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Knowledge of resident nurses on the management of cancer pain: A

crosssectional study

Article  in  Online Brazilian Journal of Nursing · December 2016

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 ISSN: 1676-4285

Knowledge of resident nurses on the

management of cancer pain: a cross-
sectional study
Flávia dos Santos Ferreira1, Juliano dos Santos2,3, Karina Cardoso Meira4

1
Portuguese Hospital
2 National Institute of Cancer
3 University of São Paulo
4 Federal University of Rio Grande do Norte

ABSTRACT
Aims: to evaluate the knowledge of resident nurses regarding the management of cancer pain and the
associated sociodemographic and professional variables. Method: a cross-sectional study with a target
population of nurses who were enrolled in a multi-professional oncology residency program. The nurses’
knowledge was evaluated through the “Nurses’ knowledge about the cancer pain management – WHO”
instrument. Poisson regression with robust variance was used to analyze the association between the variables.
Results: most (68.2%) of the interviewees presented inadequate knowledge. Adequate knowledge was
dependent on training time, as individuals with more than one year of training (PR=0.14, CI 95%, 0.02-0.97)
were less likely to present inadequate knowledge. Conclusions: there was a predominance of ignorance about
the management of cancer pain and adequate knowledge was dependent on professional training time.

Descriptors: Pain; Medical Oncology; Knowledge; Teaching; Nursing.

Ferreira FS, Santos J, Meira KC. Knowledge of resident nurses on the management of cancer pain: a cross-sectional study.
694 Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):694-703. Available from: [Link]
[Link]/nursing/article/view/5439
INTRODUCTION of implementing anti-anxiety treatment, they
are the ones that most frequently assess pain,
Inadequate knowledge and erroneous be- the response to implemented therapies and the
liefs of health professionals are among the main occurrence of any adverse reactions, which are
barriers to adequate pain control(1), since they variables that directly affect the evaluation of the
lead to underestimation of patients’ complaints effectiveness of the proposed control strategies
about pain, use of inadequate analgesic regimes and treatment(1,5).
and the persistence of myths and misconcep- Given the importance of nurses’ training in
tions of patients and relatives(1-2). pain and analgesia, as well as in the evaluation of
The beliefs related to the control of cancer the effectiveness of the inclusion of the theme
pain, from the point of view of professionals, in undergraduate and postgraduate curricula,
are well described in the literature, highlighting diagnosing the knowledge of health professio-
the fear of addiction and respiratory depression nals about the evaluation and control of these
related to the use of opioids(3). symptoms is of utmost importance, since such
In addition to the beliefs mentioned above, measures allow us to identify the gaps and varia-
among Brazilian nurses we observed a lack of bles related to inadequate control and provide
knowledge about the concepts related to stra- resources to adjust and improve education and
tegies for the evaluation of cancer pain and to training strategies about the pain theme(2).
the pharmacological and non-pharmacological Some studies have evaluated nurses’ kno-
measures to control it(1). wledge about pain assessment and manage-
These inadequate conceptions are pointed ment(6,7). However, studies that have evaluated
out as reasons for the inadequate control of the knowledge of nurses in the training process
pain(1-3), which, although frequent and consi- regarding painrelief(8-10) at the postgraduate level
dered an emergency in patients with cancer, is are scarce.
still poorly understood by professionals, a fact
that has limited the provision of care to patients.
Cancer pain occurs in between 62.0% and AIMS
90.0% of patients, manifesting at all stages of
the disease(1) and may be related to the proce- To evaluate the knowledge of resident
dures required for diagnosis or treatment, to nurses about the management of cancer pain
disease progression or its associated morbidity. and its associated sociodemographic and pro-
Currently, due to its high incidence and morta- fessional variables.
lity, cancer is considered a serious public health
issue and 596 thousand new cases of the disease
are estimated to be diagnosed in Brazil for the METHOD
2016/2017 biennium(4). We expect, therefore,
that cancer pain will remain as one of the most Sample, Location and Period
prevalent symptoms.
Pain control requires a multi-professional This is a cross-sectional study whose tar-
and multidisciplinary approach and, in this con- get population was the resident nurses who
text, nurses take a prominent role, since, althou- were enrolled in 2013 in the multi-professional
gh they are not the only professionals in charge oncology residency program (n=29) of a High
Ferreira FS, Santos J, Meira KC. Knowledge of resident nurses on the management of cancer pain: a cross-sectional study.
Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):694-703. Available from: [Link] 695
[Link]/nursing/article/view/5439
 Complexity Oncology Center (CACON) in the We determined the cut-off point for the
city of Rio de Janeiro. All subjects of the target total score and for domains using the Receiver
population were invited to participate in this Operating Characteristic (ROC) curve. Assuming
study, and the convenience sample consisted of a sensitivity of 100% and a specificity of 99.0%,
22 individuals. Six nurses refused to participate the cut-off point was set as 67 points; 22.4
(four residents of the first year and two of the points for the ‘pain assessment’ and ‘continuous
second year) and one participated as a resear- care’ domains, and 22 points for the ‘pain con-
cher and, thus, was not included in the sample. trol strategies’ domain; lower values than these
The curricular program included theoretical were considered to be inadequate knowledge.
classes on pain and analgesia, concentrated
throughout the second year of residence. Data collection procedure

Data collection instruments The instrument was distributed during

theoretical classes for residents of the first and
To perform the data collection, we used second years, between June and July 2013. The
the instrument “Nurses’ knowledge about researchers involved waited for the question-
the management of cancer pain – WHO”(11). naires to be returned on the occasion, which
It is a self-report instrument, built according took 30 minutes on average.
to the recommendations of the World Health
Organization (WHO), comprising 24 items of Data analysis
the Likert scale, distributed in three domains
(pain evaluation, control strategies and con- The statistical analysis was developed
tinuous care), with 8 items each. Each item is in four steps: descriptive analysis, bivariate
graded and scored according to the frequency analysis, multivariate analysis and residue
of occurrence of the statements that make up analysis. In the descriptive analysis of the data,
the instrument (always=4.16 points, someti- we calculated measures of central tendency
mes=1.04 points and never=0). The scores of and dispersion, as well as the absolute (n) and
the domains varied between 0 to 33.28 points relative (%) frequencies of the classificatory
and the total score varied between 0 and 100 variables. The next step involved the bivariate
points, which can be obtained by summing the analysis to verify the existence of an association
scores of each item(11). between each independent variable and the
The instrument had already been used in knowledge about the management of pain in
a previous study performed in this field(12) and cancer. The relationship between the classifica-
we evaluated its reliability through internal tory variables was assessed using the Pearson
consistency in the present study. The overall chi-square test or Fisher’s exact test. We used
scale presented good reliability (Cronbach’s the t-student test to evaluate the quantitative
alpha=0.71) and its domains, pain assessment variables and the difference between the me-
(Cronbach’s alpha=0.64) and continuous care ans, after verification of normality through the
(Cronbach’s alpha=0.66), presented reasona- Shapiro-Wilk test.
ble reliability. The ‘control strategies’ domain We performed the multivariate analysis to
presented insufficient reliability (Cronbach’s evaluate the factors associated with knowledge
alpha=0.31). about pain management in cancer, as well as
Ferreira FS, Santos J, Meira KC. Knowledge of resident nurses on the management of cancer pain: a cross-sectional study.
696 Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):694-703. Available from: [Link]
[Link]/nursing/article/view/5439
to monitor possible confounding variables. In RESULTS
this step, we used the Poisson regression with
robust variance; the outcome being adequate Women and individuals of Christian religion
or inadequate knowledge. The prevalence ratio predominated in the study sample. Half of the
(PR) and confidence intervals (95%, CI) were sample had a training time of greater than one
calculated. In these analyzes, we used the san- year, 54.5% of the interviewees were in the first
dwich library of the R [Link] statistical program. year of residence, 50.0% had less than one year
The response variable was categorized of professional experience as nurses and 54.5%
into adequate and inadequate knowledge. The had not undergone post-graduation education
independent variables were gender, religion, (Table 1).
year of residence, training time, professional
working time, age and level of education, since Table 1. Socio-demographic and professional
we believe that they influence the knowledge, characteristics of resident nurses, 2013, Rio de
Janeiro
beliefs and attitudes related to pain.
All independent variables were categori- Variables n (%) P*
Gender
zed, except for the age variable, as there was
Men 1 (4,5)
little variation between these, making it difficult Women 21 (95,5) 0,00001
to categorize age groups. Religion
In the unadjusted analysis, the covariates Christian 19(86,4)
Non-Christian 3(13,6) 0,001
that presented a critical level of p ≤ 0.20 were Residence Time  
considered as choices for permanence in the R1† 12 (54,5)
multivariate model. The adjustment of poten- R2‡ 10 (45,5) 0,66
Training Time
tially confounding variables was performed
< 1 year 5(22,7)
using the step-by-step multivariate technique, 1 year 6(27,3)
with the inclusion of the variables being signifi- > 1 year 11(50,0) 0,24
cantly associated with the response variable in Active Professional
Time  
the final model. After the simultaneous inclu-
< 1 year 11(50,0)
sion of all major effects, plausible interactions 1 year 2(9,1)
were tested. > 1 year 9(40,9) 0,04
The selection of the final model consi- Education level  
dered the value of the Akaike Criterion (AIC), Graduation 12(54,5)
Post-Graduation 10(45,5) 0,66
residue analysis by graphic observation and
Source: Study data *Pearson’s chi-square test †1st year
epidemiological significance. Values of p≤0.05 ‡2nd year
were considered significant.
Most of the resident nurses presented inade-
Ethical aspects quate knowledge about cancer pain management
(68.2%) and a statistically significant difference was
The study was approved by the Research found between knowledge level and training time
Ethics Committee of the institution involved un- (Table 2).
der the opinion 228,334, according to Resolution Source: Study data. §
T-
466/12 of the National Health Council. Student test

Ferreira FS, Santos J, Meira KC. Knowledge of resident nurses on the management of cancer pain: a cross-sectional study.
Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):694-703. Available from: [Link] 697
[Link]/nursing/article/view/5439
 Table 2. Comparison of resident nurses’ knowledge about pain management according to sociode-
mographic and professional characteristics, 2013, Rio de Janeiro
    Adequate Inadequate P Value
Variables   n % n %  
Knowledge 7 31,8 15 68,2
Age Average (SD) 24,86 (2,54) 25,73 (4,35) 0,56§
Religion
Christian 7 100,0 12 80,0
0,52
Non Christian 0 0,0 3 20,0
Residence Time
R1 6 50,0 6 50,0
R2 1 10,0 9 90,0 0,06
Training Time
< 1 year 2 28,6 3 20,0
1 year 4 57,1 2 13,3
> 1 year 1 14,3 10 66,7 0,04
Active Professional Time
< 1 year 6 40,0 5 71,4
1 year 1 6,7 1 14,3
> 1 year 8 53,3 1 14,3 0,22
Education level
Graduation 4 57,1 8 53,3
0,60
  Post-Graduation 3 42,9 7 46,7
Source: Study data. § T-Student test

Table 3. Comparison of the mean scores obtained by resident nurses according to the knowledge
about pain management in cancer, 2013, Rio de Janeiro

Knowledge about Domains

pain manage- Pain Eva- Control Conti-
P Value P Value P Value Total P Value
ment luation Strategies nuous Care
Adequate 0,0001§ 0,001§ 0,0001§ 0,0001§
Average 27,5 23,6 28,8 75,8
(Standard deviation) (4,2) (0,6) (3,2) (9,0)
Inadequate
Average 16,2 15,1 15,3 57,0
(Standard deviation) (3,9) (3,6) (6,4) (8,4)
Source: Study data §T-Student test

Nurses with adequate knowledge had hi- sion with robust variance. The model with only
gher average knowledge in all domains and total the “training time” variable presented the best
score than those who presented inadequate fit to the data, since it was the only one that
knowledge (Table 3). remained statistically significant at the 5% level
In the multivariate analysis, the “training (p≤0.05) and presented a lower AIC value (31.7),
time” and “year of residence” variables were when compared to the model that included the
included, as they presented a value of p≤0.20 variables, “training time” and “year of residence”
in the univariate analysis of the Poisson regres- (p=0.10, AIC=33.6).
Ferreira FS, Santos J, Meira KC. Knowledge of resident nurses on the management of cancer pain: a cross-sectional study.
698 Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):694-703. Available from: [Link]
[Link]/nursing/article/view/5439
 We observed that the knowledge regarding nal intervention about acknowledgement and
the management of cancer pain was dependent attitudes regarding pain, performed between
on the time of formation or, in other words, indi- the follow-up assessments, were considered
viduals with more than one year of completed unsatisfactory(12).
graduation had a lower chance of presenting These findings can be explained by failures
inadequate knowledge (PR=0.14, CI 95%, 0.02- in training in painmanagement and analgesia
0.97), when compared to those with less than observed in undergraduate courses in the health
one year of graduation (Table 4). area and documented in the literature(8,9,11,12), as
well as in those observed at postgraduate level(2),
Table 4. Prevalence ratio of the final regression which are confirmed by our results. It may still
model of the factor associated with resident
be related to the time of acquisition of know-
nurses’ knowledge on pain management in
cancer, 2013, Rio de Janeiro. ledge in the residence and to the application
of the instrument of this study, since, possibly
Adequate/inadequate
Variables knowledge
the knowledge acquired during the residence
n % ||PR (CI 95%) period may present decline(12).
Training time Typically, undergraduate curricula do not
<1 year 6 27,3 1 address specific disciplines on pain. The sub-
1 year 5 22,7 0,60 (0,17-2,02) ject is approached intermittently within larger
>1 year 11 50,0 0,14 (0,02-0,97) theoretical blocks or in elective subjects, and
Source: Study data | |Prevalence ratio there is no concern about the resumption and
interconnection of previous information(13).
DISCUSSION In the same sense, postgraduate programs
The study showed that most of the resident in the form of residency, are characterized as
nurses had inadequate knowledge regarding the in-service training, i.e., there is a prioritization
management of cancer pain. In addition, there of practice scenarios over theoretical training,
was no difference in the level of knowledge which should account for only 20% of the total
among residents of the first and second year, workload of the program(14).
and knowledge was dependent on training time The theoretical content about pain and
(Table 1 and Table 2). analgesia in the residency program, in which the
It was expected that, because they were respondents were inserted, was characterized by
enrolled in a residency program in oncology, two theoretical classes that did not reach a total
nurses presented basic knowledge and were of 10 hours, were concentrated in the second
sensitized to the evaluation, intervention and year by the practical activities in hospitalization
monitoring of pain, since, in this context, this units, where the students had contact with the
is one of the most prevalent symptoms and is systematized evaluation and registry of pain as
considered to be an oncology emergency. This the 5th vital sign from their first year of residence.
prerogative was not observed, although, we A study that evaluated the knowledge,
found its support in the literature. care measures, pain portfolios and satisfaction
A longitudinal study showed that, in the measures of 118 students in their first year of me-
initial evaluation, resident nurses showed mode- dicine, with the aim of proposing a new course
rate prior knowledge regarding aspects of pain based on pain knowledge, stated that pain ma-
management. However, the effects of educatio- nagement was a challenge and that education
Ferreira FS, Santos J, Meira KC. Knowledge of resident nurses on the management of cancer pain: a cross-sectional study.
Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):694-703. Available from: [Link] 699
[Link]/nursing/article/view/5439
 in pain relief was an important matter to change of residence, the proportion of nurses with ina-
mistaken practices. This study concluded that dequate knowledge was higher (90% vs 50%)
the addition of four days of classes with specia- among R2 nurses (Table 2). These figures are
lists was an effective educational approach(15). contrary to the findings of the aforementioned
In this respect, it is considered that this view studies, which evaluated students at different
of the post-graduation in the form of residence training moments(8).
should be adapted to the proposed objectives, It is possible that these results are related to
since the theoretical bases are the foundation the fact that first-year residents reflect the lear-
for the clinical practices, which, in turn, question ning and knowledge acquired during graduation
the theory, in an interdependent relationship(8), and the inadequate pain teaching strategy used
especially when considering that the training in the residency program, which is characterized
of these professionals regarding pain at the by two expository classes in the second year. The
undergraduate level is deficient(2,13) and, al- lack of theoretical-practical articulation, which
though it is one of the pillars of the residency, is one of the proposals of the residence post-
the teaching-practice integration as one of the graduate model and a prerogative of training
proposals for the development of specific skills, in the pain field, and the lack of knowledge, or
is still a challenge. insufficient knowledge, of the preceptors(2) that
These characteristics contribute to main- accompany residents in the practice scenarios,
tain a significant deficit of knowledge about are also possible explanations.
pain, even in professionals at the postgraduate Half of the nurses in the first year of re-
level, and evidence the need for targeted and sidence (R1) also presented knowledge that
systematized clinical practice for the consolida- is considered to be inadequate (Table 2). This
tion of knowledge(8). finding reinforces the fact that, in addition to
It was also expected that the nurses of the theoretical training, other variables are related to
second year of residence presented a higher knowledge about pain management in cancer,
level of knowledge than the first, since, theore- such as the characteristics of the postgraduate
tically, they had more theoretical content on the program and the training of preceptors on the
subject and experienced more opportunities to subject(2,14).
deal with patients with cancer pain. Considering the final model that best fit
However, this assumption was not confir- the data in the multivariate analysis, the varia-
med and differed from the observed results in a ble “training time” was the only one which was
study that analyzed the evolution of knowledge related to knowledge about pain management
and attitudes of nursing students regarding pain, in cancer, i.e., the residents with a longer training
in one year of follow-up. In the mentioned study, time had less chance of presenting inadequate
the score related to knowledge and attitudes, knowledge (Table 4).
which increased significantly as the training time This finding differed from that observed in
of the students increased, reaching 40% at the a study among 91 emergency nurses, in which
end of the four years of the course(8). age, time training and professional experience
It is important to note that, in addition to did not influence knowledge about pain and
the fact that we could observe no difference analgesia(16).
between the knowledge presented by the These findings show that, for this group,
nurses of the first (R1) and the second (R2) year the experiences during the training time were
Ferreira FS, Santos J, Meira KC. Knowledge of resident nurses on the management of cancer pain: a cross-sectional study.
700 Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):694-703. Available from: [Link]
[Link]/nursing/article/view/5439
more important for the knowledge about pain pain registry by 88%. This was the best strategy
and analgesia in oncology than the specific for the control of postoperative pain, since it
training itself. They also confirm the explana- was related to the increase in the frequency
tory variables already mentioned and reveal a of administration of supplemental morphine
relevant gap in the training process of these and the lower intensity of pain reported by the
professionals, since it is recommended that the patients(17).
training and sensitization of the students on the It is important to emphasize, however, that
subject is developed in a continuous, sequential educational interventions are more effective in
and progressive way(8). increasing knowledge than in changing attitu-
National validated instruments to assess des, as for the latter, the contact with specialists
knowledge about the management of cancer or specific training seems to be more effective(20).
pain are scarce, as are the Brazilian studies The study included the majority (78.6%) of
that have evaluated the knowledge of health the resident nurses and allowed a diagnosis to
professionals in the process of training on the be made to direct future curricular interventions
subject(2,8,9,12). in this postgraduate program.
Education on the subject is a need percei- The limitations of this study are related to
ved by professionals and seems to contribute to the instrument used in that, although originally
the improvement of professionals’ performance submitted to content validation through a com-
in pain control(17-19). Among Portuguese nursing mittee of experts, it did not have its psychome-
graduates, there was a tendency to increase the tric properties previously analyzed(14). In order to
level of self-perceived knowledge, over the years obtain a parameter of the accuracy of the mea-
of training(8). Among medical students in Greece, surement used, the reliability of the instrument
undergraduates who attended extracurricular was tested for the studied population.
courses related to the subject presented more The instrument presented good reliability
adequate knowledge regarding the treatment (Cronbach’s α=0.71) and its domains, “pain evalu-
of chronic pain and were more familiar with the ation” (Cronbach’s α=0.64) and “continuous care”
classification of the types of pain. In contrast, (Cronbach’s α=0.66), presented reasonable relia-
students who did not have this type of training bility. However, the “control strategies” domain
had little information about pain clinics and presented reliability considered insufficient
little knowledge about opioid use in cancer and (Cronbach’s α=0.31).
chronic non-oncologic pain(13). When comparing the average performance
Training on cancer pain management im- of the participants, both in relation to the total
proved the average knowledge score of Kenyan score and in relation to the scores observed by
nurses between pre- and post-intervention domain, a statistically significant difference was
educational assessment, and the mean score of observed for all outcomes between individuals
the evaluation performed two weeks after the with adequate knowledge and individuals with
intervention remained stable(18). In the same inadequate knowledge (Table 3).
sense, the sensitization of professionals for These findings demonstrated that the ins-
systematized evaluation and recording, in the trument was able to discriminate between the
context of implementing pain as the fifth vital two groups in relation to knowledge about the
sign(19), increased the evaluation registries by management of cancer pain, which was desira-
70%, and the analgesia in patients with intense ble and could be considered as an indication of
Ferreira FS, Santos J, Meira KC. Knowledge of resident nurses on the management of cancer pain: a cross-sectional study.
Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):694-703. Available from: [Link] 701
[Link]/nursing/article/view/5439
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Authors’ contribution in research:

Flávia dos Santos Ferreira: Effective scientific and intellec-

tual contribution to the study; Conception; Acquisition of
data; Interpretation of data; Preparation of the manuscript;
Writing of the manuscript.

Juliano dos Santos: Effective scientific and intellectual

contribution to the study; Design; Data analysis and inter-
pretation; Preparation of the manuscript; Writing of the ma-
nuscript. Critical review of the manuscript; Final approval.

Karina Cardoso Meira: Effective scientific and intellectual

contribution to the study; Analysis and Interpretation of
data; Preparation of the manuscript; Writing of the ma-
nuscript. Critical review of the manuscript; Final approval.

Ferreira FS, Santos J, Meira KC. Knowledge of resident nurses on the management of cancer pain: a cross-sectional study.
Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):694-703. Available from: [Link] 703
[Link]/nursing/article/view/5439

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