Joumal of Advanced Nursmg, 1993,18, 941-^47

Effect of attitudes, subjective norms andperceived control on nurses' intention toassess patients' painRobyn Nash RN RM BA DipAppSa(NEd) FRCNASenior Lecturer

Helen Edwards RN RM BA(Hons) DipAppSa(NUM) FRCNASenior Lecturer, School of Nursing, Queensland Untverstty of Technology

and Monica Nebauer RN RM BA DipAppSa(NEd) FRCNALecturer, School of Nurstng, At^straltan Catholic Untverstty, Queensland, Australta

Accepted for pubkcation 4 October 1992

NASH R, EDWARDS H & NEBAUER M (1993) Joumal of Advanced Nursing 18,941-947££Fect of attitudes, subjective norms and perceived control on nurses'intention to assess patients' painThis study examines the underlymg determinants of nurses' behaviour regardmgthe conduct of pam assessments One hundred nurses m a vanety of health carefaalities were mvited to complete an Attitude Intention Questionnaire basedupon the theory of planned action which is an extension of the theory ofreasoned action Results provide some support for the theory of planned action,as nurses' mtention to conduct pam assessment was shown to be predicted byattitude, subjective norms and perceived control, although the latter was theonly vanable to make an independent contribution to intention Additionalsupport for the importance of perceived control was provided by the analysis of'mtenders' and 'non-mtenders' (to conduct pam assessments), as perceivedcontrol was the only vanable whicJi differed significantly between the groupsThe fmdmgs are consistent with earlier studies which showed that the vanablesm the theory of plarmed behaviour provided reasonably accurate predictions ofbehavioural mtention

PAIN Although these data are important, even more so is theevidence that treatment for pam is often madequate For

Pain IS a common accompaniment of many illness some patients this may be due to an unyielcbng refracton-situahons and can be a major impediment to an adequate ness of their pam (Moms et al 1986) or a reluctance byquality of life Despite the advances in pain control over the patient to accept and collaborate m pam managementthe past decade, many pahents m both hospital and non- therapies More often, however, persistent pam may behospital settmgs contmue to expenence unrebeved pain attnbuted to a deficit m the provision of effechve health(Bomca 1985, Brody et al 1983, Ketovuon 1987, Mather & care (Portenoy 1988)Macbe 1983, Saxey 1986)

Corr^pondence Mr. R. Nash f:*"^ ^f ^"J^f J ^ ^ ^"l^l"! A key component of effective pam management isTechnology, Victona Park Road Lockd Bag No 2 Red Hill Qiaensland 4059 , , ,

Australia. the nursing assessment of the pahent's situation Nurses

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R Nash et al

generally have a high degree of responsibibty for thelmplementahon of pam-rebeving strategies and the evalu-ation of their effechveness However, studies conductedm vanous dmical settmgs have consistently shown thatnurses' assessments of patients' pam do not always matchpahents' own assessments of their pam

In general, nurses have been shown to infer the presenceof less pam than is actually bemg expenenced by thepahent (Bondestam et al 1987, Camp 1988, Chomiere et al1990, Iafrah 1986, Seers 1987) Other research has demon-strated that nurses' documentahon of pain assessmentstypically contains only a minimal amount of information(Camp & O'Sulbvan 1987, Graffam 1981) Notably, Camp& O'Sulbvan's study also showed that the pauaty ofrecorded data was not due to the unavailabibty of infor-mation from the pahent sample Their results mdicated thatnurses documented sigiuficantly less than 50% of the mfor-mahon that pahents were able to report to an mdependentmveshgator

Although some research has been undertaken mto thedetermmants of nurses' recognihon of pam (Cohen 1980,Taylor et al 1984), there has been very bttle mveshgahonof the fadors which influence nurses' pam-assessmentbehaviour The importance of behavioural factors has beensuggested m previous research by Charap (1978) and Fox(1982) which mdicated that nurses lacked positive athtudestoward the recogruhon of pam and the acfanmistration ofpam medicahon Hence the purpose of this study was toexplore further the behavioural determinants of nurses'assessment of pain.

The theory of planned achon (Ajzen 1985), which is anextension of Fishbem & Ajzen's (1975) theory of reasonedachon, offers one approach to the understanding of mdi-viduals' situation-speafic behaviours As m the ongmalmodel, the central proposition is that overt behaviour m aparticular situation is related to the mdividual's mtention tocarry out the behaviour m queshon Behavioural mtention,or the subjective probabibty that a person will engage ina parhcular behaviour, has three conceptually differentcomponents One is a personal or athtucbnal factor whichreflects a person's beliefs about a parhcular behaviour andhis/her evaluahons of those beliefs The second compo-nent of behavioural mtenhon is a soaal factor, termedsubjedive norm This refleds a person's beliefs about theexpectahons of significant others (referents) regardmgperformance of a parhcnilar behaviour and the person'smohvation to comply with the referent m question Thethird and novel antecedent of mtenhon, which was not partof the onginal theory of reasoned action, is the individual'sperceived control over the behaviour m queshon. Per-ceived control reflects a person's bebefs as to how easy cw

difificult performance of the behaviour is bkely to be, andIS related to individual perceptions about the presenceor absence of the necessary resources and opportunitiesregarcbng performance of the behaviour

In addition to the effed of perceived control upon aperson's intention to perform a behaviour, the theory alsoproposes a direct link between pjerceived control and actualbehaviour m a particular situation (Ajzen & Madden 1986)Research testmg the theory of planned behaviour hasdemonstrated that the mdusion of perceived control sig-nificantly improves the prediction of mtention to perform abehaviour (Ajzen & Madden 1986, Schifter & Ajzen 1985)Additionally, perceived control has been shown to havean influence on behaviour mdependent of its effect onmtenhon (Ajzen & Madden 1986, Schifter & Ajzen 1985)Generally speabng, the more posihve the athtude and thesubjective norm, and the greater the perceived control overthe behaviour, the stronger will be the person's intention toperform the behaviour

Nurses' subjective norms

A previous study by Renfroe et al (1990) used Ajzen &Fishbem's (1980) theory of reasoned achon to explore thedocumentation behaviour of nurses Contrary to previousresearch, they found that nurses' subjective norms, ratherthan their athtudes, contnbuted significantly to the pre-dichon of behavioural mtenhon A further importantfmding was that nurses' mtention to document signifi-cantly affected their actual documentahon behaviourHowever, this study did not consider perceived control mthe predicrtion of the nurses' mtention to document andtheir actual documentation behaviour Given the manymtemal and extemal factors which are likely to be affect-mg nurses' documentation behaviour m vanous clinicalsettmgs, it IS highly probable that perceived control isimportant in the prediction of such behaviour

CURRENT STUDY

In the current study, the mvestigators were interested inthe behavioural factors which underlie nurses' assessmentof pahents' pam Speafically, the followmg questions wereasked

1 What IS the nature of nurses' attitudes, subjech ve normsand perceived control regardmg the performance ofpam assessments?

2 Can mtention to perform a pam assessment bepredided hom nurses' athtudes, subjective norms andperceived control?

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Assessing patients' patn

Table 1 Charactmshcs of subjects sampled(m percentages)

Table 2 Examples of questionnaire items

Age (years)20-3031-4041-50

> 5 0

SexFemaleMale

Years smce lrutial registration1-56-10

11-1516-20

< 2 0

27293014

98 317

1611161740

What IS the relative contnbution of athtudes, subjec-tive norms and perceived control to the prediction ofintention to perform pain assessment?

Subjects

A total of 100 registered nurses were systemahcallysampled from the staff bsts of five health care agencieswithm the Bnsbane metropolitan area, Australia Theseagenaes included a pnvate hospital, a public hospital, anursmg home, a hospice and a community nursing serviceApproval to conduct the research was obtained from theethics committee of each health agency

A questionnaire was distnbuted to subjects invitingthem to partiapate in the study The queshonnaire alsoexplained the purpose of the research and assuredanonymity and confidentiality of responses The retum ofa completed questionnaire was considered to indicate con-sent firom the individual nurses Fifty-nme queshonnaireswere retumed for analysis and the charactenstics ofsubjects who completed the queshonnaire are displayed inTable 1

Instrument

A queshonnaire was developed to measure the constructscontamed in the theory of plarmed behaviour (Ajzen 1985)as they appbed to nurses and pam assessment To opera-honabze this theory, relevant underlymg bebefs must firstbe determmed To do this, 50 registered nurses undertakmg

J Attttudea Behavioural bebef

A comprehensive pam assessment wdl permit a moreaccurate picture of the patient's situationlikely unbkely

b EvaluahonAn accurate picture of the patient's situation isdesirable undesirable

2 Subjecttve norma Normative belief

Other nurses thmk that I should conduct compreherwivepam assessmentsbkely unbkely

b Motivation to complyI do what other nurses thmk I should do for patientslikely unlikely

terhary studies were asked to idenhfy the advantages anddisadvantages associated with pam assessment by nurses,and to idenhfy the people most likely to influence theirdecisions m this area The three most frequently occumngpositive and negahve bebefs about pam assessment wereincorporated into the questions measunng attitudes Thethree most commonly ldenhfied referents were mduded mthe measurement of normahve bebefs

MeasurementsThe measurement and sconng of the attitudinal andsubjective norm components were conducted accorcbng toguidelmes descnbed by Ajzen & Fishbem (1980) Attitudewas measured by subjects' responses to items concemmgthe SIX ldenhfied bebefs and correspondmg evaluations ofthose bebefs Examples of these items are shown m Table 2The bebef and evaluation components were measured onseven-point scales from -|-3 (likely, desirable) to —3(unlikely, undesirable), respectively Each subject's attitudescore was calculated by mulhplying eacii belief score bythe correspondmg evaluation score and then summingacross the six products

Normahve bebefs were measured by subjects' responsesto items concemmg the expectahons of the three identifiedreferents and the mohvahon to comply with the expec-tahons of those referents Examples of these items areshown m Table 2 Again, seven-pomt scales were used, + 3(likely) to — 3 (unlikely), and the sum of the cross productswas used to calculate subjeds' subjechve norm scores

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Similarly to Schifter & Ajzen (1985), the behaviouralmtention component of the theory was measured throughtwo direct questions concenimg the bkeldiood of con-ductmg pam assessments The two statements, TXinng thenext week I mtend to condud comprehensive pain assess-ments on patients who are expenencmg pam of any type'and 1 will try to conduct comprehensive pam assessmentson pahents who <n-e expenenang pam of any type', wererated on seven-pomt scales fi-om -1-3 (likely) to —3(unbkely) The behavioural mtenhon score was calculatedby summmg the two scores

Fmally, the perceived control component was measured,as m Ajzen & Madden's (1986) study, through two ques-hons which asked subjects to judge the degree to whichthey felt m control of conductmg pam assessments(complete control-very bttle control) and the degree ofease they expenenced m conductmg pam assessment(easy-difficult) Both queshons were rated on seven-pointscales (-1-3 to —3) and subjects' perceived control scorewas calculated by summing the two scores

A total of 22 items was therefore mduded m thequestionnaire to ebat subjects' athtudes, subjechve norms,perceived control and mtenhon regarcbng pam assess-ments Five demographic queshons were also mduded toobtam the charactenstics of the sample As most of thequeshormaire items used a seven-pomt semantic differen-hal format, a page with lnstruchons and examples wasmduded An mtroductory letter which explamed thegeneral nattire of the research was attached to eachqueshormaire Details about anonymity, confidentialityand the colledion of the queshonnaires were also mdudedm this letter

In the development of the questionnaire items, it wasdeaded to use the term 'comprehensive pam assessment'This was done to highlight for subjects that pam assess-ment, m the context of this mveshgahon, was to beviewed more broadly than simply the deasion to administermechcahons

Procedure

The 100 nurses selected for mdusion m the study receivedtheir queshonnaire through the mtemal mail system oftheir health agency On completion of the cjueshonnaire,subjeds were requested to place the ccnnpleted queshon-naire m the accompanymg envelope After seabng tbsenvelope, subjects were mstructed to debver it to adesignated person withm their organization The sealedenvelope, contaming the completed (]ueshonnaire, wascollected by a research assistant No envelopes wereopened at the collechon pomt

Table 3 Range, mean and standard cieviation for subjects' scores

Range Mean SD

AttihideSubjechve normPerceived controlIntention

- 8 , -t-44'-15 , -1-27''- 6 , -1-6'- 6 , -1-6''

18 375 442102 20

11428122 793 28

Note- "possible range —54 +54 ^possible range —27 +27 "possible rar\ge—6 + 6 ''possiblerange —6 + 6

RESULTS

The range, mean and standard deviation for the attitude,subjective norm, perceived control and mtention scores aredisplayed m Table 3 The results suggest that, generally,attitudes toward pam assessment were positive Theobtamed subjechve norm score suggests that subjects, to aminor degree, perceived that patients, fnends and othernurses thought they should conduct pam assessments Ingeneral, subjeds reported slight control over, and minimalmtention to perform, pam assessments

A standard multiple regression was performed todetermme the extent to which attitudes, subjective normsand perceived control explained mtention to conduct pamassessments Table 4 displays the Pearson correlationsbetween the vanables and the unstandardized and startdar-cbzed regression co-ef&aents The multiple R of 0 46 wassignificant, f(3,55) = 4 92, P<001 , with 21% of thevanability m mtenhon scores precbcted from the attitude,subjective norm and perceived control scores Perceivedcontrol was the only vanable to make a significant,mdependent contnbution to the prediction of mtention toconduct pam assessments

As well, f-tests were conducted to investigate differencesm attitudes, subjective norms and perceived controlbetween those subjects who intended to conduct pamassessments and those who did not Subjects were cbvidedmto two groups 'mtenders' — those whose mtenhonscores were greater than 0, and 'non-mtenders' — thosewhose mtention scores were less than 0 No significantdifferences were found for the attitude and subjectivenorm scores However, there was a significant difference,f(58) = 2 58, P < 0 05, between the perceived controlscores of the 'mtenders' and 'non-mtenders'

DISCUSSION

The results of this study highbght the unportimce ofmohvahonal fadors m the assessment of pam by nurses.

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Assesstng pattents' patn

Table 4 Standard multipleregression of attitude,subjective norm andperceived control onintention to conduct painassessments

•P<CMX)I

Vanables Intention Attitude Subjective norm

Athhide 015Subjective norm 0 07 0 27Perceived control 0 44* 015 0 29

003 010-0-03 - 0 0 9

0 53 0 46

and provide some support for the key constructs ofAjzen's (1985) theory of planned action Nurses' intentionto conduct pam assessment was predicted by their atti-tudes, subjective norms and perceived control regardmgthe assessment of pam Although these vanables accountedfor only 21% of the variance, this result is consistent withprevious work by Ajzen & Madden (1986) and Schifter &Ajzen (1985) who found mtenhon to perfonn a selectedbehaviour to be a function of attitude, subjecrtive norm andf>erceived control Unlike the present study, however,these previous investigations both found that the threevanables from the theory made independent contnbutionsto the predichon of mtention

Despite not mabng an independent contnbution to theprediction of mtention, nurses' athtude and subjectivenorm scores regarcbng pam assessment were positive,although in the low ranges This suggests that these nursesgenerally believed in the importance of pam assessment,and perceived a nunor degree of social pressure whichcontnbuted to their compliance with this achvity

Previous research by Charap (1978) and Fox (1982) hasmdicated that nurses lack positive attitudes towards therecognition of patients' pam and its management withar\algesic mecbcahons Although direct companson betweenthese studies is not possible because of the diffenngmethodological approaches to attitude measurement, it isnevertheless encouragmg to find that the athtude scores inthe present study were in the positive range Perhaps thisreflects the increased emphasis which has been placed onquality in the debvery of health care, both m Australiaand overseas It is also possible that improvements in theeducation of nurses may account, at least m part, for thisfinding Further research usmg larger samples of nursesfrom aaoss the dmical practice spectrum is needed beforeany more definitive condusion can be reached

Perceived control

Perceived control was the only vanable to make anmdependent contnbuhon to the prediction of mtenhonAs well, perceived control was the only vanable whichcbffered significantly between the 'mtender' and 'non-

mtender' groups This is an important findmg because, asdescnbed earlier, the theory of plarmed achon proposesthat perceived control can mfluence not only nurses' mten-hon to perfonn a behaviour but zdso the actual performanceof that behaviour as well

Perceived control over a particular behaviour can beinfluenced by several factors which mclude a person'sspecific knowledge and sblls, the amount of hme avculableand opportunities to perform the behaviour, and autonomym any decision mabng regarding performance of thebehaviour In general, the more resources and oppor-tunities individuals think they possess and the fewerobstacles or impediments they antiapate, the greatershould be their perceived control over a particularbehaviour (Ajzen & Madden 1986)

Several studies have identified that nurses lack specificknowledge regarding pain assessment and management(Charap 1978, Fox 1982, Saxey 1986, Watt-Watson 1987)This condusion has been reinforced by other researciiwhich has demonstrated that nurses' documentation ofpam assessments typically contains minimal amounts ofmformation, and there is bttle consistency in the typesof data chosen by nurses to assess patients' pam (Burokas1985, Camp & O'Sulbvan 1987, Graffam 1981)

Camp-Son-ell & O'SuIlivan (1991) mvestigated theeffechveness of a continuing education programme forregistered nurses regarcbng pain assessment and documen-tahon However, they found no significant differencesbetween either the study groups or between the studygroups and those nurses who chose not to participateThis result may be highbghtmg the unportant cbfferencebetween nurses' own perceptions of their knowledgeneeds and the perceptions of others, e g health careagenaes Unless nurses themselves perceive defiats mthe knowledge, sblls and/or resources that they possess,interventions aimed at improvement in these areas mayhave bttle impact

At present there is a dearth of research which hasexplored this area Hence one can only speculate about thefactors which may be important determinants of nurses'perceived control over pain assessment Expenencesuggests that perhaps some of the most important factorsmay be concemed with nurses' perceptions of themselves

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R Nasheid

as practihoners with a legihmate role m the mdependentplanrung and management of pam assessments, and theirpercephons regardmg the value of the mformahon which isobtained

Caution

The results of this study should be viewed with cautionbecause of the small number of nurses who parhapatedm the study Additionally, the registered nurses whoidentified the relevant underlying attitudmal and norma-hve bebefs about pam assessment were not drawn from thesame sample as the mam study It is possible that similarbebefs were held by both groups but this carmot beassumed

Different underlymg bebefs between the two groups ofnurses could explam the low athtude and subjechve normscores obtamed m the mam study Moreover, the presentstudy measured only mtenhon to perform pam assess-ments, and not the actual behaviour itself Therefore, anylink between perceived control and the assessment of pamcan only be speculated fi-om the theory of planned achonand studies which support the theory

CONCLUSION

The results of this study have provided some mterestmginsights mto factors involved in nurses' mtenhon to assesspahents' pam Questions which are raised by this studymdude the impact of perceived control on nurses' mtentionto assess pam, the important determinants of nurses' per-ceived control over the conduct of pam assessments, andthe nature of the relahonships between perceived control,mtention and pam-assessment behaviour

Regardless of the cbnical settmg, one of the mostimportant funchons of the nurse is to alleviate the suffermgof people who are expenenang pam Further research intonurses' pam assessment behaviour is essential if we are toimprove the comfort and weU-bemg of pahents who areexpenencmg pam

References

Ajzen I (1985) From mtenhon to achons a theory of plarmedbehaviour In Actton-Control From Cognition to Behaviour (KuhlJ & Beckham J eds), Spnnger, Heidelberg, pp 11-39

Ajzen I & Fishbem M (1980) Undentandtng Attttudes andPredtchng Soaal Behaviour Prenhce-Hall, Englewood Cbfis,New Jersey

Ajzen I & Madden T (1986) Prediction of goal-directedbehaviour attitudes, intentions, and perceived behaviouralcontrol Joumal of Expenmental Soaal Psychole^ 22,475-503

Bondestam E, Hougren K, Johansson F G, Jem S, Herlitz J &Hobnberg S (1987) Pam assessment by pahents and nursesm the early phase of acture mycx:arcbal infarction Jotmtal ofAivartced Nurstng 12, 677-682

BorucaJJ (1985) Treatment of cancer pam the current status andfuture needs In Advances tn Pain Research and Therapy (FieldsH L ed), Raven Press, New York, pp 589-616

Brody E, Kleban M & Moles E (1983) What older people doabout their day-to-day mental and physical health symptomsJoumal of the Amencan Genatnc Soaety 31, 89-98

Burokas L (1985) Factors affecting nurses' deasions to mediate

paediatnc patients after surgery Heart Lung 14,373-378Camp L D (1988) A comparison of nurses' recorded assessnient

of pam with percephons of pam as descnbed by cancerpatients Cancer Nurstr^ 11,237—243

Camp L & O'SuIlivan P (1987) Companson of mecbcal surgicaland oncology pahents' descnptions of pam and nurses' docu-mentation of pam assessments Joumal of Advanced Nurstng 12,593-598

Camp-Sorrell I & O'SuIlivan P (1991) Effects of contmumgeducation pain assessment and documentation CancerNurstng 14, 49-54

Charap A (1978) The knowledge, athtudes and expenence ofmecbcal i)ersormel treatmg pam m the terminally ill The MountStnat Joumal of Medtane 45,561-581

Chomiere M , Melzack R, Girard N , Rondeau J & Paqum M -J(1990) Compansons between pahents' and nurses' assessmentof pain and medication eftcacy m severe bum mjunes Patn 40,143-152

Cohen F L (1980) Post-surgical pam rebef patients' status andnurses' medicahon choices Patn 9,265-27A

Fishbem M & Ajzen I (1975) Behef Attttude, Intentton, andBehavtour An Introductton to Theory and Research Adcbson-Wesley, Reacbng, Massachusetts

Fox L (1982) Pam management m the terminally ill cancerpatient an mveshgahon of nurses' knowledge, athtudes anddmical prachce Mtlitary Mediane 447, 455-460

GrafiFamS (I981)Congruenceofnurse-pah«itexpectahonregard-

mg nursmg mtervraihon m pam Nursing Leadership 4,12-15Iafi-ah W (1986) Pam on the bum unit pahent vs nurse

percephons Joumal of Bum Care Rehabihtatton 7,413-416Ketovuon H (1987) Nurses' and patients' conceptions of wound

pam and the administrahon of analgesics Joumal of Patn andSymptom Management 2,213—218

Mather L &MadueJ (1983) The madence of postoperative pamm duldren Patn 15,271-282

Moms J N , Mor V & Goldberg R J (1986) The effect of heat-ment setting and pahent charactenstics on pain m termmalcancer pahents Joumal of Chrontc Disorders 39,27-35

Portenoy R.K (1988) Prachcal aspects of pam control m thepahent with canar CA — A Cancer Joumal For Clmiaans 38,327-352

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Renfroe D H , O'SuIlivan P &McGeeGW (1990) The relation- Seers K (1987) Perceptions of pain Nurstng Ttmes 83,ship of attitude, subjective norm and behavioural intent to 37-39the documentahon behaviour of nurses Scholarly Inqutry for Taylor A G, Skelton J A & Butcher J (1984) Duration ofNurstng Practtce 4 ,47-64 pain condition and physical pathology as determinants of

Saxey S (1986) The nurse's response to {wstoperahve pam nurses'assessments of patients in pain Nurstng Research 33,Nurstng — The Add-On Joumal of Clintcal Nursing 3,377-381 4-8

Schifter D & Ajzen I (1985) Intention, perceived control, and Watt-Watson J (1987) Nurses' knowledge of pam issues aweight loss an appbcation of the theory of planned behaviour survey Journal of Pain and Symptom Management 2,Joumal of Personality and Soaal Psychology 49, 843—851 207-211

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