RESEARCH ARTICLE
Nursing students and nurses’ knowledge and
attitudes regarding children’s pain: A
comparative cross-sectional study
Abigail Kusi AmponsahID1,2☯*, Evans Oduro2☯, Victoria Bam2‡, Joana Kyei-Dompim2☯,
Collins Kwadwo Ahoto2☯, Anna Axelin1‡
1 Department of Nursing Sciences, Faculty of Medicine, University of Turku, Turku, Finland, 2 Department of
Nursing, Faculty of Allied Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi,
Ghana
☯ These authors contributed equally to this work.
‡ These authors also contributed equally to this work.
* abkuam@utu.fi, akamponsah.fahs@knust.edu.gh, abacious@live.co.uk
Abstract
Introduction
Nurses encounter children who report of pain of diverse and unknown causes in their profes-
sional work. The current study therefore assessed and compared nursing students and
nurses’ knowledge and attitudes pertaining to children’s pain in the Ghanaian context. The
goal of this was to have a baseline information to guide the development and implementa-
tion of the content for a sustainable educational programme (short-course) for nursing stu-
dents and nurses in Ghana.
Methods
Between October and December 2018, a cross-sectional study was carried out among 554
final year nursing students and 65 nurses in Ghana. The Pediatric Nurses Knowledge and
Attitudes Survey Regarding Pain (PNKAS) was used to collect data from participants who
were affiliated to four educational institutions and eight hospitals. Data were descriptively
and inferentially analyzed using chi-square test of independence, independent samples t-
test and one-way analysis of variance (ANOVA).
Results
Our findings revealed that nursing students and nurses generally had unsatisfactory knowl-
edge and attitudes towards pain management in children. Nursing students however, had
significantly higher scores than nurses in the total PNKAS score and in 10 out of the 13 iden-
tified item-areas. Greater scores were obtained by nursing students in areas which were
related to pain physiology, pharmacokinetics, pharmacology of analgesics and pain percep-
tions (p < .05). All the participating nurses could not accurately determine: the onset of
action of orally administered analgesics, equianalgesia of orally administered morphine, and
PLOS ONE | https://doi.org/10.1371/journal.pone.0223730 October 10, 2019 1 / 12
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OPEN ACCESS
Citation: Kusi Amponsah A, Oduro E, Bam V, Kyei-
Dompim J, Ahoto CK, Axelin A (2019) Nursing
students and nurses’ knowledge and attitudes
regarding children’s pain: A comparative cross-
sectional study. PLoS ONE 14(10): e0223730.
https://doi.org/10.1371/journal.pone.0223730
Editor: Sharon Mary Brownie, Aga Khan University,
KENYA
Received: June 27, 2019
Accepted: September 26, 2019
Published: October 10, 2019
Peer Review History: PLOS recognizes the
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editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0223730
Copyright: © 2019 Kusi Amponsah et al. This is an
open access article distributed under the terms of
the Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the manuscript and its Supporting
Information files.
the right dosage of prescribed morphine for a child who consistently reported of moderate to
severe pain.
Conclusion
Final year nursing students and nurses have unsatisfactory knowledge and attitudes regard-
ing children’s pain; which reiterates the need for urgent and effective educational efforts in
this area. Regular in-service training should be offered to post-registration nurses to
enhance their pediatric pain knowledge and attitudes for improved pain care in children.
Introduction
Children have a right to adequate pain assessment and management by qualified healthcare
professionals including nurses [1]. Optimal pain relief ought to be a priority in healthcare espe-
cially for children, as they may be developmentally challenged in communicating about their
pain [2]. In spite of this, children’s pain has been reported in the international literature as reg-
ularly under-assessed and under-treated [3–5]. In sub-Saharan Africa, children have to cope
with abundance of pain-associated diseases such as sickle cell disease [6], suboptimal health-
care systems and poverty [7,8]; all of which worsen the plight of vulnerable children.
In Ghana, nursing students go through three or four years of training for a diploma or
Bachelor’s degree respectively. Afterwards, they are required to not only pass their licensing
examination but also undertake a one-year clinical rotation before qualifying as registered
nurses [9]. During the clinical rotation period, newly qualified nurses are expected to work
and enhance their nursing competencies in varied clinical departments including pediatric
care settings. In the course of their clinical rotation, they will come into contact with children
in pain, and their families, and will have to rely on their knowledge and demonstrate appropri-
ate attitudes to offer the needed support.
Specialization in children’s nursing is not required of nurses to practice within pediatric
care settings in Ghana. Many clinical nurses encountered in children’s care units are general
nurses as the pediatric nursing specialty is still new and evolving in Ghana. Nurses who work
in the children’s units of hospitals are also confronted with children who have varied levels of
pain caused by clinical conditions, injuries, hospital procedures or some unknown factors.
Conversely, children and their families equally have higher expectations of nurses and other
healthcare professionals to be able to recognize, assess and manage pain in their daily work
activities [10]. Thus, knowledge and attitude of nurses relating to children’s pain assessment
and management is very essential. In light of this, the International Association for the Study
of Pain advocates for the best possible pain education during professional training and post-
qualification [11].
Knowledge and attitudes of nursing students and nurses have been examined in previous
literature. Nursing students’ knowledge and attitudes regarding children’s pain was found to
be inadequate in studies that were conducted in Mexico [12] and Egypt [13] using the Pediatric
Nurses’ Knowledge and Attitudes Regarding Pain (PNKAS) instrument. Unsatisfactory
knowledge and attitudes of nurses have also been reported using the PNKAS tool in countries
including the United States of America [14,15], Turkey [16], Mexico [12], Norway [17] and
Saudi Arabia [18]. It seems from the review of earlier research studies that, nursing students
and nurses’ knowledge and attitudes on children’s pain have not been examined from the sub-
Saharan African region. Moreover, the results from previous studies indicate varied areas of
Comparison of nursing students and nurses’ knowledge and attitudes regarding children’s pain
PLOS ONE | https://doi.org/10.1371/journal.pone.0223730 October 10, 2019 2 / 12
Funding: The research reported in this publication
was partly funded by the researchers themselves
and the Faculty of Allied Health Sciences, Kwame
Nkrumah University of Science and Technology,
Ghana to AKA. The content was produced by the
researchers and does not in any way represent the
official view of the funder. The funder had no role in
any of the research processes from the
conceptualization stage to the manuscript
preparation phase.
Competing interests: The authors have declared
that no competing interests exist.
deficiencies in children’s pain knowledge and attitude which may not reflect those of nursing
students and nurses within the sub-Saharan African region.
The current study therefore assessed and compared nursing students and nurses’ knowl-
edge and attitudes pertaining to children’s pain in the Ghanaian context. The goal of this was
to have a baseline information to guide the development and implementation of a sustainable
short-course programme for nursing students and nurses in Ghana.
Materials and methods
Study design, setting and participants
A comparative cross-sectional survey was conducted among final year nursing students and
nurses in Ghana. Four nursing educational institutions and eight hospitals were purposively
chosen as study sites. Consideration was given to type of ownership and the geographical loca-
tion of these educational and hospital facilities.
The nursing educational institutions comprised of two universities (one private and one
public) and two nursing training colleges (NTCs) (one private and one public). These educa-
tional institutions are accredited by the National Accreditation Board (NAB) and the National
Council for Tertiary Education (NCTE) of Ghana to run undergraduate nursing programs
leading to the award of Diploma (in the case of the NTC trainees) or Bachelor’s degree (in the
case of the university trainees). A review of the training curricula for the nursing students
revealed that pain management is part of their general nursing and practical courses but not
situated in the context of most of the courses dedicated to children’s nursing.
The eight hospitals comprised of three specialist children’s hospitals, two district hospitals,
a regional hospital, a university (quasi-government) hospital and a mission (catholic) hospital.
All hospitals had both an out-patient department and in-patient facility where they cared for
hospitalized children and their families. Nurses are expected to assess and manage children’s
pain as part of their roles during vital signs monitoring and routine care activities in these hos-
pitals. As at the time of the study, the number of registered nurses at the pediatric units of the
eight facilities was 70. These nurses were being assisted by rotation nurses, student nurses and
healthcare assistants to discharge their duties. Rotation nurses are interns who have passed
their licensing examinations and undergoing post-qualification training in specified clinical
areas before receiving their registration.
The appropriate sample size for the study was guided by Yamane’s [19] formula for cross-
sectional studies assuming a 95% confidence interval and a type I error rate of 5%. Based on an
estimated population of 1100 final year nursing students and 70 nurses, a minimum of 293
nursing students and 60 nurses were considered appropriate in powering the study to draw
conclusions with a higher level of precision. Nine hundred (900) students who were in the first
semester of their final year nursing program and 70 nurses were purposefully approached, of
which 554 nursing students and 65 nurses respectively agreed and participated in the study,
giving an overall response rate of 63.8% (61.6% for the nursing students and 92.9% for the
nurses).
Data collection procedures, instrument and analysis
The researchers approached nursing students and nurses at their recess times between lectures
and nursing duties respectively to brief them about the study’s objective and characteristics.
Those who consented to participate were given hard copies of the questionnaire which took
about 20–30 minutes to complete. Over the course of three months, demographic and primary
data on participants’ pediatric pain knowledge and attitudes were collected using the Pediatric
Nurses Knowledge and Attitude Survey Regarding Pain (PNKAS) instrument [20].
Comparison of nursing students and nurses’ knowledge and attitudes regarding children’s pain
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The PNKAS instrument consists of 42 questions: 25 binary (true or false) response type
questions, 13 multiple choice questions (MCQs) and two case studies expanded into four ques-
tions. Responses given by the participants in the survey were scored one (1) for a correctly
answered knowledge question and/ a positive attitude or both; and zero (0) for a wrongly
answered question and/ a negative attitude. Thus, the possible attainable scores on the PNKAS
instrument ranged from zero to 42. Individually attained scores were converted into percent-
ages for standardization purposes using the formula: (obtained scores/ 42) � 100. In line with
earlier studies [21–23], a total score of 80% was considered as a satisfactory level of knowledge
and attitudes regarding children’s pain.
Validity and reliability of the PNKAS tool has been reported in Manworren’s [13] study.
Face and content validity of the tool was established by a panel of five nursing experts in pain
management. Test-retest reliability among 6 nurses and 6 child life specialists was reported at
a correlation coefficient of 0.67, indicating an appreciable level of instrument stability. Cron-
bach’s alpha of the instrument using data from two distinct groups of pediatric nurses ranged
from 0.72 to 0.77, signifying an acceptable level of internal consistency. In the current study,
face validity of the tool was assessed by 11 pediatric experts (six registered nurses, four nurse
educators and one pediatrician) who recommended its usage in Ghana.
Participants’ data were initially entered and cleaned in Microsoft excel before being
exported into Statistical Package for Social Sciences version 25 for further analysis. The ages of
the final year nursing students were categorised into two: regular (up to 24 years) and matured
(those aged 25 years and above). The ages of the nurses were also classified into two: those up
to 30 years and those above 30 years. Categorical variables were presented using frequencies
and percentages, while continuous variables were reported with means, standard deviations
and ranges. Chi-square test of independence analysis was used to examine the association
between nursing status (nursing students and nurses) and gender (male and female). Differ-
ences in PNKAS scores between any two groups were examined using the independent sam-
ples t-test. Differences in PNKAS scores between three or more groups was analysed using the
one-way analysis of variance (ANOVA) method. Statistical significance for all test was set at
the .05 level.
Ethical considerations
Ethical approval with reference number CHRPE/AP/574/18 was obtained from the Committee
on Human Research, Publication and Ethics. Administrative approvals were also obtained
from the respective hospitals and educational institutions involved in the study. Class repre-
sentatives and ward-in-charges were consulted for permission to engage and distribute the
questionnaires during each data collection session. Anonymity, confidentiality and partici-
pants’ right to voluntary participation were ensured during data collection.
Results
Participants’ socio-demographic characteristics
The mean age of the nursing students was 24 years with a standard deviation of 4 years; their
ages ranged from 21 to 47 years. Slightly over three-quarters of the nursing students were
females (n = 418, 75.5%) while males (n = 136) formed 24.5%. A greater proportion of the
nursing students were enrolled in the Diploma program (n = 355, 64.1%), whereas those in the
Bachelor’s degree program (n = 199) comprised of 35.9%.
On the other hand, the mean (SD) age of the nurses was 29 (4) years with a range of 23 to
38 years. Over four-fifths of the nurses were females (n = 53, 81.5%) while the males (n = 12)
formed 18.5%. Majority of the nurses had a diploma as their highest education qualification
Comparison of nursing students and nurses’ knowledge and attitudes regarding children’s pain
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(n = 42, 64.6%); this was followed by Certificate holders (n = 13, 20%) with only 15.4% having
attained a Bachelor’s or Master’s degree (n = 10). A greater number of the nurses had worked
for up to five years in the profession (n = 41, 63.1%), whereas 36.9% of them had worked for
more than five years (n = 24). Almost two-thirds of the nurses were working in general hospi-
tals (n = 43, 66.2%) whereas the remaining one-third were working in specialist children’s hos-
pitals (n = 22, 33.8%). A cross-tabulation analysis revealed that the nurses who were working
in general hospitals had relatively higher educational qualification than those who were work-
ing in the specialist children’s hospital (18.6% versus 9.1% had obtained their Bachelor’s and
Master’s degrees).
There were no statistically significant differences in the gender distribution of both nursing
students and nurses (p = .276). However, nursing students were significantly younger than the
nurses (p< .001).
Nursing students’ knowledge and attitudes regarding children’s pain
On the 42-item PNKAS instrument, an average (SD) correct answer score of 42.1% (8.0%) was
obtained by nursing students, with a minimum correct score of 21.4% and a maximum of
81.0%. The five questions most often answered correctly by nursing students were focused on
the subjective and multi-dimensional nature of the pain experience and its treatment, the
importance of pre-emptive analgesia and nonpharmacological pain management intervention
(Table 1). The top five questions most often answered incorrectly by the nursing students were
concentrated on cancer-related pain medications, opioid drug administration, pain assessment
and pain perception (Table 2).
Results of an independent samples t-test analyses revealed that, there were no statistically
significant differences in the mean PNKAS scores on the basis of the nursing students’ age clas-
sification (p = .311) and gender (male and female) (p = .158). However, there was a statistically
significant difference in the mean PNKAS scores of the nursing students on the basis of their
Table 1. Items most often answered correctly by participants (n = 619).
Items (correct answer) Students
(n = 554)
Nurses
(n = 65)
f (%) Correct;
Rank
f (%)
Correct;
Rank
Comparable stimuli in different people produce the same intensity of pain (F) 434 (78.3); 1st 41 (63.1); 5th
Children who will require repeated painful procedures should receive maximum
treatment for the pain and anxiety of the first procedure to minimize the
development of anticipatory anxiety before subsequent procedures (T)
433 (78.2); 2nd 45 (69.2); 3rd
Combining analgesics and non-drug therapies that work by different mechanisms
may result in better pain control with fewer side effects than using a single
analgesic agent (T)
386 (69.7); 3rd 48 (73.8): 1st
After the initial recommended dose of opioid analgesic, subsequent doses should
be adjusted in accordance with the individual patient’s response (T)
384 (69.3); 4th 47 (72.3); 2nd
Parents should not be present during painful procedures (F) 374 (67.5); 5th –
The child/adolescent with pain should be encouraged to endure as much pain as
possible before resorting to an opioid for pain (F)
– 43 (66.2); 4th
Note: f–frequency; %–percentage; T–True; F–False
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Comparison of nursing students and nurses’ knowledge and attitudes regarding children’s pain
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study level (p< .001). Nursing students who were enrolled on the Bachelor’s degree program
(M = 43.9%, SD = 8.9%) had significantly higher PNKAS scores than their counterparts who
were pursuing the Diploma program (M = 41.1%, SD = 7.3%).
Nurses’ knowledge and attitudes regarding children’s pain
Nurses had a mean (SD) correct answer score of 36.7% (6.9%) on the 42-item PNKAS scale,
with a minimum correct score of 21.4% and a maximum of 57.1%. The five questions most
often answered correctly by the surveyed nurses were related to the subjective and multi-
dimensional nature of the pain experience and its treatment as well as the benefits of pre-emp-
tive analgesia (Table 1). The top five (5) items where nurses frequently answered incorrectly
were centered on pharmacokinetics, pain assessment and pain perception (Table 2).
Results of an independent samples t-test and one-way analysis of variance (ANOVA)
showed that, there were no statistically significant differences in the mean PNKAS scores on
the basis of the nurses’ age classification (p = .164), gender (male and female) (p = .674), high-
est educational qualification (certificate, diploma, Bachelor’s or Master’s degree) (p = .798)
and working years in the nursing profession (up to five years and those above five years) (p =
.638). Nevertheless, there was a statistically significant difference in the mean PNKAS scores of
the nurses on the basis of the type of hospital they were working in (p< .001). Nurses who
were working in general hospitals (M = 38.8%, SD = 7.0%) had significantly greater PNKAS
scores than those who were working in specialist pediatric hospitals (M = 32.7%, SD = 4.5%).
Table 2. Items most often answered incorrectly by participants (n = 619).
Items (correct answer) Students
(n = 554)
Nurses
(n = 65)
f (%) Incorrect;
Rank
f (%)
Incorrect;
Rank
Which of the following drugs are potentially useful for treatment of children’s
cancer pain? (All of the following: Ibuprofen, Hydromorphone, Amitriptyline)
549 (99.1); 1st
The likelihood of opioid addiction occurring due to pain treatment with opioid
analgesics is (<1%)
516 (94.9); 2nd
Two hours after a child received morphine 2 mg IV, his pain ratings consistently
ranged from 6 to 8 with no clinically significant side effects. His physician’s order
for analgesia is “morphine IV 1–3 mg q1h PRN pain relief”. The most appropriate
action by the nurses is to: (Administer morphine 3 mg IV now)
511 (92.2); 3rd 65 (100.0); 1st
A 15-year old Andrew smiles on his first day post-abdominal operation. Upon
entering his room, he smiles with you and continues talking and joking with his
visitor. He rates his pain as 8 on a scale of 0 to 10 (0 = no pain, 10 = worst pain)
during assessment, how would you rate Andrew’s pain? (8)
473 (85.4); 4th 60 (92.3); 5th
The percentage of patients who over report the amount of pain they have is: (0–
10%)
456 (82.3); 5th 62 (95.4); 4th
The usual time to peak effects for traditional analgesics given orally is: (30
minutes)
65 (100.0); 1st
Which of the following IV doses of morphine administered would be equivalent
to 15 mg of oral morphine? (Morphine 5 mg IV)
65 (100.0); 1st
Note: f–frequency; %–percentage; mg–milligram; IV–Intravenous; q1h –Hourly; PRN–When necessary
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Comparison of nursing students and nurses’ knowledge and attitudes regarding children’s pain
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Comparison of nursing students and nurses’ pain knowledge and attitudes
Results of an independent samples t-test revealed that, nursing students [M = 17.69 (42.1%),
SD = 3.37 (8.0%)] correctly scored higher on the PNKAS instrument than registered nurses
[M = 15.43 (36.7%), SD = 2.88 (6.9%)], t (617) = 5.18, p< .001, two-tailed. The difference of
2.26 (5.4%) scale units indicated a small but statistically significant effect (scale range: 0 to 42)
and the 95% confidence interval around the difference between the group means was relatively
precise [1.40 (3.3%) to 3.12 (7.4%)].
There were statistically significant differences between nursing students and nurses in 13
items on the PNKAS instrument (Table 3). Nursing students significantly scored higher than
Table 3. Comparison of nursing students and nurses’ knowledge and attitudes regarding children’s pain.
Items (correct answer) Student
(n = 554)
f (%) Correct
Nurse
(n = 65)
f (%)
Correct
p
value
Comparable stimuli in different people produce the same pain intensity (F) 434 (78.3) 41 (63.1) .017
Sedation always precedes opioid related respiratory distress (F) 217 (39.2) 35 (53.8) .023
The recommended route of administration of opioid analgesics to children
with prolonged cancer-related pain is: (Intravenous)
238 (43.0) 12 (18.5) < .001
The recommended route of administration of opioid analgesics to children
with brief, severe pain of sudden onset is: (Intravenous)
228 (41.2) 18 (27.7) .027
Analgesics for post-operative pain should initially be given: (Around the
clock on a fixed schedule)
217 (39.2) 6 (9.2) < .001
Analgesia for chronic cancer pain should be given: (Around the clock on a
fixed schedule)
285 (51.4) 10 (15.4) < .001
The most likely explanation for why a child/adolescent with pain would
request increased pain medication doses is that: (He/ she is experiencing
increased pain)
268 (48.4) 16 (24.6) < .001
Which of the following drugs are useful for treating cancer pain? (All of the
above)
5 (0.9) 13 (20.0) < .001
Which of the following describes the best approach for cultural
considerations in caring for child/ adolescent in pain? (Children/ adolescents
should be individually assessed to determine cultural influences on pain)
209 (37.7) 36 (55.4) .006
What do you think is the percentage of patients who over report the amount
of pain they have? (0%)
98 (17.7) 3 (4.6) < .001
The usual time to peak effects for analgesics given orally is: (30 minutes) 294 (53.1) 0 (0.0) < .001
Which of the following intravenous (IV) doses of morphine administered
would be equivalent to 15 mg of oral morphine? (Morphine 5 mg IV)
135 (24.4) 0 (0.0) < .001
Two hours after a child received morphine 2 mg IV, his pain ratings
consistently ranged from 6 to 8 and he had no clinically significant side
effects. His physician’s order for analgesia is “morphine IV 1–3 mg q1h PRN
pain relief.” The most appropriate action by the nurses is to: (Administer
morphine 3 mg IV now)
210 (37.9) 0 (0.0) < .001
Note: f–Frequency; %–Percentage; p–the degree of making a type I error; T–True; F–False
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nurses in 10 out of the 13 identified areas (p< .05). These were noted in items that addressed
pain physiology, pharmacokinetics, pharmacology of analgesics and pain perceptions. On the
other hand, nurses had greater scores in 3 out of the 13 identified items on the PNKAS instru-
ment (p< .05). These were observed in the following items: the relationship between sedation
and opioid-related respiratory distress, useful cancer-related pain medications and cultural
influences on children’s pain.
Discussion
With the goal of developing and implementing the content for a sustainable educational pro-
gramme (short-course) on pediatric pain assessment and management, the present study sought
to assess and compare nursing students’ and nurses’ knowledge and attitudes regarding chil-
dren’s pain in the Ghanaian context. Our findings revealed that, nursing students and nurses
generally have insufficient knowledge and attitudes towards pain management in children rela-
tive to the 80% cut off mark [21–23]. There appears to be an internationally recognized knowl-
edge and attitudes deficits among nursing students and nurses on this subject [12–18]. One of
the possible reasons for this trend may be related to the insufficient pediatric pain management
training in nursing curricula [24,25]. Limited continuing educational opportunities for post-reg-
istration nurses on this subject may also be responsible for these outcomes [18,26,27]. Due to
these insufficiencies in knowledge and attitudes, pain in children globally remains inadequately
managed, which leads to unnecessary suffering in this vulnerable population.
Nursing students who were enrolled on the Bachelor’s degree program had significantly
higher pediatric pain knowledge and attitudes than their counterparts who were pursuing the
Diploma program. This is similar to the findings of Plaisance and Logan [28] whereby nursing
students in the baccalaureate degree program had a significantly higher pain knowledge and
attitudes scores compared to those in the associate degree programs. Possibly, the content and
duration of training may play a role in the final year nursing students’ acquisition of knowl-
edge and attitudes on pediatric pain in the current study. On the other hand, nurses who were
working in general hospitals also had higher pediatric pain knowledge and attitudes than those
who were working in specialist pediatric hospitals. This may be attributed to the fact that a
greater percentage of the nurses who worked in the general hospitals had relatively higher edu-
cational background than those in the specialist pediatric hospitals. This is not surprising as
the level of education has been identified as one of the influencing factors in pain knowledge
and attitudes [29,30].
In contrast to Ortiz et al.’s [12] findings, nursing students in the current study significantly
had higher scores than the nurses on the entire PNKAS instrument and also in 10 individual
items out of the 13 identified areas of significant differences. The relatively recent knowledge
acquisition by the nursing students may be responsible for these findings. The lack of regular
in-service educational courses on pediatric pain management post-qualification may also
account for the observed trend [31].
Nursing students and nurses had similarities in their top and bottom five pediatric pain
knowledge and attitudes. Consistent with earlier literature [13,17], majority of the sampled
nurses and nursing students had good pediatric pain knowledge and attitudes in items that
measured the benefits of pre-emptive analgesia as well as the subjective and multi-dimensional
nature of the pain experience and its treatment. A greater proportion of participants in both
groups performed poorly on items that were related to opioid drug administration, pain
assessment and pain perception, supporting previous research findings [12,17,18]. These iden-
tified areas of sufficient and insufficient knowledge and attitudes should be considered during
the design and implementation of educational programs on this subject.
Comparison of nursing students and nurses’ knowledge and attitudes regarding children’s pain
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Differences were also observed in the top and bottom five pediatric pain knowledge and
attitudes among the two groups. Relative to the nurses, many of the nursing students recog-
nized the relevance of parental support as an important advocacy strategy for addressing the
pain concerns of children [32] during painful procedures, which is consistent with the findings
of Gadallah and colleagues [13]. Similar to earlier literature [16–18,33], almost all the nursing
students could not identify useful cancer-related pain medications and overestimated the like-
lihood of narcotic addiction in patients who are being treated with opioids. These findings are
not surprising as nursing students in Ghana have limited care experiences with children with
cancers and appear to harbour misconceptions on narcotics. Recent evidence however, points
to a well-tolerated and effective opioid use among children in practice [34,35]. Compared with
the nursing students, a greater proportion of the nurses acknowledged the importance of early
pain treatment in children as advocated for by the International Association for the Study of
Pain (IASP) as a fundamental human right [1].
It is significant to also note that, all the surveyed nurses could not accurately determine the
onset of action of orally administered analgesics, equianalgesic dose of orally administered
morphine, and the right dosage of prescribed morphine for a child who consistently reported
of moderate to severe pain. These results are of great concern as these nurses are already prac-
tising in hospitals and may end up mismanaging children’s pain. As the problem of poor
assessment and management of children’s pain persists among nurses, there is an urgent need
to develop, implement and evaluate pain educational interventions especially in resource con-
strained setting to improve pain management for vulnerable children and their families.
Strengths and limitations of the study
To the best of our knowledge on existing literature, this study is the first of its kind in Ghana
and sub-Saharan Africa. The adequate sample size that was used in the current study reassures
that the study was sufficiently powered to support the findings, which can be applied in other
similar settings. The inclusion of diverse educational institutions and healthcare facilities also
adds to the reliability of the studied outcomes.
One of the drawbacks of the current investigation was that, participants were purposively
chosen based on their availability at the research sites without being randomly selected. The
surveyed nurses were relatively younger in age with shorter years of experience than the gen-
eral nursing population; this should be considered when interpreting the study’s findings. In
spite of these limitations, the present study provides useful information on nursing students
and nurses’ knowledge and attitudes pertaining to children’s pain management in the Ghana-
ian context.
Implications
The study has implications for nursing education, practice, policy, and research. Pediatric pain
assessment and management in nursing curricula needs to be strengthened further. Educa-
tional approaches that seek to reinforce positive knowledge and attitude translation in practice
should also be applied. Such programs should explore areas of higher and lower educational
needs to target and reinforce outcomes. Nurses should be encouraged to engage in self-
directed learning activities and continual professional educational opportunities to improve
pediatric pain management.
Existing guidelines on pain management in children should also be enforced to guide nurs-
ing practice. Future studies should use qualitative research approaches to gain an understand-
ing on the factors that underpin nursing knowledge and attitudes on the subject.
Comparison of nursing students and nurses’ knowledge and attitudes regarding children’s pain
PLOS ONE | https://doi.org/10.1371/journal.pone.0223730 October 10, 2019 9 / 12
Observational studies on how pain is assessed and managed in hospitalized children would
also be insightful and assist in guiding future educational interventions.
Conclusion
Final year nursing students and nurses have unsatisfactory knowledge and attitudes regarding
children’s pain; which reiterates the need for urgent and effective educational efforts in this
area. Regular in-service training should be offered to post-registration nurses to enhance their
pediatric pain knowledge and attitudes for improved pain care in children.
Supporting information
S1 Table. This is the S1 Table codebook for nursing students and nurses’ knowledge and
attitude regarding children’s pain: A comparative cross-sectional study in Ghana.
(XLSX)
Acknowledgments
Our profound appreciation goes to the management of the educational institutions and health
facilities for their co-operation. We are also grateful to the nursing students and nurses who
took time off their very busy schedules and participated in the study.
Author Contributions
Conceptualization: Abigail Kusi Amponsah, Victoria Bam, Joana Kyei-Dompim, Anna
Axelin.
Data curation: Abigail Kusi Amponsah, Evans Oduro, Joana Kyei-Dompim, Collins Kwadwo
Ahoto.
Formal analysis: Abigail Kusi Amponsah, Evans Oduro, Victoria Bam, Joana Kyei-Dompim,
Collins Kwadwo Ahoto, Anna Axelin.
Funding acquisition: Abigail Kusi Amponsah, Victoria Bam.
Investigation: Abigail Kusi Amponsah, Evans Oduro, Victoria Bam, Joana Kyei-Dompim,
Collins Kwadwo Ahoto, Anna Axelin.
Methodology: Abigail Kusi Amponsah, Evans Oduro, Victoria Bam, Joana Kyei-Dompim,
Collins Kwadwo Ahoto, Anna Axelin.
Project administration: Abigail Kusi Amponsah, Anna Axelin.
Resources: Abigail Kusi Amponsah, Victoria Bam, Anna Axelin.
Software: Abigail Kusi Amponsah.
Supervision: Victoria Bam, Anna Axelin.
Validation: Abigail Kusi Amponsah, Evans Oduro, Victoria Bam, Joana Kyei-Dompim, Col-
lins Kwadwo Ahoto, Anna Axelin.
Visualization: Abigail Kusi Amponsah, Evans Oduro, Victoria Bam, Joana Kyei-Dompim,
Collins Kwadwo Ahoto, Anna Axelin.
Writing – original draft: Abigail Kusi Amponsah, Evans Oduro, Joana Kyei-Dompim.
Writing – review & editing: Abigail Kusi Amponsah, Evans Oduro, Victoria Bam, Joana
Kyei-Dompim, Collins Kwadwo Ahoto, Anna Axelin.
Comparison of nursing students and nurses’ knowledge and attitudes regarding children’s pain
PLOS ONE | https://doi.org/10.1371/journal.pone.0223730 October 10, 2019 10 / 12
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