Fourth-year and newly graduated nurses have been found to have less knowledge about pain management than they require to meet the pain relief needs of patients. Studies which used the Knowledge and Attitudes Survey Regarding Pain have found that students and graduates often score very low on the survey. Appropriate pain relief is important for humane reasons as well as the negative impact of pain on healing. Therefore, this paper proposes a two-week pain management intervention for fourth-year nursing students.

Pain is one of the most significant symptoms of impaired health and it is sometimes considered the fifth vital sign (Morone & Weiner, 2013). Research has indicated that pain relief is very important since not only is it cruel to allow patients to suffer, but also pain can slow healing and lead to complications such as pneumonia, deep-vein thrombosis, and atelectasis (Apfelbaum et al., 2003). Pain places significant stress on the body which can affect the functions of the endocrine and immune systems (Chapman, Tuckett, & Song, 2008). Therefore, inadequate pain relief produces psychological and physiological trauma that can interfere with wound healing and prolong recovery (Bell & Duffy, 2009).

The literature shows that BSN students and new graduates are lacking in their knowledge and attitudes toward pain management. Using the Knowledge and Attitudes Survey Regarding Pain (KASRP) (Ferrell & McCaffrey, 2008), researchers have found that fourth-year students and even new graduates achieve low scores. For example, research conducted by Duke and colleagues (2013) found that student scores on the KASRP were lower than expected (68%); another study (Al-Khawaldeh et al., 2013) tested graduating students (n= 240) from three different nursing schools, and the average correct score was a dismal 34%. However, there were significant difference between the three schools regarding training in pain management and practice in using pain assessment tools. Goodrich (2006) found that nursing students had gaps in their knowledge of pain during sleep, incidence of respiratory depression, equating analgesics, and the definitions of addiction, tolerance, and physical dependence. In a review of these and related studies, Chow and Chan (2015) concluded that nursing students were not receiving sufficient education regarding appropriate pain management.

When nurses feel unable to properly deal with pain issues because they lack fundamental knowledge, the patients they treat can tell that they are uncertain and this can have a negative effect on patient response (Hartog et al., 2010). Schreiber and colleagues (2014) examined an educational program designed to improve the knowledge and attitudes of practicing nurses with regard to pain management. Using a different measure (the Brokopp-Warden Pain Knowledge/Bias Questionnaire, 2004), they found that, although there was no significant change in scores, the pain reported by patients showed a 50% decrease (Schreiber et al., 2014). Chiang, Chen and Huang (2006) also noted a large increase in KASRP scores after intervention (from 55.0% to 91.4%), and Owens, Smith, and Jonas (2014) found a slight increase in scores. However, there have been few (if any) studies looking at pain management interventions for fourth-year nursing students. Therefore, this study will examine the efficacy of a two-week intervention specifically designed to teach fourth-year nursing students how to manage pain.

The theoretical framework of the intervention which is outlined here is the theory of critical thinking using narrative reflection (Forneris & Peden-McAlpine, 2006). According to the authors, critical thinking can be defined as reflective thinking that examines the reasoning and explanation behind nursing practice. The process of critical thinking provides the student with more than just answers; instead, he or she develops a coherent interpretation of nursing KSA in the context of everyday situations. The method of teaching described by Forneris and Peden-McAlpine (2006) is designed to help nursing students apply critical thinking in real-world situations by focusing on content over time using reflection and dialogue (Figure 1). The four components of the intervention – content, time, reflection, and dialogue – form a conceptual framework that illustrates how the student moves from the antecedent KSA as determined by the pre-test to the consequential KSA measured by the post-test. According to Forneris and Peden-McAlpine (2006), the critical thinking framework changes the educational intervention from a simple means-to-an-end approach to a dynamic process that targets critical thinking skills in practice.

The framework determines the “who, what, and how” of the intervention. In the critical thinking model, the “what” or the goal of the intervention is represented by content – in this case, improving fourth year nursing students’ knowledge, skills, and attitudes (KSA) about pain management. The “when” or time of the intervention is crucial because students need time to process and integrate the content. The time for this intervention is two weeks, as indicated above. Content (knowledge, skills, and attitudes) over time is developed, or constructed, both externally (via dialogue with the instructor and with peers) and internally (via reflective narrative) (Forneris & Peden-McAlpine, 2006). Dialogue and reflection are the “how” components of the model. The authors emphasized the importance of reflection in learning because it helps students make connections between prior knowledge and new content, as well as addressing how to determine the value of information. Likewise, the narrative aspect of reflection is essential because it constructs knowledge in a linear fashion (Forneris & Peden-McAlpine, 2007). One way in which narrative reflection can become part of an intervention is the production of reflective journals. For example, after each day of intervention, students can be prompted to write about an incident that gave them feelings of satisfaction, accomplishment, frustration, or other emotions. Using guided questioning, they would be encouraged to write a narrative or story about what they felt and why (Forneris & Peden-McAlpine, 2007).

Characteristics of the critical thinking approach to nursing education include (1) internal narrative reflection is used by the learner to develop a coherent representation of the nursing context; (2) knowledge, skills, and attitudes are constructed by students and teachers working together; (3) collaboration at different levels is encouraged; (4) knowledge is gained through experiences of content over time via interaction coupled with thoughtful reflection, and (5) the learner’s engagement in the topic, both internally and externally, is crucial to his or her development of knowledge (Forneris & Peden-McAlpine, 2007).