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Running head: THE IMPORTANCE OF EDUCATION FOR EFFECTIVE PAIN MANAGEMENT 1

The Importance of Education for Effective Pain Management

Erica Rene Lewis

Our Lady of the Lake College

December 3, 2013

Keeley Dupuy

NURS: 4915

Capstone

THE IMPORTANCE OF EDUCATION FOR EFFECTIVE PAIN MANAGEMENT

Abstract

The purpose of this paper is to investigate the effectiveness of post licensure pain management

education, through the use of continuing education for nurses, working in a clinical care setting.

“Pain management is an important component of postoperative care in patients of all ages”

(Smith, 2012, p. 1) and providing comfort for the patient both physically and emotionally is the

job of the nurse. However, patient’s pain is going untreated due to the nurses’ inadequate

knowledge of pain assessment and management. A quasi-experimental design (in the form of a

questionnaire) was completed by six nurses working on the Trauma-Neuro Critical Care Unit

(TNCC) of Our Lady of the Lake Regional Medical Center to determine if a continuing

educational program focusing on pain assessment would improve the nurse’ ability to manage

the pain level of the patients in their care. Of the six participants, two representing 22% scored

below an 80% on the questionnaire. Based on the results, there is a clear need for the

establishment of clinical pain management guidelines and pharmacological/non-pharmacological

training. This training would improve the nurses’ ability to effectively assess pain levels and to

proficiently provide effective pain management care to all patients.

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Table of Contents

Introduction........................................................................................................................................... 4

Literature Review................................................................................................................................ 5

Methods................................................................................................................................................ 10Design................................................................................................................................................................ 10Subjects and settings.................................................................................................................................... 11Limitations...................................................................................................................................................... 12Data evaluation and analysis.................................................................................................................... 12Ethical considerations................................................................................................................................. 12

Results................................................................................................................................................... 13

Conclusion............................................................................................................................................ 13

References............................................................................................................................................ 15

Appendix.............................................................................................................................................. 17

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The Importance of Education and Pain Management

Introduction

“Pain is an unpleasant sensory and emotional experience associated with actual or

potential tissue damage”, and is one of the major reasons people are seeking medical care

assistance (International Association for the Study of Pain: Pain Definition, 2011). “Pain is a

subjective phenomenon and is triggered by a number of factors such as: age, sex, culture, and

previous experiences with pain” (Oware-Gyekye, 2008). However, an important factor to note is

that pain tolerance and sensitivity is different for men, women and children. Each individual’s

experience with pain should be addressed through effective pain management and control. For

example, children possess limited capability of pain expression because of its unfamiliarity, and

this can hinder them from communicating what they are experiencing. Whereas, as adults we

adapt the necessary skills to either suppress or seek health care assistance when pain becomes

unbearable. There is no evidence that our reaction to pain differ based on gender, however,

“cultural influence on gender may produce different expressions of pain” (Oware-Gyekye, 2008,

p. 51). In addition, a communication barrier, such as language, can also affect how health care

providers manage pain in their patients. Pain can be a debilitating experience and its existence

can hinder a person from performing their basic life skills, such as walking, bathing, or caring for

themselves, thus affecting their quality of life. As a result, pain management should be held to

the highest regard for all nurses in order to ensure that their patients are comfortable while under

their care.

Many nurses do not trust the judgment of their patient’s self- reported pain level when

asked to rate their pain on a scale of 1-10 (10 being the most severe). Consequently, there has

been a consistent theme in the literature for a lack of knowledge concerning pain assessment and

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management (Al-Shaer, Hill, & Anderson, 2011). Therefore, due to nurse’s inadequate

knowledge of assessment and management of pain, the patient’s pain is going untreated. Al-

Shaer et al. (2011) mentions, “Nurses need current knowledge and appropriate attitudes

regarding pain assessment and management regardless of patient age and origin of clinical

practice” (p. 7). Patients enter into the care of hospitals for various reasons, and each department

caters specifically to the patients’ needs, including pain management. Although the severity of

patient’s pain levels differs from unit to unit, the nurse’s knowledge of pain management and

assessment should be consistent.

This paper will discuss the lack of knowledge regarding pain management among nurses

from varying units. In addition, the purpose of this paper is to review literature that investigates

the effectiveness of post licensure pain management education, in the form of continuing

education, for nurses working in ta clinical setting. I hypothesize that establishing clinical pain

management guidelines and pharmacological/non-pharmacological training will enable nurses to

adequately assess pain levels and proficiently provide effective pain control.

Literature Review

Allcock et al. (2011) states “today’s critical care nurses are faced with the challenge of

providing effective and efficient pain management while trying to sustain the lives of their

patients.” Allcock et al. (2011) conducted a study in order to explore the challenges of a nurse in

the critical care unit in regards to providing pain management. The findings from this qualitative

study, which are similar to those found in McNamara, Harmon & Saunders (2012) study, shows

that the problem in regards to pain management is due to the lack of the critical care nurses’

ability to recognize and promptly provide treatment for patients in pain.

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To manage patient’s pain successfully, nurses need to know the physiology of pain,

myths and misconceptions about pain, how to assess pain, patients’ behaviors when

in pain, pharmacological and non-pharmacological pain-management techniques and

ethical issues in pain management (Ferrell et al.1993, Wang & Tsai, 2009 pg. 3189).

The participants from McNamara et al. (2012) mixed method experimental study stated,

“pain assessment should be carried out every 24 hours, as opposed to one to two hourly” (p.962).

However, contrary to their beliefs, pain assessment should be carried out every four hours. If

pharmacological interventions are utilized, its effectiveness should be evaluated 30 minutes after

the patient takes the medication. Medication follow-up is an important task that nurses are

required to perform in order to evaluate the effectiveness of the pain control measures being

taken. In addition, pain management is an interdisciplinary intervention that requires the

collaboration of nurses, health care professionals, the patient as well as family members. The

nurses in Allcock et al. (2011) study relied heavily on the opinions of pain expert’s, which

included the anesthetist, intensivist and acute pain team when providing pain management

interventions, because they felt they lacked similar expertise.

Recent studies on the issue of pain management suggest that there are limitations in

the area of nursing knowledge related to pain management practice and there is a

need for standardized pain management to guide nurses in decision making

(McCaffery et al. 2000, Jacobi et al. 2002, Puntillo et al. 2002, Aslan et al. 2003,

Shannon & Bucknall 2003, Allcock et al. 2011 p.1258).

The nurses expressed the need for clinical guidelines in order to guide their clinical

practice and reduce the under treatment of patient’s pain (Allcock et al. 2011). Wang et al.

(2010) states that the under treatment of the patients pain on the ICU unit is due to the improper

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documentation of the patients stated pain level. “ICU nurses have consistently rated their patients

pain lower than the patient’s self-reported pain” (Puntillo et al. 1997, Shannon & Bucknall 2003,

Wang et al. 2009 p.3194).

The limitations of the nurses knowledge of pain management due to their lack of clinical

education and training impedes their clinical judgment when collaborating with healthcare team

members, the patient and family. Wang et al. (2009) found within their cross-sectional study that

the lack of knowledge of ICU nurses was related to their educational level, nursing clinical

position, type of ICU and hospital accreditation category. “Nurses need to be equipped with

adequate knowledge of pain management in making accurate and relevant clinical judgments”

(Allcock et al. 2011, pg. 1259). Therefore, non-verbal and verbal cues should be viewed during

the assessment and evaluation of pain management. It is imperative that nurses not only be

knowledgeable, but trained on how to properly intervene for their patients when they’re

experiencing a pain level outside of their acceptable range.

Education alone may not change clinical nursing practice. Health care organizations

need to institutionalize pain management practices by incorporating basic principles

of pain assessment and management into daily practice (Berry &Dahl, 2000; Al-

Shaer et al. 2011, pg. 10)

As stated, education alone does not make a nurse competent in providing pain control.

However, nurses must be equipped with the necessary skills in order to adequately identity and

meet the needs of all patients’ pain levels. “The participants felt that when training was

provided, nurses’ knowledge was retained and they felt more confident in caring for their

patients” (Allcock et al. 2011, pg. 1258). Information is retained1 when one is able to skillfully

1 Retain -the ability to keep in mind or memory (Merriam-Webster, 2013).

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apply2 what one has been taught. Although knowledge about pain management is a necessity in

order to practice as a nurse, training and clinical experience is also a factor in the continuing

development of a nurse’s practice.

20.3% admitted that they lacked the ability to assess pain and 23.8% thought that

they did not have adequate knowledge about dealing with pain. Showing a gap

between ICU nurses’ actual knowledge and their perceived knowledge (Wang &

Tsai, 2009, p. 3194).

NcNamare et al. (2012) & Machira, Kariuki & Martindale (2013) both found within their

studies that there was an improvement in the attitudes and knowledge of those nurses who

participated in educational programs. As stated in Machira et al. (2013) there is a “need for

continuous professional development (CPD), as professional development ensures that nurses’

knowledge and skills are kept up to date and remains relevant (Quinn & Hughes, 2007),

improving patient care” (pg. 345). In order to make sure a nurse remains competent post

licensure, pain management experience should not stop in the classroom but should continue in

the clinical environment. According to Wilson (2007), though educational programs contribute

to the increase in knowledge regarding pain, “it is the clinical environment that has a significant

influence on the development and application of knowledge on pain management” (McNamara

et al. 2012, p. 958). Pain management education and training should be consistent across all

nursing academia since pain is a sensation that is universally pain. Nurses on different units tend

to possess varying degrees of knowledge toward pain management due to the different levels of

experience and education.

The nurses understanding and actions to control pain in the patient are essential for the

well-being of the patient. The registered nurses (RNs) of Al-Shaer et al. (2011) study were

2 Apply -to put into operation or effect (Merriam-Webster, 2013).

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competent in their understanding of pain management and assessment. However, they lacked

knowledge of pharmacological intervention. In regards to pharmacological intervention a

discrepancy exited in the nurses’ knowledge of side effects to medication, medication dosage and

duration of action (Al-Shaer et al. 2011). However, analgesics use isn’t the only way to suppress

painful stimuli. “Some studies have shown that relaxation therapy 3 is effective in decreasing

pre-operative anxiety in surgical patients, in decreasing postoperative pain and in speeding

postoperative recovery” (DeMarco-Sinatra 2000, Schaffer &Yucha 2004, Lin, Chiang, Chiang

&Chen 2008, p. 2033).

Lin et al. (2008) conducted a quasi-experimental study showing that after nurses

completed courses on relaxation therapy, they were more inclined to include this pain

management method into their practice. In the study conducted by Al-Shaer et al. (2011) there

were no significant differences noted between nurses based on educational level. The veteran and

oncology nurses were considerably more knowledgeable about pain as opposed to nurses on a

different unit. In addition, the oncology nurses advanced knowledge of assessment and pain

management is due to their “holistic and palliative approach, which are central to orientation and

continuing education for oncology nurses” (Al-Shaer et al. 2011, pg. 10). Although Dalton et al.

(1996) was unsuccessful in his attempt to conduct a continuing educational program on the

knowledge of pain management in cancer patients, palliative care is essential to the quality of life

of those with terminal illnesses and should be included in nurses’ health training (Machira et al.

2013).

Health policies are rules set in place within a society using decision making, planning,

and utilizing actions to achieve specific health care goal. Humana is a health care insurance

3 Relaxation Therapy – is the process of assisting an individual to retreat mentally from their surroundings through stilling thoughts, relaxing muscles and maintaining a relaxed state (Lin et al. 2008, p. 2034).

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company whose pain management services for their members are provided through OrthoNet.

OrthoNet evaluates the medical necessity of the services and request any needed medical

records. The following services are provided through OrthoNet: pain infusion pumps (back and

neck pain only), spinal fusions, Epidural injections (outpatient only) etc.… (Humana , 2013).

“Patients and health professionals continue to report that pain in often inadequately managed in

hospitals and community settings” (Godfrey, 2005, Ogston-Tuck 2012, p. 514). When caring for

the older adult in a community the nurses must possess better assessment skills in order to better

detect pain in this population

Methods

Design

A quasi-experimental pre and posttest approach was taken in order to assess the effects of

an educational program on the nurse’s knowledge of pain assessment and management. A seven-

item pretest consisting of 5 assessment and 2 non-pharmacological questions (figure1) was

administered to evaluate the participant’s baseline knowledge of pain management. A posttest

would be administered following an online course. Information on how to develop a training

course was gathered from the Manager of Clinical Experiences in the training and development

department of the Our Lady of the Lake Regional Medical Center. In following the Institutional

Review Board (IRB) process certification would be obtained and a proposal would be composed

before conducting the study. The proposal would include the purpose of the research, plans on

how the research would be carried out and all the materials used to conduct the research.

However, before submitting a proposal an IRB application would be completed. A PowerPoint

presentation documenting pain management would be composed based on low scores achieved

in particular content areas regarding pain. The PowerPoint presentation would be reviewed and

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evaluated by the Clinical Educator for flaws and redundancy. After evaluation and approval by

the Clinical Educator, the Training Specialist would upload it as a computer-based module onto

to the Decision Critical Application. Next, the modules would be assigned to each nurse based

their recorded score on the pre-test. Scores lower that 80% would require enrollment into the

online course. In order to gain access to their modules the nurses would enter their employee

login on a work based computer. The participants would be given six to eight weeks to complete

the online-based course. There would be three modules in this online course: assessment,

pharmacological and non-pharmacological pain interventions. If the participants do not complete

the modules within the allotted time frame they will be suspended without pay until it is

completed. In order to keep the nurses compliant with completing their course, the nurse

manager will be contacted electronically by email the fourth week after the modules have been

assigned to remind them of the nurses who are required to complete the modules.

Subjects and settings

The study would be conducted at Our Lady of the Lake Regional Medical Center. The

sample size would consist of six registered nurses (RNs) on the Trauma-Neuro Critical Care

(TNCC) unit. This is a 10-bed unit with two patients assigned to each nurse. Inclusion would be

based on having at least three years of clinical experience on the TNCC unit, hold a BSN degree,

providing direct patient care during the study and being an employee of the hospital where the

study is being conducted. Nurses were excluded if they had less than one-year experience on the

TNCC unit or a new nurse orientee.

Limitations

There were limitations to this study due to sample size and demographics of the nursing

staff. The participants were all female and only one unit was considered for this study. There was

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a lack of randomization when selecting the participants. The pretest used in this study showed no

validity and reliability due to its lack of the evaluation of the nurses’ pharmacological

background and minute consideration of non-pharmacological items

Data evaluation and analysis

Data was collected using a pretest to evaluate the nurse beginning level of knowledge in

regards to pain management. All six nurses participated in completed the pretest. The

instruments used in this study were the Decision Critical Application and Microsoft Office

(Excel, PowerPoint &Word). The participant’s knowledge of the content presented in the

modules would be evaluated using a posttest to which they will have to make an 80% or higher

to be consider competent. The nurses’ were evaluated on a 7-point grading scale. The

participants would be given the same test in order to evaluate the effectiveness of the online

training.

Ethical considerations

Before conducting this study approval from the IRB of the research institute would first

have to be obtained. Permission to distribute the pre-test to the nurses on the unit was obtained

from the nurse manager. Participants were informed that entry into the study was completely

voluntary and that they could withdraw at anytime during the study period. It was explained that

consent would be implied if they choose to complete the pre-test. Before administering the pre-

test the purpose, both the benefits and penalization and selection criteria of the study were also

clearly explained. No identifying information was asked of potential participants. The nurses

were told that their results to both the pre and posttest would be made available to them and the

confidentially would be maintained through the use of codes, rather than names.

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Results

One hundred per cent of the sample completed the pre test (n=6). Of the six participants

only two participants (22%) scored below an 80%. Table 1 shows how the nurses scored on the

pretest. Majority of the nurses on this unit was knowledgeable about how to assess their patients

for pain as represented by the test. The most frequently missed question pertained to non-

pharmacological interventions for pain, however some assessment questions were missed (Table.

2). Items 5 and 6 of the pre test explored non-pharmacological intervention for pain and 22% of

the participants answered correctly. The effect of the pain management education program on

the nurses’ knowledge could not be evaluated because a posttest was not administered. Due to

the lack of reliability of the pre/posttest and the fact that only one unit was considered this study

would not contributed nor helped resolve the issue of the nurses’ lack of knowledge of pain

management.

Conclusion

In the closing of this paper it has been discovered that patients pain have been

undertreated due to the lack of pain management knowledge on behalf of the nurse.

Improvement in the pain management skills of the nurses is imperative because they are involved

in direct care of their patients. Nurses are responsible for providing both pharmacological and

non-pharmacological pain relieving interventions in order to increase their patient’s outcomes.

Although the test lack reliability the results of this study indicates majority of the nurses were

knowledgeable about pain management. With advancement in professional knowledge and skills

of the nurse, improvement can be made in the quality of care of the patient and shorten their stay

in the hospital. Because nurses in different departments deal with varying degrees of pain, and

most come in contact with it more often than others. Some nurses’ lack the clinical experience

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needed to maintain the knowledge they once obtained. However, with the incorporation of

continuing educational programs nurses’ knowledge of pain management and assessment has

said to be improved.

References

1.

Allcock, N., James, V., & Lathlean, J. (2011). Challenges faced by nurses in managing pain in critical care setting. Journal of Clinical Nursing , 1254-1260.2. Al-Shaer, D., Hill, P. D., & Anderson, M. A. (2011). Nurses' Knowledge and Attitudes

Regarding Pain Assessment and Intervention. MedSurg Nursing , 1-10.

3. American Nurses Credentialing Center. (2013). ANNC. Retrieved November 25, 2013, from

ANNC: Pain Management Nurse Exam Sample Questions:

http://www.nursecredentialing.org/PainMgmt-SampleTest.aspx.

4. Aslan FE, Badir A & Selimen D (2003) How do intensive care nurses assess patients’ pain?

Nursing in Critical Care 8, 62–67

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5. Berry, P.H., & Dahl, J.L. (2000). The new JCAHO pain standards: Implications for pain

management nurses. Pain Management Nursing, 1(1), 3-12.

6. DeMarco-Sinatra J (2000) Relaxation training as a holistic nursing intervention. Holistic

Nursing Practice 14, 30–39.

7. Ferrell BR, Grant M, Ritchey KJ, Ropchan R & Rivera LM (1993) The pain resource nurse

training program: a unique approach to pain management. Journal of Pain & Symptom

Management 8, 549–556.

8. Flanagan J (1954) The critical incident techniques. Psychological Bulletin 51, 327–358.

9. Godfrey H (2005) Understanding pain, part 1: physiology of pain. Br J Nurs

14(16):846-52

10. Humana . (2013). Humana: Pain Management . Retrieved November 30, 2013, from

Humana : https://www.humana.com/provider/medical-providers/education/referral/pain-

management

11. International Association for the Study of Pain: Pain Definitions [Retrieved 10 Sep 2011].

"Pain is an unpleasant sensory and emotional experience associated with actual or

potential tissue damage, or described in terms of such damage" Derived from Bonica JJ.

The need of a taxonomy. Pain. 1979;6(3):247–8. doi:10.1016/0304-3959(79)90046-0.

PMID 460931.

12. Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D & Wittbrodt ET (2002) Clinical

practice guidelines for the sus- tained use of sedatives and analgesics in the critically ill

adult. Critical Care Medicine 30, 119–141.

13. Lin, P.-C., Chiang, H. W., Chiang, T.-T., & Chen, C.-S. (2008). Pain management:evaluating

the effectiveness of an efucational programme for surgical nursing staff. Journal of

Clinical Nursing , 2032-2040.

14. Machira, G., Kariuki, H., & Martindale, L. (2013). Impact of an educational pain

management programme on nurses' pain knowledge and attitudes in Kenya .

International Journal of Palliative Nursing , 341-345.

15. McNamare, M. C., Harmon, D., & Saunders, J. (2012). Effects of education on knowledge,

skill and attitutdes around pain . Bristish Journal of Nursing , 958-963.

16. Oware-Gyekye, F. (2008). Pain managemnent: The role of the Nurse . West African

Journal of Nursing , 50-54.

15

http://www.iasp-pain.org/AM/Template.cfm?Section=Pain_Defi...isplay.cfm&ContentID=1728

http://www.ncbi.nlm.nih.gov/pubmed/460931?dopt=Abstract

http://dx.doi.org/10.1016%2F0304-3959(79)90046-0

http://en.wikipedia.org/wiki/Digital_Object_Identifier


17. Puntillo KA, Kehrle K, Gleeson S & Nye P (1997) Relationship between behavioral and

physiological indicators of pain, critical care patients’ self-reports of pain and opioid

administration. Critical Care Medicine 25, 1159–1166.

18. Puntillo K, Stannard D, Miaskowski C, Kehrle K & Gleeson S (2002) Use of a pain

assessment and intervention nota- tion (P.A.I.N.) tool in critical care nursing practice:

nurses’ evaluations. Heart and Lung 31, 303–314.

19. Quinn FM, Hughes SJ (2007) Quinn’s Principles and Practice of Nurse Education. 5th edn.

Nelson Thornes Limited, UK

20. Schaffer SD & Yucha CB (2004) Relaxation and pain management: the relaxation response

can play a role in managing chronic and acute pain. American Journal of Nursing 104,

75–76, 78–79, 81–82.

21. Shannon K & Bucknall T (2003) Pain assessment in critical care: what have we learnt from

research. Intensive and Critical Care Nursing 19, 154–162.

22. Smith, N. (2012, December 7). Pain Management in Adults, Posteroperative. Nursing

Practice & Skills , pp. 1-4.

23. Wang, H.-L., & Tsai, Y.-F. (2009). Nurses' knowledge and barriers regarding pain

management in intensive care units . Journal of Clinical Nursing , 3188-3195.

Appendix

Figure 1.By completing the survey you are implying informed consent. There is no risk to completing this competency test

1. Which statement indicates the development of opioid tolerance?a) Larger doses of opioids are needed to control pain compared to several weeks

earlier.b) Stimulants are needed to counteract the sedating effects of opioids.c) The patient becomes anxious about knowing the exact time of the next dose of

opioid.d) The patient no longer experiences constipation from the usual dose of opioid.

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2. When assessing a patient's cultural beliefs about pain, the pain management nurse asks about:

a) A family history of pain.b) Home remedies used to treat pain.c) The frequency of visits to health care facilities.d) The patient's dietary preferences.

3. When assessing a patient for possible side effects related to acetaminophen (Tylenol), the pain management nurse asks the patient about the use of:

a) Alcohol.b) Marijuana.c) Opioids.d) Tobacco.

4. A 45-year-old male patient reports pain in his foot that moves up along his calf. The patient states, "My right foot feels like it is on fire." The patient further describes that he has no previous history of injuries or falls, and that his pain started yesterday. Which components of pain assessment has the patient reported?

a) Aggravating and alleviating factorsb) Exacerbation, and associated signs and symptomsc) Intensity, temporal characteristics, and functional impactd) Location, quality, and onset

5. Which behavioral therapy works best to relieve pain with muscle tension and spasms in patients who are anxious about their pain?

a) Distractionb) Hypnosisc) Relaxationd) Stress management

6. Which non-pharmacologic intervention is difficult to use with older adults who are cognitively impaired?

a) Aromatherapyb) Distractionc) Guided imageryd) Heat application

7. The pain management nurse notices a male patient grimacing as he moves from the bed to a chair. The patient tells the nurse that he is not experiencing any pain. The nurse's response is to:

a) Clarify the patient's report by reviewing the patient's nonverbal behavior.b) Confronting the patient's denial of pain.c) Obtaining an order for pain medication.d) Supporting the patient's stoic behavior

(American Nurses Credentialing Center, 2013)

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Table 1. Distribution of Letter Grades for the Pain Management Knowledge Pretest

(N=6)Grades Percent Correct N (%)

A 94-100 0B 87-93 0C 80-86 4 (66. 7)D 77-79 1 (16.7)F ≤74 1 (16.6)

Table 2.

Most Frequently Missed Items

Incorrect

Which behavioral therapy works best to relieve pain with muscle tension and spasms in patients who are anxious about their pain

66.7%

The pain management nurse notices a male patient grimacing as he moves form the bed to a chair. The patient tells the nurse that he is

not experiencing any pain. The nurse’s response is to:

33.3%

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THE IMPORTANCE OF EDUCATION FOR EFFECTIVE PAIN MANAGEMENT 19

THE IMPORTANCE OF EDUCATION FOR EFFECTIVE PAIN MANAGEMENT 20

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