Knowledge and attitude of nursing students toward pain management and opioids: A cross-sectional survey in the western region Saudi Arabia

Abstract

Introduction:

Pain management is a global epidemic with grave effects on the patients and communities. Nurses are an important part of the multidisciplinary pain management team. Multiple studies have found inadequate knowledge and a negative attitude toward pain among nurses. We aim to examine the knowledge and attitude of nursing students in Saudi Arabia and the potential effects on future patient care.

Methods:

We employed a previously validated tool; the Nurses’ Knowledge and Attitude Survey Regarding Pain NKASRP. Our population included two of the major Nursing Colleges in Western Saudi Arabia. We published the survey and collected the data electronically. We analyzed the data calculating averages and regression analysis as needed.

Results:

We collected 261 responses. Our results showed that the average score on the NKASRP was 44.9% – inadequate – with only two students passing the 80% cutoff point. Also, the score is not statistically different according to academic level, which implies that the curriculum does not improve the knowledge nor the attitude of nursing students over its course.

Conclusion:

Our study suggests there is a very strong need for the Nursing College Curriculum review by nursing educational leaders in Saudi Arabia regarding the pain education component. Improving curriculums might improve nursing students’ outcomes, hence improving the quality of life for our patients and community.

Introduction

Pain is defined by the International Association of Study of Pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”.[1] In Saudi Arabia, the prevalence of chronic pain was found to be 46.4% of the population affecting millions of patients and a different manuscript found that 48.5% of responders suffer from musculoskeletal pain.[2,3] Under- and untreated pain has multiple physical, psychological, and economic consequences on the patients and the community.[4]

Pain management can be complex and require a multidisciplinary team approach.[5] Nurses play a critical role in pain management. Multiple research projects found that the knowledge and attitude in Saudi Arabia are inadequate and in need of improvement.[6,7,8,9,10]

One factor that could contribute to that is pre-graduate education. Globally, nursing students have inadequate knowledge and attitudes toward pain management.[11] Our aim in this study is to assess knowledge and attitude of nursing students in two of the major nursing colleges in Saudi Arabia to examine the adequacy of preparing nursing students for their role in pain management after graduation.

Methods

We performed a cross-sectional survey design to examine nursing students’ knowledge and attitudes toward pain management and opioids.

Survey tool

We used a previously validated tool; the Nurses’ Knowledge and Attitude Survey Regarding Pain NKASRP.[11] The NKASRP is composed of 22 True/False, 15 Multiple-Choice Questions MCQs, and 2 Case Scenarios, of 2 MCQs each. The NKASRP is a well-known tool developed by pain management experts over several years and validated in a vast number of research projects.[12,13,14,15,16,17] The content of the NKASRP is synthesized from guidelines of respected organizations as the World Health Organization, the American Pain Society, and the National Comprehensive Cancer Network Pain Guidelines. It has been found to be valid as a tool differentiating between nurses’ levels of expertise.

We translated the tool into Arabic to avoid any language barrier the new students might have. The translated version was a backward, forward translation by a certified linguistician, anesthesiologist, general physician, and pharmacologist. It was then piloted among a sample of 10 healthcare workers to ensure validity. It is worth mentioning we excluded one of the questions – question 32 – as it was constructed to reflect the United States community and it is not applicable to our local community. We also added a demographic section to help guide our analysis later.

Participants

We sampled nursing students across all years – first, second, third, fourth, and internship – enrolled in the nursing Bachelor program (B.S.N.) at two of the largest academic colleges of Nursing in the Western Saudi Arabia.

Data collection procedures

After acquiring an Ethical approval from King Abdulaziz University Biomedical Ethics Research Committee (NCBE Registration No: (HA-02-J-008)), we deployed our survey. Over a 1-year period from September 2023 to August 2024, we collected data from participants using a Google Forms platform to survey, distribute, and collect the data electronically to participants at their colleges.

Data analysis

To determine the adjusted sample size, we used[18] a sampling frame of the total nursing students at these two schools of around 950 students with Effect size = 0.2, Power = 0.80, Alpha = 0.05, and Margin of error ≈ 5%. The adjusted sample size is ≈ 274 participants.

We followed the NKASRP recommendations in analyzing the data; “we have found the most benefit to be gained from analyzing the data in terms of the percentage of complete scores as well as in analyzing individual items”.[11]

Statistical analysis

We used Microsoft Excel and Python: 3.11.8 for data entry analysis. We gave a value of 1 to correct responses, and 0 was given to the incorrect ones. As advised by NKASRP, we calculated the average mean, its percentages, and standard deviation score for the overall and individual questions. Finally, we calculated the independent sample t-test to examine any significant variations among subclasses.

Results

We collected 261 responses. Demographics of participants are shown in [Table 1].

Table 1.

Demographics

Characteristics	Number
Age 21 and less	189
Age >21	65
1st year	116
2nd year	60
3rd year	31
4th year	26
Internship	21
Male	23
Female	231
College 1	56
College 2	195
Prefer not say	3

The average mean score for participants was 17.97 STD 3.6 out of 40, which is 44.9%. Table 2 represents the number and percentage of correct responses on each question of the KASRP. Only two participants scored more than the suggested failing cutoff point of 80%.[19]

Table 2.

Number and percentage of correct responses on each question of the KASRP

Question number	No. of correct answers	Percentage of correct answers	Question number	No. of correct answers	Percentage of correct answers
1	103	40.55%	21	193	75.98%
2	93	36.61%	22	223	87.80%
3	124	48.82%	23	34	13.39%
4	142	55.91%	24	146	57.48%
5	111	43.70%	25	132	51.97%
6	142	55.91%	26	99	38.98%
7	144	56.69%	27	126	49.61%
8	89	35.04%	28	56	22.05%
9	65	25.59%	29	140	55.12%
10	115	45.28%	30	134	52.76%
11	96	37.80%	31	96	37.80%
12	167	65.75%	32	117	46.06%
13	212	83.46%	33	154	60.63%
14	221	87.01%	34	84	33.07%
15	57	22.44%	35	78	30.71%
16	158	62.20%	36	70	27.56%
17	52	20.47%	37	32	12.60%
18	108	42.52%	38	15	5.91%
19	140	55.12%	39	50	19.69%
20	223	87.80%	40	25	9.84%

The average mean score for participants was 17.97 STD 3.6 out of 40

We also analyzed the distribution of scores by different academic levels, see Table 3 and Figure 1. We conducted a one-way ANOVA to compare the mean scores across the five academic levels: 1^st year, 2^nd year, 3^rd year, 4^th year, and Internship. The analysis revealed no statistically significant difference in the mean scores between the groups, F (4, 249) = 0.57, P = 0.683. This suggests that academic level did not have a significant effect on the outcome variable under investigation. The mean scores ranged from 17.32 (SD = 4.02) in the 1^st year to 19.09 (SD = 3.26) in the 3^rd year, with relatively small variations observed across all groups.

Table 3.

Distribution of scores by academic levels

	Average	SD	n
1st year	17.32	4.02	116
2nd year	18.1	3.41	60
3rd year	19.09	3.26	31
4th year	18.38	3.95	26
Internship	19.04	2.99	21

Figure 1.

Distribution of scores by academic levels

Finally, to investigate the effect of different colleges on the average score, an independent sample t-test was conducted to compare the mean scores between College 1 and College 2. The results showed there is no statistically significant difference between the two groups, t= -0.70, P = 0.485. The mean score for College 1 was 17.8 (SD = 3.71), while College 2 had a mean score of 18.65 (SD = 3.96).

Discussion

Pain is a global issue that is also present in Saudi Arabia.[2,3] A multidisciplinary approach including nursing is a crucial element to combat pain management. Our aim is to investigate the undergraduate nurse’s preparation for pain management as the main future workforce stream in Saudi. Our study is unique in that all previous research projects were conducted on licensed nurses not students.

Our study showed that the average score on the NKASRP was 44.9% – inadequate – with only two students passing the 80% cutoff point.[19] It is worth mentioning that both passing scores were 1^st-year nursing students. Also, the score is not statistically different according to academic level, which implies that the curriculum does not improve the knowledge nor the attitude of nursing students over its course. By examining both colleges’ curriculum, we found only a few scattered lectures about pain assessment and management; hence, a nursing student might be able to graduate without adequately learning how to assess and manage pain.

The nursing student’s inadequate knowledge and negative attitude toward pain are not unique to our country as a previous meta-analysis found after analyzing 29 studies indicated that they indeed have similar findings.[20] On the other hand, the lack of improvement over the course of the curriculum is not a typical finding compared to other studies, which might reflect the need to investigate this in our college curriculums to improve the outcome.[21,22]

Our finding might explain part of the reasons that most, if not all, studies adopting the NKASRP tool for the same purpose on Saudi nursing workforce showed the majority have an inadequate score despite the variety of settings, geographical areas, and subspeciality of the participants.[6,7,8,9,10] Globally, studies involving nurses in Saudi have lower average NKASRP scores comparable to studies in other countries like China, Jordan, Mexico, and Bahrain but lower than those in other countries.[23,24]

It has been suggested in a previous study to examine and improve undergraduate nursing education and assessment of pain-related topics to combat this phenomena,[25] and our study suggests there is a very strong need for the Nursing College Curriculum review by nursing educational leaders in Saudi Arabia in regard to the pain education component.[4]

Limitations of our study include the following: The required sample size was initially calculated to be 274 participants; however, only 261 responses were obtained, resulting in a slight shortfall of approximately 3.6%. Post hoc power analysis indicated that this sample size yields an estimated power of approximately 0.78. While this is marginally below the desired threshold, it is considered acceptable for the purposes of this study. Another limitation was the varying number of students between academic classes; however, the analysis showed that this is not related to the outcomes of the tool.

In conclusion, controlling pain may lead to improving quality of life for the patients and community. Improving quality of life is a main pillar of the 2030 Saudi Health vision that the country strives to achieve, and improving educational outcomes is a major part of achieving the goal Vision 2030.

Data availability

Data are available upon reasonable request.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.