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Exploring the Knowledge Regarding Pain Management among Nursingstudents in Kuwait: A Neural Network Andsemantic Analysis Approach

Noura H. Aladwani, Dr. Mahdi Hussain, Dr. Bander Albagawi
American Journal of Nursing Research. 2020, 8(2), 278-283. DOI: 10.12691/ajnr-8-2-17
Received December 13, 2019; Revised January 28, 2020; Accepted February 16, 2020

Abstract

Pain is an unpleasant and highly uncomfortable experience patients can have. It causes stress, decreased quality of life and alterations in the physical, emotional and spiritual aspects of a patient’s well-being. Deficient knowledge toward pain management hinders effective pain management among nurses and future nurses such as nursing students.This research aims to explore on the essential concepts on pain management cognition among nursing students on pain management. The research employed a descriptive, exploratory design using semantic network analysis and artificial neural network approach. Data were obtained using the knowledge and attitudes survey regarding pain (KASRP) tool. Descriptive and inferential statistics were utilized to interpret data. Findings revealed that the concepts of pain, analgesia, assessment and patient were important concepts related to the knowledge on pain management among nursing students in Kuwait. Further, their current study status, work experience and exposure to pain management books were crucial in their education regarding pain management. Pain management should be integrated and comprehensively discussed in the undergraduate nursing program to enhance the knowledge on pain management of the future nurses.

1. Introduction

Pain is an unpleasant and highly uncomfortable experience patients can have 1. It causes stress, decreased quality of life and alterations in the physical, emotional and spiritual aspects of a patient’s well-being 2. Physiologically, pain is a result of reduced pain threshold due to the effect of chemical substances such as bradykinin, serotonin and prostaglandin secondary from damaged cells and tissues 3, 4.

The negative effects of pain on a patient, holistically, are major concerns for nurses. Thus, pain management among nurses is crucial 5. Nurses’ need to be proficient in their knowledge on pain management such as assessment, interventions, and prevention in order to provide prompt and effective pain relief 6. Pain has been widely studied internationally 7, 8, however, in spite of the developments in pain management, many patients, globally, still receive inadequate and inappropriate treatment.

Similarly, in Kuwait, the prevalence of pain is ubiquitous thereby necessitating a reform in health care organizations and improve pain management practices 9. Further, musculoskeletal problems, overweight and obesity have been identified as common factors that contribute to pain in Kuwaitis 10, 11. There is a deficiency in the knowledge of nurses in the concept of pain management 12, 13, 14. A study was conducted by Dessie et al 15 to assess the Knowledge and attitudes of 433 Ethiopian nurses regarding post-operative pain management. Results determined that 56.5% of the study sample had adequate knowledge on pain management and only 8.9% had a positive attitude towards pain management.

Indeed, knowledge on pain management is vital in the nurses’ competency development in providing efficient and adequate pain management. Literature is sparse regarding nurses’ knowledge on pain management in the Arab world including Kuwait. This research focuses on determining the essential knowledge-based concepts on pain management important among nursing students’ pain competency in Kuwait.It aims to explore on concepts or factors that may be crucial in enhancing pain management skills. This research utilized unconventional approaches in the study of knowledge on pain management in the form of artificial neural network and a semantic analysis approach to probe on the important factors or concepts regarding pain management.

This research used the process of ANN as a novel approach in determining the important factors and concepts that may be affective in the cognition of pain management among nursing students in Kuwait. Artificial neural network (ANN) is commonly used to ascertain the linear relationship of data using a perceptron. It aims at eliciting the connection pattern and network topology among data which mimics the action of a biological neuron 16, 17. Meanwhile, Semantic network analysis is used to seize the relations among key concepts and explore the context of the main topic 18. This research utilized the process of semantic network analysis to accurately determine which concept in pain management is important and be the focus of future pain management courses for the nursing students.

2. Methods

2.1. Design

This research utilized a descriptive, exploratory approach in probing the knowledge on pain management among nursing students in Kuwait. A total of 106 nursing students completed the survey having a response rate of 83% as a result of convenience sampling. This research was done in the Nursing college of the Public Authority of Applied Education and Training in Kuwait. Data collection started in October 2019 and ended in December 2019. The inclusion criteria were set to those nursing students currently having their clinical duty and have voluntarily agreed to participate.

2.2. Instrument

A demographic data sheet was used to gather data from the nursing students. Information about the participant’s gender, age, educational qualification, current study status, participation in a training course on pain, work experience, and have read a book on pain management were elicited from the participants.

This research utilized the Knowledge and Attitudes Survey Regarding Pain (KASRP) tool developed by Betty Ferrell. It is a 37- item questionnaire composed of 21 true or false questions and 16 multiple choice questions regarding the concept of pain 19. It encompasses concepts such as pain management, pain assessment, and the use of analgesics. The instrument was validated by four experts in the field with a doctorate degree in the field of nursing. Thereafter, it was subjected for reliability testing with 10 nursing students who were not included in the actual data gathering.

2.3. Ethical Consideration

This study has been approved by the authorities of the nursing college. Written informed consent from the participants has been sought.

2.4. Data Analysis

Data were entered and analyzed using the Statistical Package for Social Sciences (SPSS) version 25. Descriptive statistics was used to describe the participants’ profile. Semantic analysis was used to determine the significant key concepts in the KASRP tool and was correlated with the participants’ response using Pearson’s Coefficient of Correlation. Meanwhile, artificial Neural Network analysis was used to identify the factors and themes that are highly predictive and significant to the nursing students’ knowledge on pain management.

3. Results

Most of the nursing students were female (70%; n=74) with an average age of 20-25 years old (92%; n=98). Majority of them hold a secondary school certificate (97%; n=103) and are currently in Level 4 (69%; n=73). There were 80 nursing students (75%)witha training course on pain. Most of them do not have work experience (82%; n=87). Of the 106 nursing students participating in the study, 61 (58%) have read a book on pain management while 45 (42%) have not. (Table 1)

The concepts in the KASRP tool were derived based on its occurrence in the items of the tool using semantic analysis. Concurrently, the average percentage of the knowledge scores were obtained based on the responses of the nursing students. This resulted in the identification of concepts that are meaningful in the representation of the knowledge base of the nursing students in Kuwait regarding pain management which were (from highest to lowest) “analgesic” (55.09%), “opioid” (54.98%), “opioid analgesic” (53.21%), “patient” (51.23%), and “pain” (49.69%). Meanwhile, the concept of “significant respiratory depression” (9.69%) has the least relevance(Table 2).

Results revealed a “very strong positive” correlation between the concepts of “pain” and “patient” (r=0.85), “assessment” and “year” (r=0.92) and “hour” and “morphine” (r=0.80). This finding may pertain to significant relevance of getting correct answers when the concepts (e.g. “pain” and “patient”) are present in the KASRP tool. A value of Pearson Correlation Coefficient (r) of +1 is indicative of a positive relationship 20. (Table 3)

Using the neural network analysis, the data set was generally partitioned in the following: 70% training, 20% testing and 10% holdout (Table 4 and Table 5).

Table 4 shows the demographic variables that are highly predictive of affecting the knowledge of the nursing students regarding pain management. Specifically, data partitioning were automatically calculated into 74.3% training, 18.1% testing, and 7.6% holdout. The network structure was composed of the Input layer(48 units), hidden layer(9 units), and output layer (1 unit). Based from the importance coefficients obtained, three variables were statistically significant: “reading a book on pain” (100%), “current study status” (78.6%) and “work experience” (71.7%). The relative errors were 0.990 training, 0.954 testing and 1.002 holdout.

Using ANN, concepts such as “patient’s pain” (100%), “analgesic” (95.4%), “pain” (88.6%) and “opioid” (83.7%) were highly predictive of affecting the knowledge on pain management among the nursing students in Kuwait. Meanwhile, the concepts of “injection” (28.1%) and “significant respiratory depression” (28.9%) yielded the lowest importance coefficients. Data set were specifically partitioned into 76.5% training, 15.7% testing, and 7.8% holdout. Subsequently, network structure was composed of several layers (Input layer=92 units; hidden layer= 27 units; output layer=1 unit). Based from the importance coefficients obtained, three variables were statistically significant: “patient’s pain” (100%), “analgesic” (95.4%), “pain” (88.6%) and “opioid” (83.7%). The relative errors were 0.49 (training), 0.221(testing) and 0.209(holdout). (Table 5)

4. Discussion

This present research determines the knowledge-based concepts on pain management important among nursing students’ pain competency in Kuwait. It aims to explore on concepts or factors that may be crucial in enhancing pain management skills. The present finding reveal that the concepts of analgesic, opioid, opioid analgesic, patient and pain as the most meaningful in relation to the nursing students’ responses in the KASRP tool. It may indicate that these identified concepts must be given priority and extensively discussed in a pain management training course. In a study conducted by Ferrell 21, nursing textbooks were analyzed of its concept of pain content and it was found that only 0.05 percent of the total text content of 50 nursing textbooks contained a discussion on pain management. Newly graduate nurses must be educationally prepared to be responsive of contemporary needs of patients in the clinical setting including managing patient pain 22. Thus, there is a need that the aforementioned concepts need to be integrated in the concept of pain in order for the nursing students to have a full understanding as regards pain management. This helps students to strategize their safe intervention when dealing pain management.

This research focused on finding the essential concepts in relation to pain management as knowledge in pain management involves understanding of pain theories, facts regarding pain assessment and pain treatments that must be embedded throughout the nursing curricula 23. According to Weber & Kelley 24, the ability of nurses to assess and treat patients pain and achieve positive outcomes is depended on the nurses’ level of knowledge in pain management that would encompass the physiological, psychological, pharmacological and non-pharmacological aspects of pain management. The low level of knowledge among nurses 12, 13, 14 may be due to minimal concepts on pain management in the undergraduate nursing program.

Moreover, results show the very strong relationship with pain and pain assessment which entails higher tendencies of nursing students getting correct answers when these concepts are encountered in the KASRP tool. Inadequate and inappropriate pain management is the result of poor and inaccurate pain assessment by nurses 25. This is concurred by Ferrell & McCaffrey 26, objectivity in pain assessment with continued education results into elimination of personal opinions and biases among nurses. Meanwhile, Rose et. al 27 found that 42 percent of nurses suffer from lack of education and training on the use of pain assessment tools. This may indicate the necessity to intensify the concept of pain management and assessment in international nursing programs.

Results also identified that current study status, work experience and having read a book on pain are important factors affecting the knowledge of nursing students in pain management. Most of the respondents are having their theoretical concept regarding pain and clinical rotation during the conduct of the study, which may indicate that exposure in the clinical setting promotes better understanding and application of pain management practices and interventions. This confirms the study of Sigsby 28 that baccalaureate nursing students learn pain management best in the clinical setting. Nursing students improve their knowledge on pain as they progressed through the program and that the concept of pain should be comprehensively be integrated into the study plan for consistency and enhance effectiveness 29.

The artificial neural network result on the important themes relevant to the knowledge of nursing students on pain management supports the result of the semantic network analysis. ANN is used in various sectors in health care for clinical diagnosis, image analysis and interpretation and including prediction of key indicators 30. Thus, in this research, ANN was used to predict the key indicators related to knowledge on pain management. On the other hand, Semantic Network Analysis was used in this research as a method of extracting meaning from the text or in this case the KASRP tool through network building of the concepts that occur in close proximity 18.

4.1. Limitation

This research was limited to having a small sample size.

4.2. Conclusion

This research has shown that the concepts of pain, patient’s pain, opioid, and analgesia are meaningful in the enhancement of knowledge among nursing students in pain management. These concepts are strongly correlated to the concepts of assessment, year, hour and morphine. Further, this research identified that current study status, work experience and reading a book regarding pain are important variables that may affect the knowledge of nursing students in pain management. It is recommended that these identified concepts be given more focus in pain management courses in continuing education and undergraduate curricula. Further studies are needed to evaluate the effectiveness of pain management courses.

4.3. Disclosure

There are no conflicts of interest.

References

[1]  Christie, O., Olayinka, O., & Olufunke, O. (2018). Factors associated with utilization of pain assessment tools in pain management among nurses in selected hospitals in ekiti state. International Journal of Caring Sciences, 11(1), 163-170. Retrieved from https://search.proquest.com/docview/2058267522?accountid=35493
In article      
 
[2]  Samarkandi, O. (2018). Knowledge and Attitudes of nurses toward pain management. Saudi Journal of Anesthesia, 12(2), 220-226.
In article      View Article  PubMed
 
[3]  Daly, L. (1999). The physiology of pain. Australian Nursing Journal, 7,(3), 1-3.
In article      
 
[4]  Hawthorn, J. & Redmond, K. (1998). Pain causes and management. Blackwell Scientific, Oxford, pp. 10-11.
In article      
 
[5]  Bartoszczyk, D., Gilbertson-White, S. (2015). Interventions for nurse-related barriers in cancer pain management. Oncol Nurs Forum, 42(1), 634-41.
In article      View Article  PubMed
 
[6]  Kafkia, T., Vehviläinen-Julkunen, K., & Sapountzi-Krepia, D. (2014). Assessment and management of pain in hemodialysis patients: A pilot study. Progress in Health Sciences, 4, 1, 53-60.
In article      
 
[7]  International Association for the Study of Pain, (IASP, 2012). IASP Curriculum Outline on Pain for Nursing. Retrieved on 13th March 2015 from http://www.iasppain.org/AM/Template.cfm?Section=Nursing
In article      
 
[8]  Registered Nurses’ Association of Ontario,(RNAO, 2013). Assessment and Management of Pain (3rdEd.). Toronto. ON Registered Nurses’ Association of Ontario. Retrieved on 15th April 2015 from http://www.ipts.org.il/dbsAttachedFiles.
In article      
 
[9]  Lakha, S., Pennefather, P., Bader, H., & Mailis-Gagnon, A. (2016). Health Services for Management of Chronic Non-Cancer Pain in Kuwait: A Case Study Review. Medical Principles & Practice, 25: 29-42.
In article      View Article  PubMed
 
[10]  Al-Tabtabai, H. (2002). Analyzing construction site accidents in Kuwait. Kuwait J Sci Eng, 29: 3-15.
In article      
 
[11]  Badr, H., Shah, N., & Shah, M. (2013). Obesity among Kuwaitis aged 50 years or older: prevalence, correlates and comorbidities. Gerontologist , 53: 555-566.
In article      View Article  PubMed
 
[12]  Salameh, B. (2018). Nurses’ knowledge regarding pain management in high acuity care units: A case study of Palestine. International Journal of Health Sciences, 12(3): 51-57
In article      
 
[13]  Alnazly, E., Abojedi, A. (2018). Jordanian Nurses’ Knowledge and Attitudes Regarding Pain Management Principles for Hospitalized Patients. Al-Balqa Journal of Research & Studies, 21(1): 43-59
In article      View Article
 
[14]  Lokapur, M., Vasani, P., & Page, N. (2018). Evaluation of knowledge, attitude, and practices of nurses regarding pain management in tertiary care hospitals of Pune, India. Indian Journal of Pain, 32(1): 30-35
In article      View Article
 
[15]  Dessie, M., Asichale, A., & Belayneh, T. et al (2019). Knowledge and Attitudes of Ethiopian Nursing Staff Regarding Post-Operative Pain Management: A Cross-Sectional Multicenter Study. Patient Related Outcome Measures, 10: 395-403.
In article      View Article  PubMed
 
[16]  Chukwu, S., Nwachukwu, A. (2012). Analysis of some meteorological parameters using artificial neural network method for Makurdi, Nigeria. African Journal of Environmental Science and Technology, 6(3): 182-188.
In article      View Article
 
[17]  Zupan, J. (1994). Introduction to Artificial Neural Network (ANN) methods: What are they and how to use them. Acta Chimica Slovenica, 41(3): 1-27. Retrieved from https://www.researchgate.net/publication/251626579_Introduction _to_Artificial_Neural_Network_ANN_Methods_What_They_Are _and_How_to_Use_Them
In article      
 
[18]  Gao, M. (2014). Culture-based interpretation of projected destination images: A semantic network analysis. Proquest Dissertations Publishing, 1616660816. Retrieved from https://search.proquest.com/docview/1616660816?accountid=35493
In article      
 
[19]  Ferrell, B. R. (2007). Reducing barriers to pain assessment and management: An institutional perspective. Journal of Palliative Medicine, 10(1S), S15-S18.
In article      
 
[20]  Kowang, T., Long, C. & Rasli, A. (2015). Innovation Management and Performance Framework for Research University in Malaysia. International Education Studies, 8(6): 32-44.
In article      View Article
 
[21]  Ferrell, B. R., Virani, R., Grant, M, Vallerand, A., & McCaffery, M. (2000). Analysis of pain content in nursing textbooks. Journal of pain and symptom management, 19(3), 216-228.
In article      View Article
 
[22]  Ambrosio Mawhirter, D. (2010). Senior baccalaureate nursing students' preparation in pain management, cultural pain management, beliefs about pain management, nursing standards for pain management and culturally competent pain management. Proquest Dissertation Publishing, 3416074. Retrieved from https://search.proquest.com/docview/734662876/fulltextPDF/1D34B87268A54D5DPQ/1?accountid=35493
In article      
 
[23]  Joint Commission. Pain Assessment Standards (2007). Retrieved from http://www.jointcommission.org
In article      
 
[24]  Weber, J., & Kelley, J. (2007). Health assessment in nursing (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
In article      
 
[25]  Wood, S. (2008) Assessment of pain. Nursing Times, 1861174. Retrieved from http://www.nursingtimes.net
In article      
 
[26]  Ferrell, B. R., & McCaffery, M. (2007). Knowledge and attitude survey regarding pain. Retrieved from http://prc.coh.org/res inst.asp
In article      
 
[27]  Rose, L., Haslam, L., & Craig, D. et al (2011). Survey of assessment and management of pain for critically ill adults. Intensive Crit Care Nurs, 27 (3) 121-128.
In article      View Article  PubMed
 
[28]  Sigsby, L.M. (2001). Effective learning about the concept of pain from a preoperative clinical rotation. Pain Management Nurse, 2(1), 19-24.
In article      View Article  PubMed
 
[29]  Goodrich, C. (2006). Student's and faculty members' knowledge and attitudes regarding pain management: A descriptive Survey. Journal of Nursing Education, 45(3), 140-144.
In article      View Article  PubMed
 
[30]  Shahid, N., Rappon, T. & Berta, W. (2019) Applications of artificial neural networks in health care organizational decision-making: A scoping review. PLoS ONE 14(2): e0212356. https://doi.org/10.1371/journal.pone.0212356
In article      
 

Published with license by Science and Education Publishing, Copyright © 2020 Noura H. Aladwani, Dr. Mahdi Hussain and Dr. Bander Albagawi

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Noura H. Aladwani, Dr. Mahdi Hussain, Dr. Bander Albagawi. Exploring the Knowledge Regarding Pain Management among Nursingstudents in Kuwait: A Neural Network Andsemantic Analysis Approach. American Journal of Nursing Research. Vol. 8, No. 2, 2020, pp 278-283. http://pubs.sciepub.com/ajnr/8/2/17
MLA Style
Aladwani, Noura H., Dr. Mahdi Hussain, and Dr. Bander Albagawi. "Exploring the Knowledge Regarding Pain Management among Nursingstudents in Kuwait: A Neural Network Andsemantic Analysis Approach." American Journal of Nursing Research 8.2 (2020): 278-283.
APA Style
Aladwani, N. H. , Hussain, D. M. , & Albagawi, D. B. (2020). Exploring the Knowledge Regarding Pain Management among Nursingstudents in Kuwait: A Neural Network Andsemantic Analysis Approach. American Journal of Nursing Research, 8(2), 278-283.
Chicago Style
Aladwani, Noura H., Dr. Mahdi Hussain, and Dr. Bander Albagawi. "Exploring the Knowledge Regarding Pain Management among Nursingstudents in Kuwait: A Neural Network Andsemantic Analysis Approach." American Journal of Nursing Research 8, no. 2 (2020): 278-283.
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  • Figure 1 shows the semantic linkages of the concepts in the KASRP tool. Findings reveal that the concepts of patient, pain, morphine, pain relief, and assessment are essential in the comprehension of pain management.
  • Table 4. Importance of Demographic Variables to KASRP Total Scores in a Two-Layer Neural Networks (Perceptron/Regression) Model
  • Table 5. Importance of Themes to Actual Outcomes in a Two-Layer Neural Networks (Perceptron/Regression) Model
[1]  Christie, O., Olayinka, O., & Olufunke, O. (2018). Factors associated with utilization of pain assessment tools in pain management among nurses in selected hospitals in ekiti state. International Journal of Caring Sciences, 11(1), 163-170. Retrieved from https://search.proquest.com/docview/2058267522?accountid=35493
In article      
 
[2]  Samarkandi, O. (2018). Knowledge and Attitudes of nurses toward pain management. Saudi Journal of Anesthesia, 12(2), 220-226.
In article      View Article  PubMed
 
[3]  Daly, L. (1999). The physiology of pain. Australian Nursing Journal, 7,(3), 1-3.
In article      
 
[4]  Hawthorn, J. & Redmond, K. (1998). Pain causes and management. Blackwell Scientific, Oxford, pp. 10-11.
In article      
 
[5]  Bartoszczyk, D., Gilbertson-White, S. (2015). Interventions for nurse-related barriers in cancer pain management. Oncol Nurs Forum, 42(1), 634-41.
In article      View Article  PubMed
 
[6]  Kafkia, T., Vehviläinen-Julkunen, K., & Sapountzi-Krepia, D. (2014). Assessment and management of pain in hemodialysis patients: A pilot study. Progress in Health Sciences, 4, 1, 53-60.
In article      
 
[7]  International Association for the Study of Pain, (IASP, 2012). IASP Curriculum Outline on Pain for Nursing. Retrieved on 13th March 2015 from http://www.iasppain.org/AM/Template.cfm?Section=Nursing
In article      
 
[8]  Registered Nurses’ Association of Ontario,(RNAO, 2013). Assessment and Management of Pain (3rdEd.). Toronto. ON Registered Nurses’ Association of Ontario. Retrieved on 15th April 2015 from http://www.ipts.org.il/dbsAttachedFiles.
In article      
 
[9]  Lakha, S., Pennefather, P., Bader, H., & Mailis-Gagnon, A. (2016). Health Services for Management of Chronic Non-Cancer Pain in Kuwait: A Case Study Review. Medical Principles & Practice, 25: 29-42.
In article      View Article  PubMed
 
[10]  Al-Tabtabai, H. (2002). Analyzing construction site accidents in Kuwait. Kuwait J Sci Eng, 29: 3-15.
In article      
 
[11]  Badr, H., Shah, N., & Shah, M. (2013). Obesity among Kuwaitis aged 50 years or older: prevalence, correlates and comorbidities. Gerontologist , 53: 555-566.
In article      View Article  PubMed
 
[12]  Salameh, B. (2018). Nurses’ knowledge regarding pain management in high acuity care units: A case study of Palestine. International Journal of Health Sciences, 12(3): 51-57
In article      
 
[13]  Alnazly, E., Abojedi, A. (2018). Jordanian Nurses’ Knowledge and Attitudes Regarding Pain Management Principles for Hospitalized Patients. Al-Balqa Journal of Research & Studies, 21(1): 43-59
In article      View Article
 
[14]  Lokapur, M., Vasani, P., & Page, N. (2018). Evaluation of knowledge, attitude, and practices of nurses regarding pain management in tertiary care hospitals of Pune, India. Indian Journal of Pain, 32(1): 30-35
In article      View Article
 
[15]  Dessie, M., Asichale, A., & Belayneh, T. et al (2019). Knowledge and Attitudes of Ethiopian Nursing Staff Regarding Post-Operative Pain Management: A Cross-Sectional Multicenter Study. Patient Related Outcome Measures, 10: 395-403.
In article      View Article  PubMed
 
[16]  Chukwu, S., Nwachukwu, A. (2012). Analysis of some meteorological parameters using artificial neural network method for Makurdi, Nigeria. African Journal of Environmental Science and Technology, 6(3): 182-188.
In article      View Article
 
[17]  Zupan, J. (1994). Introduction to Artificial Neural Network (ANN) methods: What are they and how to use them. Acta Chimica Slovenica, 41(3): 1-27. Retrieved from https://www.researchgate.net/publication/251626579_Introduction _to_Artificial_Neural_Network_ANN_Methods_What_They_Are _and_How_to_Use_Them
In article      
 
[18]  Gao, M. (2014). Culture-based interpretation of projected destination images: A semantic network analysis. Proquest Dissertations Publishing, 1616660816. Retrieved from https://search.proquest.com/docview/1616660816?accountid=35493
In article      
 
[19]  Ferrell, B. R. (2007). Reducing barriers to pain assessment and management: An institutional perspective. Journal of Palliative Medicine, 10(1S), S15-S18.
In article      
 
[20]  Kowang, T., Long, C. & Rasli, A. (2015). Innovation Management and Performance Framework for Research University in Malaysia. International Education Studies, 8(6): 32-44.
In article      View Article
 
[21]  Ferrell, B. R., Virani, R., Grant, M, Vallerand, A., & McCaffery, M. (2000). Analysis of pain content in nursing textbooks. Journal of pain and symptom management, 19(3), 216-228.
In article      View Article
 
[22]  Ambrosio Mawhirter, D. (2010). Senior baccalaureate nursing students' preparation in pain management, cultural pain management, beliefs about pain management, nursing standards for pain management and culturally competent pain management. Proquest Dissertation Publishing, 3416074. Retrieved from https://search.proquest.com/docview/734662876/fulltextPDF/1D34B87268A54D5DPQ/1?accountid=35493
In article      
 
[23]  Joint Commission. Pain Assessment Standards (2007). Retrieved from http://www.jointcommission.org
In article      
 
[24]  Weber, J., & Kelley, J. (2007). Health assessment in nursing (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
In article      
 
[25]  Wood, S. (2008) Assessment of pain. Nursing Times, 1861174. Retrieved from http://www.nursingtimes.net
In article      
 
[26]  Ferrell, B. R., & McCaffery, M. (2007). Knowledge and attitude survey regarding pain. Retrieved from http://prc.coh.org/res inst.asp
In article      
 
[27]  Rose, L., Haslam, L., & Craig, D. et al (2011). Survey of assessment and management of pain for critically ill adults. Intensive Crit Care Nurs, 27 (3) 121-128.
In article      View Article  PubMed
 
[28]  Sigsby, L.M. (2001). Effective learning about the concept of pain from a preoperative clinical rotation. Pain Management Nurse, 2(1), 19-24.
In article      View Article  PubMed
 
[29]  Goodrich, C. (2006). Student's and faculty members' knowledge and attitudes regarding pain management: A descriptive Survey. Journal of Nursing Education, 45(3), 140-144.
In article      View Article  PubMed
 
[30]  Shahid, N., Rappon, T. & Berta, W. (2019) Applications of artificial neural networks in health care organizational decision-making: A scoping review. PLoS ONE 14(2): e0212356. https://doi.org/10.1371/journal.pone.0212356
In article