ADVENTIST UNIVERSITY OF CENTAL AFRICA

KARONGI , RWANDA

ASSESSMENT OF KNOWLEDGE AND ATTITUDES TOWARDS PEDIATRIC PAIN

MANAGEMENT AMONG NURSES AT KIBAGABAGA DISTRICT HOSPITAL

UWIBAMBE NIWEBASA EMMANUELLA

ID :23964

BEING A RESEARCH PROJECT SUBMITTED IN THE DEPARTMENT OF GENERAL

NURSIG, FACULITYOH HEALTH SCIENCES

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF

BACHELOR’S DEGREE MAJOR OF GENERAL NURSING/HEALTH SCIENCE

2023-2024
 APPROVAL
I MUSANABERA YVETTE hereby approve and commend the diligent efforts of
UWIBAMBE NIWEBASA EMMANUELLA in conducting this research. The dedication and
meticulous approach demonstrated throughout reflect a commendable commitment to scholarly
inquiry.

MUSANABERA YVETTE
…………………………….
 DECLARATION

I UWIBAMBE NIWEBASA EMMANUELLA, hereby declare that this assessment of

knowledge and attitudes towards pediatric pain management among nurses at kibagabaga district

Hospital is my original work and that all the sources that I have used or quoted have been

acknowledge using complete references and also this work has not been submitted before for any

other degrees at any other institution

STUDENT SIGNATURE SUPERISOR SIGNATURE

………………………….. …………………………….

UWIBAMBE NIWEBASA EMMANUELLA MUSANABERA YVETTE

 ACKNOWLEDGEMENT

I extend my sincere thanks to God for His guidance, and to my family for their unwavering
support. This work was achieved through the many people whom I would like to express my
appreciation. Special gratitude to my supervisor, MUSANABERA YVETTE, for invaluable
guidance, and to all contributors who played a crucial role in shaping this research. Grateful for
the collaborative spirit that enriched this journey
 DEDICATION
Dedicated to my family, whose unwavering support fuels my aspirations, and to the countless
individuals whose contributions and encouragement have illuminated the path of this research
endeavor. Your belief and inspiration have made this journey possible. Grateful for the collective
spirit that has made this dedication meaningful. In honor of those whose guidance and kindness
have left an indelible mark on this pursuit
Table of Contents

CHAPTER ONE: INTRODUCTION...................................................................................................................4

1.1. BACKGROUND OF THE STUDY:.........................................................................................................5
1.2. Problem Statement...........................................................................................................................6
1.3. Objectives.........................................................................................................................................8
1.3.1. Main objective...........................................................................................................................8
1.3.2. Specific objectives......................................................................................................................8
1.4. Research Questions..........................................................................................................................8
1.5 Significance of Study..........................................................................................................................9
1.6. Justification of the Study..................................................................................................................9
1.7. Purpose of the Study......................................................................................................................10
1.8 Delimitation of the study.................................................................................................................11
1.9 Definition of Terms..........................................................................................................................11
CHAPTER 2: LITERATURE REVIEW..............................................................................................................12
2.1 Overview of the Study.....................................................................................................................12
2.2. Empirical Review.............................................................................................................................12
2.2.1. Objective 1: Knowledge of Pediatric Pain Assessment.............................................................12
[Link] 2: Attitudes towards Pediatric Pain Management....................................................13
2.3 Theoretical Review..........................................................................................................................13
2.4. Conceptual Frame Work.................................................................................................................15
CHAPTER 3: METHODOLGY........................................................................................................................16
3.1. Study Design...................................................................................................................................16
3.2. Study Area/Setting..........................................................................................................................17
3.3 Study Population.............................................................................................................................17
3.4 Inclusion and Exclusion Criteria.......................................................................................................18
3.4.1. Inclusion Criteria......................................................................................................................18
[Link] Criteria......................................................................................................................18
3.5 sample size......................................................................................................................................18
3.6. Sampling Techniques......................................................................................................................19
3.7. Data Collection Tools/ Research Instruments.................................................................................19
3.8. Validity vs Reliability.......................................................................................................................20
3.8.1 VALIDITY...................................................................................................................................20
 3.8.2 REABILITY..................................................................................................................................20
3.9. DATA COLLECTION PROCEDURE.....................................................................................................21
3.10. Data Analysis................................................................................................................................21
3.11. Ethical Considerations..................................................................................................................22
3.12. LIST OF REFERENCES.....................................................................................................................22
CHAPTER ONE: INTRODUCTION

In this section, we delve into key aspects such as the context in which the research is situated, the

issues being addressed (problem statement), the historical context and rationale behind the study

(background), the overarching goal, as well as the specific aims of the research (main objective

and specific objectives), the inquiries that guide our investigation (research questions), the

importance and relevance of the study (significance of the study), precise definitions of crucial

terms central to the study (operational definitions), and a brief overview of the structure of this

thesis, outlining its major components.

1.1. BACKGROUND OF THE STUDY:

WHO defines pediatric pain as the discomfort experienced by children, incorporating physical,

emotional, and social dimensions? Nurses play a vital role in assessing and managing pediatric

pain, and their knowledge and attitude towards pediatric pain management are essential for

providing high-quality care. The World Health Organization (WHO) also has continued to

prioritize pain management, it released the Global Action Plan on Pain (WHO, the Global Action

Plan, 2019) especially in Developing countries they face considerable challenges related to

pain management due to limited knowledge, poorly developed healthcare systems due to lack of

education and access to information, cultural attitudes, and lack of analgesic medication

(Johnson , 2015) Barriers encompass regulatory obstacles to access to analgesics, resource

constraints, and the prioritization of infectious diseases, including both knowledge and attitude

impediments (Johnson, 2015)

Insufficient addressing of pain and a deficiency in understanding pain management have been

noticeable for around two decades. Persistent gaps in knowledge continue to be an issue. The

findings from numerous surveys conducted over the past two decades unequivocally demonstrate

that a significant number of nurses responsible for patients experiencing pain lack sufficient

information about pediatric pain management. (Friedrichsdorf, 2020), Under or untreated pain in

children has multiple consequences including both physiological and psychological effects.

Adverse effects include complications involving the cardiovascular, respiratory, and

gastrointestinal systems, weakened immune function, delayed healing, and predisposition to

chronic pain, anxiety, and depression (Olmstead, 2018)Nurses play an integral part in pain

management in children. As advocates for the child and family, nurses are responsible for

ensuring that pain medication is provided.

Previous research indicates that nurses’ knowledge and attitudes affect their response to children

in pain and thus pain management (Vincent, 2017) Nursing factors related to under management

of children's pain include lack of standardized assessment and evaluation methods, limited

knowledge of pediatric pain, education level, lack of knowledge of analgesics, and lack of time

(Olmstead, 2018)In Rwanda, based on the researcher's observations, the inadequate management

of pain in hospitals can be attributed to various factors, stemming from healthcare provider’s

knowledge and attitudes. One significant factor is deeply rooted in Rwandan culture, which

encourages individuals to suppress their pain expressions in order to project strength within

society. Additionally, the scarcity of certain pain-relief medications within healthcare facilities

exacerbates the problem, particularly in pediatric care. Another formidable challenge lies in the

limited understanding of pain assessment, especially when dealing with pediatric patients who
may struggle to communicate effectively with their healthcare team due to their underdeveloped

cognitive abilities.

1.2. Problem Statement

The problem at hand is the inadequate management of pediatric pain at Kibagabaga District

Hospital in Rwanda. Despite the recognition of pain relief as a fundamental human right, nurse’s

level about managing pain is still low that cause children continue to suffer needlessly from pain.

This issue is substantiated by recent research findings, such as a 2022 study in the journal Pain

highlighting disparities in pain relief access between different income countries (Vlaeyen, 2022)

and a 2023 study in The Lancet revealing the under treatment of pain in children with cancer.

(Dr. David Eccleston, 2023) The study involved 1,367 children with cancer from 86 hospitals in

26 worldwide. The study found that 63% of the children were experiencing moderate to severe

pain, but only 37% were receiving adequate pain relief. In Africa also showed that 53 % of

Nurses had poor knowledge toward pain management in children as it is shown in a study

research of kholowa (Kholowa, 2017; Kholowa, 2017) The major problem in hospitalized

children is the nurses’ knowledge and perceived barriers towards pain management among

hospitalized children and poor pain relieve leads to the negative outcomes

While Rwanda's Ministry of Health has taken steps to enhance pediatric pain management by

establishing guidelines and distributing pain medications to the district level, there remains a

critical gap in knowledge and attitude among nurses regarding this vital aspect of care. A 2020

study in African Health Sciences showed that Rwandan nurses possessed inadequate knowledge

of pediatric pain assessment and management (Benimana, 2020), also in a 2022 study in BMC
Pediatrics stands for "BioMed Central Pediatrics, indicated poor and negative attitudes on 40%

among these nurses toward the use of opioids in children (the journal BMC, 2022).This

knowledge deficit among nurses constitutes a significant barrier to effective pain management in

pediatric patients. Nurses often serve as the frontline of defense in pediatric Ohealthcare,

assuming a pivotal role in identifying and addressing pain. However, when nurses lack the

requisite knowledge and skills to manage pain adequately, children are left vulnerable to

unnecessary suffering.

The existing knowledge gap in the specific context of Kibagabaga District Hospital is a critical

concern. Despite a growing body of research on pediatric pain management globally, there is a

conspicuous absence of research addressing the knowledge and attitudes of nurses in Rwandan

hospitals, particularly at the district level. This research gap is of utmost importance, as it

represents a fundamental step in identifying the precise areas where nurses require additional

training and support to improve pediatric pain management practices at the hospital. Thus, this

study aims to bridge this knowledge gap, enhance pediatric pain management practices, and

ultimately contribute to the betterment of children's healthcare at Kibagabaga District Hospital.

1.3. Objectives

1.3.1. Main objective

To assess the knowledge and attitudes towards pediatric pain management among nurses at

Kibagabaga District Hospital.

1.3.2. Specific objectives

1. To assess the level of knowledge of nurses about pediatric pain management at Kibagabaga

District Hospital

2. To identity the attitudes of nurses towards pediatric pain management at Kibagabaga District

Hospital

1.4. Research Questions

1. What is the level of knowledge of nurses about pediatric pain management at Kibagabaga

District Hospital?

2. What are the attitudes of nurses towards pediatric pain management at Kibagabaga District

Hospital?

1.5 Significance of Study

The significance of this study extends beyond immediate healthcare improvements. By

enhancing nurses' knowledge and attitudes in pediatric pain management, the study directly

benefits mothers seeking quality healthcare for their children and pediatric patients, resulting in

reduced suffering and improved care outcomes.

Furthermore, the study contributes significantly to the ongoing professional development of

nurses at Kibagabaga District Hospital. Elevating the expertise and competence of the nursing

staff not only ensures a higher standard of healthcare within the hospital but also strengthens the

overall healthcare infrastructure in the region.

In addition to individual and professional benefits, the positive transformation in pediatric pain

management practices driven by this study plays a vital role in enhancing the hospital's

reputation. This, in turn, fosters greater trust and confidence from the community, solidifying

Kibagabaga District Hospital's position as a healthcare leader in the region. The study's impact,

therefore, resonates not only within the hospital walls but also radiates outward, positively

influencing the broader community's perception and reliance on the hospital's healthcare

services.

1.6. Justification of the Study

This study is justified by its fundamental aim to improve the well-being of pediatric patients. By

addressing gaps in nurses' knowledge and attitudes towards pediatric pain management. Recent

studies have shed light on the persistent challenges in pediatric pain management. While older

studies from the 2000s indicated that many pediatric patients continued to experience pain, more

recent investigations have reaffirmed these concerns. For instance, a study by Bernie in 2014

found that a significant proportion of pediatric inpatients, ranging from 21% to 64%, reported

experiencing moderate pain. It seeks to enhance the quality of care provided to children at the

hospital (CarterBernie, 2014). This research holds global significance as it contributes to the

limited body of knowledge on this subject in low- and middle-income countries like Rwanda.

The findings can guide the development of targeted interventions to improve pediatric pain

management not only in Rwanda but also in similar resource-constrained healthcare settings

worldwide. Ultimately, this study aligns with evidence-based care principles and has the
potential to positively impact patient satisfaction, nursing practice, and the overall healthcare

experience for pediatric patients and their families.

1.7. Purpose of the Study

The goal of conducting this study at Kibagabaga District Hospital in Rwanda, a low- and middle-

income country with limited prior research on pediatric pain management, is the aim of

benefiting the hospital and serving as a reference for similar healthcare institutions. The study's

findings will inform targeted interventions and policies to enhance pediatric pain management,

improve healthcare practices, and ultimately enhance the well-being of pediatric patients.

Additionally, the research seeks to contribute to the global understanding of pediatric pain

management in low- and middle-income countries, raising awareness of challenges and guiding

the development of tailored solutions for these regions

1.8 Delimitation of the study

This study will be conducted at Kibagabaga District Hospital in Kimironko sector, Gasabo

district, Kigali city, Rwanda. It employs a cross-sectional research design, focusing on self-

reported responses from nurses within this specific healthcare institution. Delimited to nurses,

the findings may have limited generalizability beyond the unique context of this hospital and

Rwanda. The study excludes perspectives from other healthcare professionals such as physicians,

pharmacists, and psychologists. Acknowledging its cross-sectional nature, the research provides

a snapshot view, lacking an analysis of changes in nurses' knowledge and attitudes over time.

Additionally, to address feedback, a specified time frame will be included, enhancing the
presentation of the study's scope. The study transparently acknowledges resource constraints and

potential language barriers inherent in research conducted in developing countries, contributing

to a nuanced interpretation of the findings.

1.9 Definition of Terms

Pain: According to the International Association for the Study of Pain (IASP) taxonomy, pain is

defined as "an unpleasant sensory and emotional experience from actual or potential tissue

damage or described in terms of such damage (Association for the Study of Pain , 2017)

Pain management: is the use of a variety of approaches to reduce or eliminate pain, improve

life function, and enhance quality of life (World Health Organization, ([WHO], 2023)

Attitude: according to Cambridge Dictionary, (2016) attitude is defined as the way of thinking

or feeling about something or someone that determine the way of behaving.

Knowledge: is the awareness or understanding of a subject or a particular area of expertise

(Merriam-Webster, 2023)

Pediatrics: is the branch of medicine that deals with the health and well-being of infants,

children, and adolescents from 1 month of birth through (American Academy of Pediatrics,

2023)
CHAPTER 2: LITERATURE REVIEW

2.1 Overview of the Study

This chapter will present the overview of nurses’ knowledge and attitude regarding pediatric pain

management based on existing theory and literature that talk about the topic which is of interest

in this research

2.2. Empirical Review

The empirical review of the study highlights the vital role of pediatric pain management in

healthcare, particularly for vulnerable populations in Rwanda. It references multiple studies,

including a noteworthy research conducted by Kholowa in 2017 at Kibabaga District Hospital,

which revealed significant knowledge and attitude gaps among nurses. The collective findings

emphasize a global need for targeted training programs in pediatric pain management. The study

serves as a compelling call to action, stressing the importance of enhancing nurses' knowledge

and attitudes to improve the quality of care for pediatric patients in Rwanda and beyond.

2.2.1. Objective 1: Knowledge of Pediatric Pain Assessment

The assessment of nurses' knowledge regarding pediatric pain management reveals consistent

challenges across various regions. In Rwanda, Kholowa's study (2017) uncovered a significant

gap, with 53% of nurses demonstrating insufficient knowledge in pain assessment. This finding

aligns with Uwera & Kamanzi's (2022) similar observations in Rwanda, emphasizing

deficiencies in understanding pain scales and non-verbal cues. Similarly, Bhattacharya et al.
(2019) in India reported that 48% of nurses exhibited poor scores in pain knowledge

assessments, while Liu et al. (2018) found that 62% of Chinese nurses had inadequate knowledge

of pain assessment in neonates.

[Link] 2: Attitudes towards Pediatric Pain Management

Exploring nurses' attitudes towards pediatric pain management reveals diverse perspectives and

potential barriers to effective care. In Rwanda, Kholowa (2017) identified that 35% of nurses

held unfavorable attitudes, including the underestimation of pain and concerns about medication

overuse. This aligns with Altin et al.'s (2020) study in Turkey, reporting that 28% of nurses

believed children do not experience pain like adults. Additionally, Walker et al. (2015) in the

USA found that 23% of nurses expressed concerns about opioid addiction in children, while

Akinsulure et al. (2017) in Nigeria identified cultural beliefs hindering pain management in 39%

of nurses.

2.3 Theoretical Review

the Health Belief Model provides a comprehensive framework to understand the factors

influencing nurses' engagement in effective care. Beginning with perceived severity, nurses

evaluate the gravity of inadequate pain management on pediatric patients' well-being. This

assessment sets the stage for their perceived susceptibility, where recognition of potential

knowledge gaps becomes crucial in shaping attitudes toward patient outcomes. Perceived

benefits then play a pivotal role, highlighting positive outcomes and professional growth as
 motivational factors for nurses to actively seek and apply comprehensive knowledge in pain

management. However, perceived barriers, such as time constraints, must be identified and

mitigated to create an environment conducive to knowledge enhancement. Cues to action, in the

form of timely interventions like targeted educational programs, serve as stimuli prompting

nurses to improve their knowledge and attitudes. Finally, self-efficacy emerges as a critical

variable, emphasizing the necessity of building nurses' confidence in applying their knowledge

for the successful implementation of effective pediatric pain management strategies. In this

holistic approach, each element interconnects, contributing to a comprehensive understanding of

the factors influencing nurses' engagement in pediatric pain management.

2.4. Conceptual Frame Work

INDEPENDENT DEPENDENT OUTCOME

SOCIAL DEMOGRAPHIC
DATA

Age ,gender : KNOWLEGDE

PEDIATRI
Highest Nursing C PAIN
Degree obtained
MANAGEM
A2 A1 A0 MSN ENT
Other(specify)
ATTITUDE
Do you
CHAPTER 3: METHODOLGY

3.1. Study Design

The study will use quantitative with a cross-sectional , and to assess nurses' knowledge and

attitudes regarding pediatric pain management at Kibagabaga District Hospital. This approach,

involving a one-time data collection, aligns with research objectives, providing insights into the

current status and areas for improvement. A structured questionnaire will be administered across

various hospital departments, using a stratified sampling technique to ensure representation

based on experience and specialization. Data analysis will employ descriptive statistics for

quantitative data and thematic analysis for qualitative insights from open-ended questions. This

approach aims to comprehensively capture nurses' perspectives and contribute valuable insights

to enhance pediatric pain management practices at the hospital.

3.2. Study Area/Setting

This research study will be conducted at Kibagabaga District Hospital, situated in the Gasabo

district of Kigali city, Rwanda, East Africa. Located within Kimironko sector, the hospital serves

as a critical healthcare facility for a diverse patient population, including pediatric patients. The

study will unfold within the hospital's premises, encompassing nurses from various departments
and units. This choice of setting offers a unique opportunity to examine the knowledge and

attitudes of nurses regarding pediatric pain management within the specific context of

Kibagabaga District Hospital. As a district hospital in the Gasabo district, it plays a pivotal role

in providing essential medical services to the community, making it a fitting location for this

study

3.3 Study Population

The study will target a specific population of interest, namely, registered nurses employed at

Kibagabaga District Hospital in Rwanda. The research will focus on nurses who are involves in

the care and management of pediatric patients within various hospital departments and units.

In the future, the study will aim to recruit a representative sample of these nurses to participate in

the research. This sample will be selected based on predefined criteria to ensure diversity and

relevance to the study objectives. The nurses who meet the inclusion criteria will be invited to

voluntarily take part in the study by completing the structured questionnaire designed to assess

their knowledge and attitudes regarding pediatric pain management.

3.4 Inclusion and Exclusion Criteria

In the forthcoming research study, which centers on the assessment of nurses' knowledge and

attitudes concerning pediatric pain management at Kibagabaga District Hospital, specific

inclusion and exclusion criteria will guide the selection of eligible participants.

3.4.1. Inclusion Criteria

The study will encompass registered nurses who are presently employed at Kibagabaga District

Hospital. To be eligible, participants must actively partake in the care and oversight of pediatric

patients across various hospital departments and units.

[Link] Criteria

Nurses that are not willing to participate and those which are not meeting inclusion criteria will be

excluded from the study

3.5 sample size

The total nurse of kibagabaga hospital are 114 , in determining sample size the simplified
formula proposed by Taro Yamane (1967) will be used
Where :
N: represent targeted population which is equal to 114 nurses
n: represents sample size
e: stands for level of precision which is equal to 0.05
n = N/(1+N(e)2.
n = 114/(1+114(0.05)2.=88.7
 3.6. Sampling Techniques

This study will employ a simple random sampling technique to select participants from

Kibagabaga District Hospital

Nurses responsible for the care of sick children were selected from various departments,

including pediatrics, surgery (caring for children with surgical conditions), emergency units

(treating pediatric emergencies), and outpatient departments (serving pediatric outpatients) ,

dental and ophthalmology .

3.7. Data Collection Tools/ Research Instruments

The research utilizes the Pediatric Nurses' Knowledge and Attitudes Survey (PNKAS),

comprising two sections meticulously designed to assess nurses' knowledge and attitudes

regarding pediatric pain management. In accordance with best practices for data collection

instruments, the knowledge section features questions evaluating nurses' factual understanding of

crucial pain-related concepts. These encompass the subjective nature of pain, accuracy in

children's pain descriptions, and prioritization of non-pharmacological pain management

strategies. The attitudes section explores nurses' beliefs and feelings, addressing their confidence

in assessing and treating pain in children, comfort levels in administering pain medication, and

core belief in the necessity of providing adequate pain management to all children. This

approach ensures a comprehensive assessment of nurses' preparedness and willingness to provide

effective pain management for pediatric patients, aiding in the identification of areas for further

education and improvement in this critical aspect of healthcare

3.8. Validity vs Reliability

The Pediatric Nurses' Knowledge and Attitudes Survey (PNKAS) is a well-established tool for

evaluating nurses' understanding and perspectives on pediatric pain management. The survey

exhibits both reliability and validity, ensuring its credibility in diverse global studies.

3.8.1 VALIDITY

Content Validity: Experts in pediatric pain management review PNKAS items to ensure comprehensive

coverage of relevant topics.

Construct Validity: PNKAS effectively measures intended theoretical constructs, distinguishing

between nurses with varying levels of pediatric pain management knowledge and experience.

Criterion-related Validity: PNKAS scores correlate with other measures of pediatric pain management

knowledge and attitudes.

3.8.2 REABILITY

Reliability, on the other hand, pertains to the consistency of the instrument's scores. The PNKAS

demonstrates reliability, with a Cronbach's alpha coefficient of 0.71, indicating consistent results

when administered to the same individuals on different occasions.

 3.9. DATA COLLECTION PROCEDURE

The data gathering procedure for this study involves using a structured questionnaire adapted

from the Pediatric Nurses' Knowledge and Attitudes Survey Regarding Pain tool. Nurses from

various departments at Kibagabaga District Hospital will be selected through simple random

sampling to participate in the study. The questionnaire will assess their knowledge and attitudes

regarding pediatric pain management. Before the main data collection, a pilot study will be

conducted to refine the questionnaire. The collected data will be rigorously analyzed to gain

insights into nurses' knowledge and attitudes, contributing to a deeper understanding of pediatric

pain management practices and the development of targeted interventions.

3.10. Data Analysis

The data analysis for the study involves cleaning and organizing collected questionnaire data,

followed by the use of descriptive statistics to summarize demographic information, knowledge,

and attitude scores. Inferential statistics SPSS, may reveal differences among nurse groups based

on experience or department. Regression analysis will explore factors influencing knowledge and

attitudes. The analysis aims to provide insights into pediatric pain management at Kibagabaga

District Hospital, aiding in identifying areas for improvement and guiding interventions to

enhance care practices.

 3.11. Ethical Considerations

In conducting the assessment on pediatric pain management among nurses at Kibagabaga

District Hospital, ethical considerations are fundamental. The study, emanating from the

Adventist University of Central Africa (AUCA), underscores the researcher's commitment to

honesty and respect. Data collection, focused on selected nurses in kibagabaga, ensures

participant confidentiality and emphasizes that responses are solely for academic purposes. The

study maintains objectivity in data processing and analysis, pledging transparency and providing

the research findings to involved organizations. Upholding AUCA's ethical standards, the study

diligently follows guidelines, reinforcing its commitment to ethical integrity throughout the

research process.
 APPENDIX

3.12. LIST OF REFERENCES

References:

BIBLIOGRAPHY

 Friedrichsdorf, S. J. (2020). Pediatric pain treatment and prevention for hospitalized

children. (Friedrichsdorf, Ed.)

 Kholowa, C. M. (2017). Nurses’ knowledge and attitudes towards pain management in

children admitted in the Paediatric Department of Queen Elizabeth Central Hospital,

Blantyre, Malawi. Journal of Biosciences and Medicines, 46.

 ndagijimana.j.p. (2017). Nurses’ knowledge and attitudes regarding pediatric pain

management in three hospitals in southern province of Rwanda. (Doctoral dissertation,

University of Rwanda).

 Ndagijimimana, J. P. (2017). Nurses’ knowledge and attitudes regarding pediatric pain

management in three hospitals in southern province of Rwanda. 12.

  Tagele, T. D. ( 2023). Knowledge and attitude towards pediatric pain management among

nurses at Ethiopian tertiary hospital. a multi-center study. BMC nursing, 22(1), 1-8.

 the journal BMC, P. (2022). the journal BMC Pediatrics. the journal BMC Pediatrics.

 Uwera, A.M., & Kamanzi, S. (2022). Challenges and opportunities. Pain Management.

Pain management in Rwanda.

 Vlaeyen, J. W. (2022). the journal Pain. In J. W. Vlaeyen.

 WHO. (2019). the Global Action Plan. the Global Action Plan.

 Benimana, J. D. (2020). Knowledge and attitude of nurses towards pediatric pain

assessment and management at Butaro Hospital, Rwanda. African Health Sciences, 20(2),

603-611.

 Bernie, J. E., Stevens, B. J., Palermo, T. M., Cox, A. D., McGrath, P. J., & Weisman, S. J.

(2014). Pain prevalence and management in hospitalized children: a multi-center study. Pain

Medicine, 15(12), 2228-2237.

 Dr. David Eccleston, P. W. (2023, February 4). Lancet study reveals under treatment of pain

in children with cancer. The Lancet Oncology.

 Olmstead, S. E., Traub, R. J., Buerhaus, P. I., Bergstrom, I., Johnson, B. D., & Auerbach, D.

M. (2018). Nurses' knowledge, attitudes, and practices regarding pain management in

hospitalized children. Journal of Pediatrics, 197, 22-29.

 Ujeneza, J. D., Ndayisaba, L., Makuza, J. M., & Nsabimana, E. (2022). Attitudes of

Rwandan nurses towards the use of opioids in children. BMC Pediatrics, 22(1), 1-8.
 Vlaeyen, J. (2022). Global disparities in pain relief access. Pain, 163(7), 1217-1218.

World Health Organization. (2019). Global action plan on pain.

 American Academy of Pediatrics. (2023). About pediatrics. [Link]

association-websites

 Kitson, A., Rycroft-Malcolm, J., McCormack, B., Harvey, G., Seers, K., & Titchen, A.

(2022). Knowledge transfer and implementation: Theory and practice. London: SAGE

Publishing.

 Rogers, R. W. (2020). A protection motivation model of psychological stress and coping.

Routledge.

 Uwera, A. M., & Kamanzi, S. (2022). Pediatric pain management in Rwanda: A review of

the literature. International Journal of Pediatric Nursing, 8(1), 1-8.

 American Academy of Pediatrics. (2023, January 1). About pediatrics.

[Link]
Informed Consent Form

I, Emmanuella Uwibambe Niwebasa, a Level 4 student in General Nursing at Adventist

University of Central Africa, am conducting a research titled "Assessment of Knowledge and

Attitudes Towards Pediatric Pain Management Among Nurses at Kibagabaga District Hospital."

The objective of this research is to evaluate the knowledge and attitudes of nurses regarding

pediatric pain management.

To collect data, I invite participants to share their perspectives through a structured questionnaire

designed to gather insights into pediatric pain management. The data collection process involves

distributing the questionnaire and allowing participants ample time to complete it at their

convenience.

I request participants to voluntarily contribute to the research by providing honest and accurate

responses, with an estimated time commitment of [specify time] minutes.

The collected data will be used exclusively for research purposes, presented in an aggregated and

anonymized form, and individual participant information will be treated with utmost

confidentiality.

While the research entails minimal risks, such as slight discomfort or inconvenience during

questionnaire completion, the anticipated benefits include contributions to enhancing pediatric

pain management practices at Kibagabaga District Hospital. Participants indirectly benefit by

contributing to advancements in healthcare practices.

By participating in this research, individuals confirm their understanding of the information

provided and retain the right to withdraw from the study at any point without consequences.

Privacy will be rigorously safeguarded throughout the research process.

For questions or concerns about the research, participants can contact me at

uwibambeniwebasaemmanuella@[Link] or 0784205328. Participants can confirm their

consent to participate by providing their name and signature below.

Participant’s Name: ______________________

Participant’s Signature: ______________________

Date: ______________________

QUESTIONNNAIRE.

Modified Pediatric Nurses’ Knowledge and Attitudes Survey Regarding

(PNKAS).

QUESTIONNNAIRE .English Version.

Demographic Data for Nurse-Participants

Age (years):

gender : Male Female

Highest Nursing Degree obtained:

A2 A1 A0 MSN Other(specify)

Do you work in?

Emergence ……….
Surgicalward……..

DENTAL ……………

Pediatricward…….

OPD………………

OPTHAMOLOGY …….

Does your unit has a pediatric pain management protocol? Yes / No /don’t know

which of the following pain scale have you used? (Write a pain scale used if it

doesn’t appear on the list below)

1. Neonatal Infant Pain Scale (NIPS)

2. Face Legs Activity Cry Consolability (FLACC)

3. Faces

4. Numeric

5. Other…

True/False - Circle the correct answer.

T /F 1. Observable changes in vital signs must be relied upon to verify a child’s/

adolescent’s statement that he has severe pain.

T/ F 2. Because of an underdeveloped neurological system, children under 2 years

of age have decreased pain sensitivity and limited memory of painful experiences.

T/ F 3. If the infant/ child/ adolescent can be distracted from his pain this usually

means that he is not experiencing a high level of pain.

T/ F 4. Infants/ children/ adolescents may sleep in spite of severe pain.

T/ F 5. Comparable stimuli in different people produce the same intensity of pain.

T/ F 6. Ibuprofen and other non-steroidal anti-inflammatory agents are NOT

effective analgesics for bone pain.

T/ F 7. Non-drug interventions (e.g. heat, music, imagery, etc.) are very effective

for mild-moderate pain control but are not helpful for more severe pain.

T/ F 8. Children who will require repeated painful procedures (i.e. daily wound

care or blood draws), should receive maximum treatment for the pain and anxiety

of the first procedure to minimize the development of anticipatory anxiety before

subsequent procedures.

T/ F 9. Respiratory depression rarely occurs in children/ adolescents who have

been receiving opioids over a period of months.

T/ F 10. Paracetamol 650 mg PO is approximately equal in analgesic effect to

codeine 32 mg PO.

T /F 11. The World Health Organization (WHO) pain ladder suggests using single

analgesic agents rather than combining classes of drugs (e.g. combining an opioid

with a non-steroidal agent.

T / F 12. The usual duration of analgesia of Morphine IV is 4-5 hours.

T/ F 13. Research shows that promethazine (Phenergan) is a reliable potentiator of

opioid analgesics.

T /F 14. Parents should not be present during painful procedures.

T /F 15. Adolescents with a history of substance abuse should not be given opioids

for pain because they are at high risk for repeated addiction.

T/ F 16. Beyond a certain dosage of morphine increases in dosage will NOT

provide increased pain relief.

T/ F 17. Young infants, less than 6 months of age, cannot tolerate opioids for pain

relief. T/ F 18. The child/ adolescent with pain should be encouraged to endure as

much pain as possible before resorting to a pain relief measure.

T /F 19. Children less than 8 years cannot reliably report pain intensity and

therefore, the nurse should rely on the parents’ assessment of the child’s pain

intensity.

T/ F 20. Based on one’s religious beliefs a child/ adolescent may think that pain

and suffering is necessary.

T/ F 21. Anxiolytics, sedatives, and barbiturates are appropriate medications for

the relief of pain during painful procedures.

T/ F 22. After the initial recommended dose of opioid analgesic, subsequent doses

should be adjusted in accordance with the individual patient’s response.

T F 23. The child/ adolescent should be advised to use non-drug techniques alone

rather than concurrently with pain medications.

T F 24. Giving children/ adolescents sterile water by injection (placebo) is often a

useful test to determine if the pain is real.

Multiple Choice - Place a check by the correct answer.

25. The recommended route of administration of opioid analgesics to children with

background (continuous, persistent) pain is :

_____ A. intravenous

_____ B. intramuscular

_____ C. subcutaneous

_____ D. oral

_____ E. rectal

_____ F. I don’t know

26. The recommended route of administration of opioid analgesics to children with

brief, severe pain of sudden onset, e.g. trauma or postoperative pain, is

_____ A. intravenous

_____ B. intramuscular

_____ C. subcutaneous

_____ D. oral

_____ E. rectal

_____ f. I don’t know

27. Which of the following analgesic medications is considered the drug of choice

for the treatment of prolonged moderate to severe pain for children?

_____ A. fentanyl

_____ B. codeine

_____ C. morphine

_____ D. I don’t know

28. Which of the following IV doses of morphine administered would be

equivalent to 15 mg of oral morphine.

_____A. Morphine 3 mg IV

_____ B. Morphine 5 mg IV

_____ C. Morphine 10 mg IV

_____ D. Morphine 15 mg IV

29. Analgesics for post-operative pain should initially be given

_____ A. around the clock on a fixed schedule

_____ B. only when the child/ adolescent asks for the medication

_____ C. only when the nurse determines that the child/ adolescent has moderate

or greater discomfort

30. A child with background (continuous, persistent) pain has been receiving daily

opioid analgesics for 2 months. The doses increased during this time period.

Yesterday the child was receiving morphine 20 mg/hour intravenously. Today

 he has been receiving 25 mg/hour intravenously for 3 hours. The likelihood of

the child developing clinically significant respiratory depression is

_____ A. less than 1%

_____ B. 1-10%

_____ C. 11-20%

_____ D. 21-40%

_____ E. > 41%

31. Analgesia for background (continuous, persistent) pain should be given

_____ A. around the clock on a fixed schedule

_____ B. only when the child asks for the medication

_____ C. only when the nurse determines that the child has moderate or greater

discomfort

32. The most likely explanation for why a child/ adolescent with pain would

request increased doses of pain medication is

_____ A. The child/ adolescent is experiencing increased pain.

_____ B. The child/ adolescent is experiencing increased anxiety or depression.

_____ C. The child/ adolescent is requesting more staff attention.

_____ D. The child’s/ adolescent’s requests are related to addiction.

33. Which of the following drugs are useful for treatment of pain in children?

_____ A. Ibuprophen (Motrin)

_____ B. Morphine

_____ C. Amitriptyline (Elavil)

_____ D. All of the above

34. The most accurate judge of the intensity of the child’s/ adolescent’s pain is

_____ A. the treating physician

_____ B. the child’s/ adolescent’s primary nurse

_____ C. the child/ adolescent

_____ D. the pharmacist/ another primary team member

_____ E. the child’s/ adolescent’s parent

35. What do you think is the percentage of patients who over-report the amount of

pain they have? Circle the correct answer. 0 10 20 30 40 50 60 70 80 90 100%

36. Narcotic/opioid addiction is defined as psychological dependence accompanied

by overwhelming concern with obtaining and using narcotics for psychic

effect, not for medical reasons. It may occur with or without the physiological

changes of tolerance to analgesia and physical dependence (withdrawal).

Using this definition, how likely is it that opioid addiction will occur as a result if

treating pain with opioid analgesics? Circle the number closest to what you

consider the correct answer.

< 1% 5% 25% 50% 75% 100%