Nursing Students’ Knowledge and Attitude toward Pain Management in Gaza Strip, Palestine

Background: Pain is considered as one of the most common reasons that oblige people to seek medical care. Graduates in nursing have a vital role in administering medication and have an essential role in pain management. However, applying these roles require that nursing students attain an adequate knowledge and management toward pain. So, the present study was conducted to examine the level of nursing students’ knowledge and attitude toward pain management in Gaza Strip. Method: A quantitative cross-sectional survey was used. Two hundred and fourteen knowledge and attitudes survey regarding pain management were submitted to nursing students who studying in different universities and colleges in Gaza Strip and participated in this study. Data were analyzed with the Statistical Package for the Social Sciences software (SPSS; version 22). Results: One hundred and ninety-one questionnaires were returned with response rate 90%. The results of the study showed that a mean score of knowledge and attitude were (45.4%). A significant difference in the mean was observed in regard to student's Grade Point Average, attending training courses concerned to pain management, reading books or journals about pain management, and frequency of using pain assessment tools (P < 0.05). Conclusion: Nursing students had a deficit in knowledge and negative attitudes toward pain assessment and management. Thus, there is a need to design educational program related to pain management, and a thorough review of nursing core curriculum should be performed.

the study questionnaire. As shown in Table 1, 62.3% of the participants were female, 81.2% of them were single, and 45.5% have a very good GPA. In addition, more than half of the students have family monthly income less than 1000 NIS, and 42.4% of them studying at the Islamic university. Furthermore, 62.3% of the students' nurses attended training courses concerned to pain management. Also, 59.2% of the participants were reading journals or books regarding pain management. Moreover, 48.7% of the students' nurses are frequently using pain assessment tools.
Students were asked to answer 24 true/false, and 18 multiple-choice questions. Frequency and percentage of correct answers are shown in (Table 2), and it was found that the total mean score of nursing students' knowledge and attitudes regarding pain management was 45.4%. The lowest score was 31.4%, and the highest score 64.4%. Furthermore, since the to patient characteristics, and not relying on patient self-report. These identified gaps in the literature indicate a need for a more detailed assessment of nursing students' knowledge and attitudes of pain assessment and management to identify the accurate nature and depth of their knowledge and attitudes [10,11].

Design and sample
A quantitative, cross-sectional survey was conducted at four main universities and colleges (The Islamic University of Gaza, Al Azhar University-Gaza, University college of applied sciences, and Palestine college of nursing) in Gaza Strip. The target population was all fourth-year nursing students "baccalaureate" who are studying in these universities and colleges and who met the sample criteria and agreed to participate in the study. The total number of fourth-year nursing students in Gaza Strip are 480 students. The sample size was calculated by using raosoft sample calculator and was 214 nursing students, 191 of them are positively responded with a response rate of 90%. "Simple random sampling".

Study instruments
Data were collected by using a questionnaire that contains informed consent, a demographic form, and modified nurses' knowledge and attitudes survey regarding pain (NKASRP), the original NKASRP was developed to reflect the standards for pain management from the American Pain Society, World Health Organization, and the Agency for Health Care Policy and Research. The first 24 items are true/false questions, items 25-38 are multiple-choice questions, and items 39 and 40 are case studies. It includes aspects of pain assessment, pharmacological and non-pharmacological interventions and attitudes towards pain management [12].

Ethical considerations
Ethical approval for the study was obtained from the head of faculty of nursing departments at non-governmental universities and colleges, administrative approval from Ministry of health for data collection at governmental college, and all students participant were asked to sign consent forms after reading an information sheet.

Data analysis
Data were analyzed using the Statistical Package for Social Sciences (SPSS) software version 22. Descriptive statistics, including frequencies, percentages, means, and standard deviations were used to describe the demographic characteristics. Moreover, the percentage of the correct answers for each item was calculated. Independent sample t test, one-way ANOVA tests were used to detect differences in the mean total score of knowledge and attitude in relation to demographic and personal characteristics. A p-value of < 0.05 was considered statistically significant.

Results
A total of 191 nursing students completed and returned   the mean score for all participants was 20.9 which translates to 52.3%, indicating that the students' knowledge and attitudes were suboptimal [14]. Moreover, the current study agreed with Al-Khawaldeh, et al. (2013) who said that students demonstrated a poor understanding of pain knowledge and attitudes with a KASRP score of 34.1% (SD = 9.9) [15], and consistent with Alsaqri (2018) who found that nursing students have a lack of knowledge and attitudes towards pain management and the mean correct score for the entire scale was 41.8% (SD = 3.71) [16]. Furthermore, the current study is consistent with the results of Karman, et al. (2018) who stated that the mean score of the NKASRP was 15.85 ± 3.25% (poor level of pain knowledge and attitude) [17]. And similar to the result of study conduct by Hroch (2017) who found that the mean score of the NKASRP was 66.7% and the major areas of weakness in pain knowledge and attitudes were related to understanding populations at risk of respiratory depression after receiving an opioid, dosage calculations, medication administration and pharmacology [18].
The result of this study showed that there was a significant statistical difference in the level of nursing students' knowledge and attitude score with regard to attending training courses concerned to pain management, this result is agreed with result of Al-Khawaldeh, et al. (2013) who found that there was a significant statistical difference in the students' scores related to pain management training [15]. On the contrary, this result is inconsistent with study of Al Khalaileh and Al Qadire (2013) who found that there was no significant statistical difference in the mean of total knowledge and attitude scores between students who received pain education and those who did not [13]. Also, the result of the current study disagreed with Alsaqri (2018) who stated that there was no significant statistical difference found in the students' mean scores in terms of attending a training course on pain management [16].
Moreover, the result of this study showed that there was a significant statistical difference in the level of nursing students' knowledge and attitude score with regard to frequency of using pain assessment tools, this result is agreed with study of Al-Khawaldeh, et al. (2013) who found that there was significant statistical difference in the students' scores related to frequency of using pain assessment tools and revealed that students who reported that they used pain assessment tools more frequently had significantly higher scores than students who reported that they never or rarely use pain assessment tools [15]. Also, this result is consistent with study of Alsaqri (2018) who stated that there was significant statistical difference related to the frequency of using pain scales and revealed students who use pain scales more frequently had significantly higher KASRP scores [16].

Conclusion
The findings of this current study suggest that nursing students have serious knowledge deficits and erroneous beliefs that may influence effective management of patients' pain. So, the nursing students in the universities and colleges of mean score was 45.4%, and it's lower than 60%, This means that nurses' knowledge and attitudes level were very low. Moreover, the majority of participants 86.5% had less than 60% of correct answers, while 12.5% of nurses their scores were between 60-79%, however, only 1% of nurses passed with a score of 80% or greater in NKASRP scores. Table 3 showed that the students who are attending training courses, reading books or journals, and frequency of using pain assessment tools have significantly higher mean level of knowledge and attitude than who did not. Moreover, there is no significant statistical difference in the level of nursing students' knowledge and attitude score with regard to their gender (p > 0.05). Table 4 showed that there is a significant statistical difference in the level of nursing students' knowledge and attitude score with regard to their GPA (p < 0.05). Tukey Post hoc was conducted to know the differences between which groups, the test shows that the difference is between the students who have excellent and very good GPA in favor to those who have an excellent GPA. Moreover, statistical analysis revealed that there were no significant differences found in the students' mean scores in terms of marital status and family monthly income.

Discussion
The study was designed to assess nursing students' knowledge and their attitude toward pain management at Gaza Strip. Nursing students had a mean percentage of correct answers of 45.4% on the NKASRP indicating lack of knowledge and attitudes towards pain management. The results of this study are congruent with study conduct by Al Khalaileh and Al Qadire (2013) who found that the students demonstrated a poor understanding of pain knowledge and attitudes, with their KASRP being 16 out of 40 (SD = 5.1), which translates to 40% [13]. Also, the results consistent with Chan & Hamamura (2016) who stated that Gaza Strip require educational program and continues training regards pain management, a thorough review of nursing core curriculum at under-graduate level should be performed to ensure the content of educational modules provide adequate, relevant and appropriate information and subsequently equipping nursing students to effectively manage pain, encourage nursing students and motivate them to reading books and journal about pain assessment and management, enhancing the use of pain management tools by students in practical training, and work collaboratively with local, regional, and national organizations related to pain management awareness, research, and support for nursing students.