer pain, which can be caused by tissue damage due to tumor invasion or as a result of treatment, such as radiation therapy and chemotherapy, can have adverse effects on the quality of life of the patients and their caregivers. Consequently, guidelines for pain management in oncology have been developed to foster better assessment techniques and interventions.6-8 The prevalence of pain in cancer patients has been estimated to range from 52% to 77%. The mean prevalence of pain in patients with various stages of cancer was 50%.9

Nurses can play an effective role in pain management; therefore, nurses’ knowledge is of critical importance in the care of patients with cancer pain.10 Pain management of cancer patients can influence by their knowledge and attitudes of nurses.12 Untreated and undertreated pain significantly interferes with the patient’s physical, emotional and spiritual wellbeing, thus can alter the patient’s quality of life.13

To manage pain, nurses must have understanding of important features of cancer pain and its’ management. In depth knowledge in all areas as pain background, previous experiences to manage pain and identified barriers that resist in management help to improve the existence and quality in pain management. So, the purpose of this study was to assess the association of the knowledge of the nurses and their attitude about the pain management of cancer patients. ‘Nurses Knowledge and Attitude Survey’ (NKAS) tool was used for this purpose.


This quantitative, descriptive cross sectional study included 100 consecutive Registered Nurses (RN’s) from four hospitals of Lahore; Institute of Nuclear Medicine and Oncology, (INMOL), Mayo Hospital, Jinnah Hospital, and Gulab Devi Chest Hospital, were during the period of 1st July 2013 to 1st July 2014.

Nurses working in oncology units both (medical & surgical), were included in the study, while high positioned (head nurses) and nurses with higher education (MSc (N), Post RN-BSc (N), other postgraduate nursing courses) were excluded from the study because mostly working in administrative posts, they are not directly involved with patient management.

Data were collected using the structured survey questionnaire KASRP which is comprised of two sections, and 36 items. Twelve out of thirty six questions were presented in a multiple choice format with one correct answer, whereas 22 items were true or false questions, and rest of two questions were in ‘yes’ or ‘no’ form.

A score of ‘1’ was awarded for each correct answer. 70% was the cut off score, with ≤ 70% designated as poor knowledge, and ≥ 70% was termed as good knowledge

Statistical analysis: Data were analyzed by using Statistical Package for the Social Sciences (SPSS) version 21.0. Mean ± SD was given for quantitative variables. Frequencies, percentages were given for qualitative variables. Correlation of the knowledge and attitude of the nurses in the pain management of cancer patients was analyzed by using Pearson correlation coefficient. Level of significance was taken as ≤ 5%. A chi-square test of independence was used to measure association between knowledge and attitude.


Out of 100 nurses, 90 were females while 10 were males. The mean age of the participants was 30.88 ± 8.91 years. Regarding education, 37% had secondary school certificate, 34% had higher secondary school (intermediate) certificate; whereas, 23% were graduate and 6% had earned a masters degree. One third (66%) nurses were married. The mean knowledge score on cancer pain management was 59 ± 18.3. Majority (59%) of the nurses had inadequate knowledge about cancer pain management (Table 1). The mean attitude score was 60 with a range score of 34-90. Knowledge of pain management was significantly associated with nurses’ attitudes towards pain management (p = 0.001) as shown in Table 2.

Table 1: Demographic data

Variables Result
gender Male 10 (10)
Female 90 (90)
Age (mean ± S.D) 30.88 ± 8.91
Marital status Single 34 (34)
Married 66 (66)
Knowledge score(mean ± SD) 59 ± 18.3
Adequate/sufficient 41 (41)
Inadequate/insufficient 59 (59)

Data shown as n (%) or mean ± SD

Table 2: Association of the knowledge of nurses with their attitude towards pain management.

Attitude towards pain management Knowledge score p-value
<70% 70%
Good 32 (32) 80 (80) 0.001
Poor 68 (68) 20 (20)


Our results showed that majority of the nurses engaged in pain management of cancer patients were females (90% vs. 10%). Miller AJ et al. in their study reported that most nurses were females (97.1%).15 Another study by Latchman et al. concluded a similar result.6 Our study showed similar results, while Shahnazi H et al. reported that female nurses for the pain management of cancer patients were 81.6% vs. 18.4%.4

The mean age of the nurses in our study was 30.88 ± 8.91 years. Shahnazi et al. found mean nurse age to be 38.7 ± 7.04 years.4 In contrast with the present study Miller AJ et al. demonstrated that the mean age of the nurses was 58.2 ± 6.96 years, which may be due to small sample size in the study.15

The criterion for minimally acceptable percentage score on the NKAS is 70%. Present study reported that majority of the nurses had inadequate knowledge with a mean knowledge score of 59%. The attitude toward cancer pain management was reported as average 60% supported by findings by Manwere A et al. who examined that the total mean knowledge and attitude scores were 64.5% and 56%.10 Shahnazi et al. analyzed that the total mean knowledge and attitude scores were 61.2% and 63%, and it showed poor knowledge and attitude regarding the pain management. Another study by Latchman Jet al. analyzed that the total mean knowledge and attitude score were 17% and 48%, showed very poor knowledge and attitude regarding the pain management.6  Yava A et al. reported poor knowledge of the nurses towards the cancer pain management at 39.65%; perhaps due to different sampling frame this study showed contradictory results.16

Present study proved that knowledge of pain management was significantly associated with nurses’ attitudes towards pain management (p-value 0.001);  similar results were shown by other studies.4,6

In contrast Ho SE et al. reported that knowledge of the nurses towards the pain management was insignificantly associated with their attitude (p ≤ 0.05).11

Present study reported that there was a direct correlation between the knowledge of the nurse and their attitude. (r = 0.410; p = 0.001), as shown by Shahnazi H et al. (r = 0.313; p = 0.002).


We conclude that there is a positive association between the knowledge of the nurses about the cancer and cancer pain and their attitude towards cancer pain management.

Acknowledgement: The authors gratefully acknowledge the kind permission by Betty Ferrell, RN, PhD, FAAN and Margo McCaffery, RN to use the tool “Knowledge and Attitudes Survey Regarding Pain” developed by them in the conduct of this study (http://prc.coh.org).

Conflict of interest: None declared by the authors

Author contribution: NT: Concept, conduction of the study work and manuscript writing

KZ: Review of literature, overall supervision

MG: Manuscript editing

SA &AS: Data analysis, interpretation


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Questionnaire: Knowledge and Attitudes Survey Regarding Pain ANNEXURE B

S.No Statement T F
1.  Because their nervous system is underdeveloped, children under two years of age have decreased pain sensitivity and limited memory of painful experiences. T F
2. Vital signs are always reliable indicators of the intensity of a patient’s pain T F
3. Patients who can be distracted from pain usually do not have severe pain. T F
4. Patients may sleep in spite of severe pain. T F
5. Aspirin and other non-steroidal anti-inflammatory agents are NOT effective analgesics for Painful bone metastases. T F
6.  Respiratory depression rarely occurs in patients who have been receiving stable doses of opioids over a period of months. T F
7. Combining analgesics that work by different mechanisms (e.g., combining an opioid with an NSAID) may result in better pain control with fewer side effects than using a single analgesic agent. T F
8. The usual duration of analgesia of 1-2 mg morphine IV is 4-5 hours. T F
9. Research shows that promethazine (Phenergan) and hydroxyzine (Vistaril) are reliable potentiators of opioid analgesics. T F
10. Opioids should not be used in patients with a history of substance abuse. T F
11. Morphine has a dose ceiling (i.e., a dose above which no greater pain relief can be obtained). T F
12. Elderly patients cannot tolerate opioids for pain relief. T F
13 Patients should be encouraged to endure as much pain as possible before using an opioid. T F
14. Children less than 11 years old cannot reliably report pain so nurses should rely solely on the parent’s assessment of the child’s pain intensity. T F
15. Patients’ spiritual beliefs may lead them to think pain and suffering are necessary. T F
16. After an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with the individual patient’s response. T F
17. Giving patients sterile water by injection (placebo) is a useful test to determine if the pain is real. T F
18. Vicodin (hydrocodone 5 mg + acetaminophen 500 mg) PO is approximately equal to 5-10 mg of morphine PO. T F


19. If the source of the patient’s pain is unknown, opioids should not be used during the pain evaluation period, as this could mask the ability to correctly diagnose the cause of pain. T F


20. Anticonvulsant drugs such as gabapentin (Neurontin) produce optimal pain relief after a single dose. T F


21. Benzodiazepines are not effective pain relievers unless the pain is due to muscle spasm. T F
22. Narcotic/opioid addiction is defined as a chronic neurobiological disease, characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. T F


Multiple Choice – Place a check by the correct answer.

  1. The recommended route of administration of opioid analgesics for patients with persistent cancer-related pain is
    1. intravenous
    2. intramuscular
    3. subcutaneous
    4. oral
    5. rectal
  2. The recommended route administration of opioid analgesics for patients with brief, severe pain of sudden onset such as trauma or postoperative pain is
    1. intravenous
    2. intramuscular
    3. subcutaneous
    4. oral
    5. rectal
  3. Which of the following analgesic medications is considered the drug of choice for the treatment of prolonged moderate to severe pain for cancer patients?
    1. codeine
    2. morphine
    3. meperidine
    4. tramadol
  4. Which of the following IV doses of morphine administered over a 4 hour period would be equivalent to 30 mg of oral morphine given q 4 hours?
    1. Morphine 5 mg IV
    2. Morphine 10 mg IV
    3. Morphine 30 mg IV
    4. Morphine 60 mg IV
  5. Analgesics for post-operative pain should initially be given
    1. around the clock on a fixed schedule
    2. only when the patient asks for the medication
    3. only when the nurse determines that the patient has moderate or greater discomfort
  6. A patient with persistent cancer pain has been receiving daily opioid analgesics for 2 months. Yesterday the patient was receiving morphine 200 mg/hour intravenously. Today he has been receiving 250 mg/hour intravenously. The likelihood of the patient developing clinically significant respiratory depression in the absence of new comorbidity is
    1. less than 1%
    2. 1-10%
    3. 11-20%
    4. 21-40%
    5. 41%
  7. The most likely reason a patient with pain would request increased doses of pain medication is
    1. The patient is experiencing increased pain.
    2. The patient is experiencing increased anxiety or depression.
    3. The patient is requesting more staff attention.
    4. The patient’s requests are related to addiction.
  8. Which of the following is useful for treatment of cancer pain?
    1. Ibuprofen (Motrin)
    2. Hydromorphone (Dilaudid)
    3. Gabapentin (Neurontin)
    4. All of the above
  9. The most accurate judge of the intensity of the patient’s pain is
    1. the treating physician
    2. the patient’s primary nurse
    3. the patient
    4. the patient’s spouse or family
    5. the pharmacist
  10. The time to peak effect for morphine given IV is
    1. 15 min.
    2. 45 min.
    3. 1 hour
    4. 2 hours
  11. The time to peak effect for morphine given orally is
    1. 5 min.
    2. 30 min.
    3. 1 – 2 hours
    4. 3 hours
  1. Following abrupt discontinuation of an opioid, physical dependence is manifested by the following:
    1. sweating, yawning, diarrhea and agitation with patients when the opioid is abruptly discontinued
    2. Impaired control over drug use, compulsive use, and craving
    3. The need for higher doses to achieve the same effect.
    4. a and b


  1. Do you use assessment tool? Yes No
  2. Which assessment tool do you use?