Pain is experienced by most hospitalized patients.1 Although substantial progress in pharmacologic technologies, nonpharmacologic strategies, and clinical guidelines has been made in recent years for pain management, patients continue to experience pain.2,3 A systematic review found the prevalence of acute pain and severe pain among adult patients in the United Kingdom ranged from 37.7% to 84% and 9% to 38%, respectively.4 Another systematic review reported that the prevalence of chronic pain and moderately severe disabling chronic pain among the UK population ranged from 35.0% to 51.3% and 10.4% to 14.3%, respectively.5 Close to 1.5 million individuals 15 years or older living in Canada reported the prevalence of chronic pain was 36% among people with neurological conditions.6 A cross-sectional study in Vietnam found that, among 12 136 adults, approximately 86.5% of respondents reported experiencing pain, with 24.1% complaining of acute pain and 62.4% experiencing chronic pain.7 Untreated pain negatively impacts patients' physical and psychological health and overall health outcomes.8,9 These consequences may associate with increased morbidity, functional and quality of life impairment, delayed recovery time, prolonged duration of opioid use, extended hospitalization, increased readmission, healthcare costs, and patient dissatisfaction with the quality of care.8–10

Nurses play an important role in supporting patients enduring pain in both assessment and treatment.10,11 Effective pain management may reduce complications, increase satisfaction, and lead to early hospital discharge.12,13 Adequate knowledge and positive attitudes among nurses can lead to better pain management results, improving the quality of care.14,15 Despite the development of evidence-based training courses, pain management strategies, and pain management teams, nurses continue to experience knowledge deficits and negative attitudes toward pain management.16 A cross-sectional study found the total correct percentage score on the Knowledge and Attitude Survey Regarding Pain (KASRP) was 36.6 among Ethiopian nurses and stated that nurses had inadequate knowledge and negative attitudes regarding pain management.17 Similarly, a multicenter cross-sectional study in Italy reported the correct percentage score on KASRP of 31.21 and emphasized that nurses need to improve knowledge and attitudes regarding pain management.18 Two recent cross-sectional studies in China reported that nurses had inadequate knowledge and negative attitudes regarding pain management with a correct percentage score on KASRP of around 55.5.19,20 A systematic review stated that a lack of knowledge and negative attitudes among nurses lead to inadequate pain management.21 Evaluating nurses' knowledge and attitudes is necessary to ensure the provision of adequate pain management.

Some factors associated with nurses' knowledge and attitudes toward the provision of pain management have been identified, such as working unit,17 work experience,19 and educational levels.22,23 Nurses who attended preservice17,20,23 and in-service pain training courses18 were more likely to display adequate knowledge and positive attitudes toward pain management. However, the factors that contribute to nurses' knowledge and attitudes toward pain management remain unclear and should be further explored.

In Vietnam, little evidence is available in the literature regarding the knowledge and attitude among nurses toward pain management and associated factors.24,25 The purpose of this study is to assess pain management knowledge and attitudes among Vietnamese nurses. A secondary aim is to identify key factors that may influence knowledge and attitudes.

Methods

This is a cross-sectional study using a convenience sample conducted in a 3100-bed national hospital in Vietnam from May to June 2021. Two hundred eighty-three participants were recruited from all clinical units (medical-surgical wards, obstetric wards, intensive care unit, pediatric center, stroke center, oncology center, emergency, and specialized departments). Nurses and midwives who worked full-time who consented to respond to the questionnaire were included in the study. Participants working with nontenure contracts were excluded. The study was approved by the institutional review board of the principal researcher's hospital.

The KASRP scale was used to evaluate knowledge and attitudes regarding pain management. Demographic data and work characteristics were collected based on previous studies of factors related to pain management.17,22,23 Information regarding age, sex, educational level, work experience, work units, job titles, participation in preservice and in-service training, reading books or journals on pain and applied knowledge of pain management, the use of numeric rating tools to assess pain intensity, and the use of unit-based pain guidelines were collected.17,22,23

The KASRP was developed to assess knowledge and attitudes regarding pain management and has good test-retest reliability (Pearson r > 0.8) and good internal consistency reliability (Cronbach α > 0.7).26 It has 41 questions, including 22 true/false questions, 15 multiple-choice questions, and 2 case studies (each with 2 questions). Correct answers are scored as 1 point. Total score ranges from 0 to 41, where higher scores indicate a higher level of knowledge and attitude of pain management.

With permission from the developer, the KASRP was translated from English into Vietnamese by a translation team that included the principal researcher, 1 coordinator, 2 bilingual scholars, and 1 reviewer. One scholar translated the original English version into Vietnamese. A second scholar translated the Vietnamese version back into English. The Vietnamese version of KASRP was compared with the KASRP to ensure the translation accuracy. The translation team scrutinized the semantic equivalence of items between the English and Vietnamese versions. Five experts were asked to rate the relevance of each item using a 4-point scale, ranging from 1 (not relevant) to 4 (highly relevant). The scale content validity index was 0.97, and no data were missing from the overall items.27 Ten nurses were recruited to answer questions and provide their opinions regarding the item clarity. No revisions were performed after this pretesting stage. Thirty nurses who met study inclusion criteria were invited to assess the stability of the scale and completed this scale twice with a 14-day interval. The test-retest reliability using Pearson r was 0.88, and no revisions were made. The internal consistency reliability for this study was Cronbach α of 0.79.

KASRP scores are presented as a percentage of correct responses and should not be viewed as a differential measure of either knowledge or attitude.26 In addition to calculating a total score of the KASRP Vietnamese version, 3 domains of scale were defined: pain assessment (12 items), pain medications and their management (24 items), and symptom management (5 items). A score of 80% or higher indicates acceptable knowledge and attitudes regarding pain management.19,22

Data Collection and Analysis. Five research assistants were trained for 3 hours by the principal researcher. These assistants screened all potential participants based on the established inclusion criteria. Participation was voluntary, and consent was obtained from all study participants. Subjects did not receive any compensation in this study. The time to complete the questionnaire was approximately 30 minutes.

Data are presented as mean (standard deviation) or frequency (percentage). To identify factors associated with knowledge and attitudes regarding pain management, a bivariate analysis was conducted using either an independent t test or a 1-way analysis of variance. Factors with a P < .05 were included in a multiple linear regression analysis. A value of variance inflation factor greater than 10 and a tolerance less than 1 indicated the absence of multicollinearity. Significance was set to P < .05. Data were analyzed using SPSS v.22.

Results

Among 283 recruited participants, 279 (98.6%) finished the questionnaires. The mean age was 36.09 (8.26) years, and 225 (80.6%) were female. One hundred seventy-three (62%) had at least a bachelor's degree, and 129 (47%) had 5 to 10 years of nursing experience. Only 24 (8.6%) participated in preservice training, whereas 48 (17.2%) attended in-service training regarding pain management. As shown in Table 1, 25 participants (9.0%) used unit-based pain guidelines and 77 (27.6%) used a numeric rating tool to assess pain intensity.

TABLE 1 - Demographic and Work Characteristics of Participants in KASRP Score (N = 279) Characteristics Total Sample (N = 297) Mean KASRP Score P Age, mean (SD), y 36.09 (8.26) Sex, n (%) .109  Male 54 (19.4) 22.22  Female 225 (80.6) 23.60 Educational level, n (%) <.010  College degree 86 (30.8) 17.29  Bachelor's degree 173 (62.0) 25.85  Master or higher 20 (7.2) 27.60 Working years, n (%) .126  <5 100 (35.8) 24.82  5–10 129 (46.3) 23.02  >10 50 (17.9) 23.01 Working units, n (%) .060  Medical 81 (29.0) 23.46  Surgical 80 (28.7) 23.30  Obstetric/pediatric 20 (7.2) 21.70  ICU/ER 25 (9.0) 22.52  Specialty unit 30 (10.7) 21.70  Othersa 43 (15.4) 25.56 Job titles, n (%) .368  Nurses/midwives 228 (81.7) 23.49  Leader/administrator 36 (12.9) 22.11  Educator/specialist 15 (5.4) 23.93 Preservice PM training, n (%) .350  Yes 24 (8.6) 23.24  No 255 (91.4) 24.38 In-service PM training .820  Yes 48 (17.2) 23.37  No 231 (82.8) 23.17 Read a book or journal about pain, n (%) <.010  Yes 152 (54.5) 26.75  No 127 (45.5) 19.25 Unit-based pain guidelines, n (%) <.010  Yes 25 (9.0) 31.88  No 254 (91.0) 22.50 Application of knowledge of PM, n (%) .324  Yes 131 (47.0) 23.02  No 148 (53.0) 23.69 Used a numeric rating tool, n (%) <.010  Yes 77 (27.6) 29.39  No 202 (72.4) 21.03 KASRP, mean (SD), score 23.34 (5.69) — — KASRP, correct answers, % 54.90 — —

Abbreviations: ER, emergency room; ICU, intensive care unit; KASRP, Knowledge and Attitudes Survey Regarding Pain; PM, pain management.

aOthers: oncology center and stroke center.

The mean number of correct responses on the KASRP was 23.34 (5.69). Only 16 participants (5.7%) scored higher than the cutoff point (80%) for acceptable knowledge and positive attitudes regarding pain management (Table 1). Correct responses ranged from 24.7% to 80.3%, with an overall mean correct response rate of 54.9%. The domain of the top 5 correct responses including items 10, 11, 22, 29, and 38-A was pain assessment and pain symptom management. The domain of the top 6 incorrect responses including items 8, 15, 20, 21, 23, and 39-B was pain medications and their management (Supplemental Digital Content 1, available at https://links.lww.com/JNN/A407, illustrates the KASRP items with the top 5 correct and incorrect response rates).

Bivariate analysis indicated that participants who held a bachelor's degree or higher, read about pain, used a numeric tool, and used unit-based pain guidelines were associated with higher KASRP scores (P < .01; Table 1). Participants who held a bachelor's degree or higher had a mean KASRP score of 25.85 or 27.60, respectively, compared with a score of 17.29 for participants without a college degree (P < .01). Participants who reported reading about pain had a mean KASRP score of 26.75 compared with a score of 19.25 for those participants who did not read about pain (P < .01). Using a numeric tool was associated with a mean KASRP score of 29.39, compared with a score of 21.03 for those who did not (P < .01). Using unit-based pain guidelines was associated with a mean KASRP score of 31.88, compared with a score of 22.50 among those who did not (P < .01; Table 1). Multiple linear regression identified that holding a bachelor's degree (95% confidence interval [CI], 4.14-5.89; P < .01) or higher (95% CI, 4.76-7.76; P < .01), reading about pain (95% CI, 2.03-3.69; P < .01), using a numeric tool (95% CI, 2.98-4.81; P < .01), and using unit-based pain guidelines (95% CI, 2.37-4.97; P < .01) were associated with higher KASRP scores (Table 2).

TABLE 2 - Factors Associated With Knowledge and Attitude Toward Pain Management (N = 279) Factors βa ± SEb 95% CI P Educational level  Bachelor's degree vs college degree 5.02 ± 0.45 4.14-5.89 <.010  Master or higher vs college degree 6.26 ± 0.76 4.76-7.76 .010 Read a book or journal about pain  Yes vs no 2.86 ± 0.42 2.03-3.69 <.010 Used a numeric rating tool  Yes vs no 3.89 ± 0.46 2.98-4.81 <.010 Unit-based pain guidelines  Yes vs no 3.67 ± 0.66 2.37-4.97 <.010

Abbreviation: CI, confidence interval.

a“β” indicates unstandardized regression coefficient.

b“SE” indicates standard error of β.

Discussion

This study provides important information on knowledge and attitudes regarding pain management among nurses in Vietnam. Finding that only 5.7% nurses had passing scores indicates that nurses generally lack knowledge and hold negative attitudes regarding pain management. This is consistent with the results of a previous study19 reporting a mean correct response rate for the KASRP scale of 54.4% among Chinese nurses. In the United States, a mean correct response on the KASRP scale of 77.2% was reported and 43% obtained a benchmark of 80% of correct scores among nurses.28 Nurses in Canada had a mean percentage response on the KASRP scale of 72%, and 26% achieved a passing score of 80% or greater.29 Several reasons could explain for these results.

All nurses in this study were from mountain areas, wherein learning opportunities are relatively limited and learning resources are quite scarce. The study hospital does not provide sufficient support for ongoing education programs regarding pain management. This study revealed that relatively few nurses (8.6%) attended preservice training, indicating that our current university nursing programs are not well equipped to provide information regarding knowledge and attitudes toward pain management for future nurses. Approximately 83% of nurses reported not receiving in-service training, and the level of pain knowledge and attitude was similar regardless of whether they attended pain training or not. Our findings are consistent with those of Ou et al's23 study, were nearly half of the nurses had never received in-service training and the level of pain knowledge and attitude was similar regardless of whether they received pain training or not. A recent study in Vietnam found that only 75.8% of nurses were not trained in postoperative pain management after recruitment to a hospital.25 These results indicate that nurses generally lack attention toward in-service pain training and imply that the available pain training courses were not adequate to improve knowledge and attitudes regarding pain.

The lowest scores were identified for items related to pain medications and their management. These results were consistent with previous findings that the most commonly missed items among surgical nurses25 and cancer nurses19,20 were related to pain medications and their administration. This can be explained by two reasons. First, Vietnamese nurses might not be adequately trained in pain medication use, pharmacological knowledge, and side effects before and during clinical work. Second, they often perform doctors' orders regarding pain medications and their management and only focus at the stage of disease treatment; they are less likely to make decisions regarding the type, dose, or timing of pain medication administration. Therefore, educating and empowering nurses on making independent decisions regarding pain management is necessary in clinical settings.

The 5 items that were most commonly answered correctly are related to pain assessment and pain symptom management. These results were in accordance with previous findings,19,20 which reported that nurses' responses were typically correct for items regarding pain assessment. These tasks are commonly performed by Vietnamese nurses, as documented in a recent study, suggesting that nurses regularly performed pain assessment and management in clinical practice.25

Independent influencing factors on KASRP scores included educational level, reading books or journals on pain, use of a numeric rating tool, and use of unit-based pain guidelines. These results were consistent with previous studies, which identified that education levels,20,22,25 the use of a numeric rating tool,23,25 reading about pain,17 and the use of unit-based pain guidelines25 had an influence on KASRP scores. It is understandable that nurses with a higher level of education and who are frequently reading pain resources have more knowledge regarding pain management and are more likely to implement it to their current practice. Using a numeric tool enhances patient-nurse communication, enabling patients to clearly express their pain intensity and the need for pain medication, which may or may not assist nurses in increasing their understanding of both the physiological and behavioral responses of patients to pain.30 However, the percentage of nurses reporting the use of a numeric tool in this study was quite low, even lower than those reported in other settings.17,25 Thus, encouraging the frequent use of numeric rating tools among nurses should be prioritized in future interventions. Furthermore, the percentage of nurses reporting the use of unit-based pain guidelines was very low, and only 54.48% of nurses reported reading about pain. Similar findings were documented in previous studies, suggesting that a lack of knowledge and accessibility to documents about pain could lead to the inadequate performance of pain management.11,25 These issues may be challenging to address by hospitals attempting to improve pain management performance among nurses, requiring the implementation of systematic pain guidelines and continuous training for clinical nurses.

The strengths of this study include the recruitment of nurses across a range of clinical units in a national hospital caring for residents from 6 provinces of Northern Vietnam. This study was thus representative of the Vietnamese nursing population. We also used a widely validated questionnaire to evaluate knowledge and attitudes regarding pain management. The limitations include the correlational nature of our study, which can only identify associations between knowledge and attitudes regarding pain and other factors without defining causative relationships. Future studies are needed to identify associations between pain management practices and other factors among nurses.

Implication for Practice

The low scores obtained for the knowledge and attitudes toward pain management can serve as a baseline reference to guide the development of educational interventions regarding pain management for Vietnamese nurses. Hospitals may benefit from creating more learning opportunities and providing sufficient learning resources for nurses regarding pain management. Individual nurse characteristics should be taken into consideration if they are empowered regarding pain management. Hospitals in Vietnam need to implement pain guidelines and encourage nurses to frequently use numeric tools and read about pain management.

Conclusion

Our study highlighted the far-from-satisfactory knowledge and attitudes regarding pain management among Vietnamese nurses. Educational level, reading books or journals about pain, using a numeric rating tool, and implementing unit-based pain guidelines were influencing factors on knowledge and attitudes regarding pain management. Vietnamese hospitals and health administration department need to provide sufficient support for ongoing education regarding pain management.

Acknowledgments

The authors thank the experts and Vietnamese nurses who participated in the survey. Gratitude is also given to the Training and Direction of Healthcare Activity Center of Thai Nguyen National Hospital and Dai Nam University, Vietnam.

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