Pain has been defined by the International Association for the Study of Pain (IASP) as:
‘An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissu damage.’
Pain is described as chronic when it has lasted more than 3 months (National Institute for Health and Care Excellence (NICE), 2021). The term ‘chronic pain’ – sometimes known as long-term pain or persistent pain – can refer to a wide range of painful conditions. It can be secondary to an underlying condition such as osteoarthritis, rheumatoid arthritis, ulcerative colitis or endometriosis. Chronic pain can also be the primary injury, with no clear underlying condition, or the pain (or its impact) appears to be out of proportion to any observable injury or condition (NICE, 2021). Although ‘chronic pain’ is useful terminology for research studies, the term can cause confusion among patients and friction between health professionals and patients. Patients may fear that their daily pain is caused by a misdiagnosed condition (Raffaeli et al, 2021).
In the UK, chronic pain is estimated to affect one third to one half of the population (NICE, 2021). Despite chronic pain being a common complaint in health care, patients are still poorly managed, which can have major consequences for their quality of life, including depression and loss of employment (British Pain Society (BPS), 2018). Byma and Wheeler (2021) reported that nurses treated patients with chronic pain with more suspicion because they thought they were exaggerating their pain compared with those experiencing acute pain. Lack of appropriate support and services for chronic pain patients is a significant issue for the NHS (Betteridge and Johnson, 2019). Pain, particularly when chronic, has been identified as a global health issue (Carr et al, 2016).
More than 10 years ago, the Chief Medical Officer highlighted the difficulties facing healthcare staff in caring for patients with chronic pain and recommended that education on the subject should be included in all health professional curricula (Department of Health (DH), 2009). UK universities determine how much pain education to include in their curriculum (BPS, 2018). A survey into hours dedicated to pain education within undergraduate nursing found that, on average, there were 10.2 hours per programme, compared, for example, with 37.5 hours on physiotherapy education (Briggs et al, 2011).
The IASP has produced a free pain curriculum for healthcare disciplines to help develop undergraduate knowledge and skills to manage pain as part of an interprofessional team (IASP, 2018). However, despite this resource, pain education is allocated few hours in undergraduate health professional courses (BPS, 2018).
To understand current undergraduate education on chronic pain, a literature review was conducted using Medline and the author's university internal library catalogue database. Search terms used are listed in Box 1.
Box 1.Literature review search terms
- Chronic pain education
- Chronic pain/persistent pain/long-term pain
- Newly qualified nurses/new nurses/novice nurses/newly graduated nurses
- Nursing students/student nurse/undergraduate student nurses
- Undergraduate
- 2009−2022
Undergraduate nursing pain education
Use of the IASP undergraduate pain curriculum (originally produced in 2010 and updated in 2018) has been reported increasing health professional students' knowledge on the assessment and management of patients with chronic pain (Briggs et al, 2011). However the uptake of the IASP curriculum within the UK is unclear (Briggs et al, 2011). According to Briggs et al (2011), UK undergraduate adult nursing courses spend 13 hours on pain education on average, less than 1% of the total programme hours. An international review, including UK participants, concluded that undergraduate nursing pain education remained inadequate and students themselves were concerned about the lack of undergraduate pain education they received (Chow and Chan, 2015). Pain education programmes, when used, were found to be effective at improving nursing students' pain knowledge and attitudes (Chow and Chan, 2015). A systematic review (Cousins et al, 2022) into nursing students' knowledge and attitudes towards pain management over the past 20 years highlighted that students' pain knowledge was lacking and that they failed to have an appropriate attitude towards pain. The review highlighted the need for pain curricula to be based upon the IASP (2018) curriculum (Cousins et al, 2022).
Mackintosh-Franklin (2017) found that pain is not a specific aim or learning outcome of the taught modules of UK undergraduate nursing curricula. Similar to other healthcare disciplines, pain education is largely integrated throughout the programme rather than offered as standalone content (Briggs et al, 2011). This fragmented approach to pain education could lead to gaps in students' knowledge as they have to integrate learning from across different modules (Ung et al, 2016). The IASP (2018) interprofessional pain curriculum covers both acute and chronic pain. Undergraduate nurses may not have a particular interest or understanding of chronic pain when commencing their education. If not exposed to chronic pain education during their course they will qualify as nurses who lack knowledge that could affect their patients' treatment (Mackintosh–Franklin, 2017). Cousins et al's (2022) review found that nursing students did not recognise that a patient who was not grimacing was in pain, despite the patient reporting that they were in pain.
Carr et al's (2016) UK survey into the factors affecting inclusion of pain education in undergraduate curricula found that some challenges of inclusion are linked to the drive for more interprofessional education, which can be time-consuming and difficult to co-ordinate between different courses. An already overcrowded curriculum, and confusion over whether students were taught about pain in their clinical placements were also challenges (Carr et al, 2016). A limitation of this study is that only 19 UK universities were examined and, in some cases, it was difficult to extract the particular pain content of curricula because universities felt they had successfully integrated it into their programme, potentially biasing the results of the survey (Carr et al, 2016).
The IASP (2018) has provided a pain curriculum for interprofessional learning. However this could be difficult to translate into undergraduate courses because it does not describe the content or level of competency required at undergraduate level (van Lankveld et al, 2020). Pain curriculum at undergraduate level is often discipline specific. The IASP (2018) also provides discipline-specific pain curricula. For interprofessional collaboration to be successful, competencies for all disciplines need to be clearly defined (van Lankveld et al, 2020). The BPS (2018) has provided a UK guidance curriculum that complements the IASP (2018) interprofessional learning curriculum, which has core curriculum outcomes that all undergraduate health professional disciplines should achieve before registration. However, the level of uptake of this guidance is unclear.
International variances in pain education
Similar to the UK, in Canada, pain education in undergraduate nursing studies is incorporated throughout the programme, with a strong reliance on clinical placements (Carr et al, 2019). Clinical placements can expose students to multiple pain perspectives and attitudes. However these can be dependent upon the placement, how much exposure their clinical supervisor has had to chronic pain, and the clinical supervisor's own attitudes and knowledge, which could be outdated (Carr et al, 2019).
Student nurses in New Zealand were found to have misconceptions about patients' experiences of chronic non-malignant pain. Their undergraduate education was deemed to lack some pain content, particularly information on chronic pain (Shaw and Lee, 2010). New Zealand's undergraduate curricula for students studying to be a registered nurse requires focus on the Nursing Council's (NCNZ) competencies for the registered nurse's scope of practice (NCNZ, 2016). The competencies are broadly defined and similar to that of the UK's Nursing and Midwifery Council (NMC) (2018a) proficiencies; none of them are specific to chronic pain. However, curricula for New Zealand students studying to be an enrolled nurse specifies pain management as a practical topic to be studied (NCNZ, 2022).
Similar to the UK (Mackintosh-Franklin (2017), Campbell's (2020) US study found that pain education within undergraduate nursing tended to be integrated through programmes rather than taught as standalone content. Participants felt that only basic pain education was covered but struggled to see how it could be developed further in an already overcrowded curriculum (Campbell, 2020).
Nursing students in Canada, New Zealand and the USA all have to pass a national exam assessing their competencies as a newly registered nurse (NCNZ, 2017; National Council of State Boards of Nursing (NCSBN (USA), 2018; NCSBN (Canada) 2020). Some of the questions on the New Zealand and US exams can directly relate to pain assessment and management (NCSBN, 2018; NCNZ, 2023). The Canadian School of Nursing exam requires candidates to prove their competency in pain assessment, intervention and prevention (NCSBN, 2020). In comparison with the UK, the NMC (2018a) has produced standards of proficiencies that are applicable to all registered nurses. These proficiencies discuss pain, but there is no mention of chronic pain specifically, and there is no final regulatory body examination that students need to pass before being admitted on to the nursing register.
Teaching interventions
Pain education can be taught in many formats, including pain neurophysiotherapy education (PNE), which addresses some of 's (2018) learning outcomes (Colleary et al, 2017). PNE can improve patients' and clinicians' knowledge of chronic pain by using neurophysiological information to teach people that the pain they feel can be an ‘overprotective’ message from the brain as the original injury has healed. A 70-minute PNE session was found to increase UK and Ireland physiotherapy students' knowledge of chronic pain by 34% and caused a large positive change in attitudes towards patients with chronic pain (Colleary et al, 2017). However, because there was a lack of follow-up to assess retention of knowledge and attitudes, PNE would need to be further investigated.
A US study into newly registered nurses' experiences of managing patients' pain (Byma and Wheeler, 2021) reported that participants felt there was a practice-theory gap between what was taught at university versus the reality in clinical practice, particularly in relation to chronic pain management. Shaw and Lee (2010) found that students and nurses were often unaware of their own limited knowledge of chronic pain, and were often influenced by their colleagues' attitudes. Byma and Wheeler (2021) also found that other registered nurses influenced how newly registered nurses managed patients' pain because the registered nurses had previous clinical experience to provide context for their pain management plan, which newly registered nurses lacked.
Byma and Wheeler (2021) also reported on the importance of the relationship between the nurse and the rest of the multidisciplinary team (MDT) to provide effective pain management. Chronic pain management requires a holistic, multiprofessional approach (Briggs et al, 2011). However, newly registered nurses can sometimes feel reluctant to raise their concerns about a patient's pain management plan to other members of the MDT (Byma and Wheeler, 2021). Wilson et al (2021) found that when investigating interprofessional education activity on opioid use between pharmacy, medical, nursing, addiction study and social work undergraduate students, the students found interprofessional education to be valuable and it helped to prepare them for working collaboratively in an MDT. Interprofessional education promotes good communication and team collaboration, which is essential for providing patients with high-quality pain care (BPS, 2018).
The BPS (2018) guidance on how to incorporate pain education into pre-registration curricula for health professionals in the UK recommended a variety of teaching methods that have been used by their collaborators, including inviting patients living with chronic pain into the teaching environment to discuss their experience with students. Involving service users in undergraduate health professional training has been found to be helpful in developing students' communication skills and professional attitudes, particularly empathy (BPS, 2018). Providing students with an opportunity to appreciate the perspectives of patients with chronic pain has also been found to have a positive impact on their learning and future practice (Shaw and Lee, 2010).
Student assessment
Although the IASP (2018) has provided a curriculum for pain education it does not provide guidance on how undergraduates should be assessed on their knowledge and skills. There is disparity over the best way to evaluate students' knowledge of pain education (Ung et al, 2016). Ung et al (2016) conducted a literature review of 26 articles assessing nursing and medical students' knowledge of and attitude towards pain, and found the ‘Knowledge and Attitudes Survey Regarding Pain' (KASRP) originally created in 1987 and since updated (Ferrell and MacCaffery, 2014) was the most frequently used assessment tool. Although useful for assessing knowledge following pain education programmes, its original purpose was to measure the attitude and knowledge of professional caregivers on the subject of pain and not intended for assessing students' knowledge, but has been adapted for this use over time (Ferrell and MacCaffery, 2014). Despite the different evaluation tools used a common finding was students' poor knowledge of pain. For the KASRP (Ferrell and MacCaffery, 2014) assessment, the minimum pass rate is 80%, which none of the students achieved in Ung et al's study (2016). A lack of a formal pain curriculum within undergraduate education inhibits the ability to comprehensively assess students' knowledge with summative assessment strategies (Briggs et al, 2011).
Within clinical placements students are assessed by their practice assessors and supervisors with a practice assessment document (PAD). The way that PADs are split into sections covering aspects such as professional values and essential skills, could encourage student nurses to think about the care that they provide for chronic pain patients in a reductionist way rather than taking a holistic approach (Young et al, 2018).
Clinical placements
Nurses work regularly with patients who experience pain and are frequently responsible for co-ordinating and caring for patients with chronic conditions (Shaw and Lee, 2010). Exposure to patients with chronic pain gives students the opportunity to apply their theoretical knowledge to clinical situations (Briggs et al, 2015). However, students' clinical placements can vary from a hospital setting to the community, and there is a chance that a student will not be exposed to patients with chronic pain during their placement (Carr et al, 2016).
To complete a pre-registration nursing programme the student must complete 4600 hours of training, of which 2300 hours must be in a clinical setting (NMC, 2018b). Undergraduate nursing students are exposed to a wide set of clinicians' and individuals' views on pain from their clinical placement and there is no certainty that the information provided to them is the most up-to-date evidence-based practice. Nurses are required by The Code (NMC, 2018c) and revalidation (NMC, 2021) to continue to professionally update their knowledge and treat patients with the latest evidence-based practice post registration. The European Pain Federation (2019) provides a pain curriculum for a Diploma in Pain Nursing for registered nurses, but there is lack of financial support and time for nurses to complete mandatory training, let alone developmental training, often through university courses, for knowledge and career development (Royal College of Nursing, 2018). The impact of COVID-19 has also contributed to a reduction in the number of nurses continuing with their professional development (Dean, 2020).
Recommendations
From this review the author would recommend that chronic pain needs to be a specific learning outcome outlined within the nursing undergraduate module directory to be taught as a generic module, using the IASP pain curriculum (2018), to ensure that all undergraduate nursing students are exposed to the subject.
Theoretical knowledge could be assessed using the KASRP tool (Ferrell and MacCaffery, 2014; Ung et al, 2016). Depending on the format, this assessment could be embedded online within the student's virtual learning environment (VLE), thereby also providing a way to monitor their understanding and engagement with the topic. The use of online assessments has been linked to improvements in registered nurses' pain-management skills (Phillips et al, 2014).
The PAD should contain an essential skill specifically aimed at chronic pain. As noted earlier, learning exposure can vary depending on the clinical environment in which the student is placed. This skill could be achieved by the student discussing chronic pain with affected patients or seeking outreach exposure with chronic pain nurses within a clinical placement (Shaw and Lee, 2010; Liljedahl et al, 2015).
The literature suggests that chronic pain education should take an interprofessional approach (Carr et al, 2016; IASP, 2018). In order to achieve this, undergraduate healthcare programmes should have a member of staff designated to lead on interprofessional learning within their university. The IASP pain curriculum (2018) is a free resource that can be used to guide the curriculum. Service users should be invited to share their experiences with students (BPS, 2018). Further research into how chronic pain education is incorporated into undergraduate nursing programmes and the factors that affect its delivery within UK universities is required.
Limitations
As Carr et al (2016) discussed, a limitation to this review could be that chronic pain is so integrated within the undergraduate nursing curriculum that it is hard for lecturers to extract and understand the amount of teaching time that specifically discusses it. A further limitation similar to that found by Ung et al (2016) is that the literature reviewed either discussed pain in general or a subset of pain, such as chronic lower back pain, rather than chronic pain as a topic. Due to the difficulty in finding literature that discusses chronic pain education some of the literature used is dated and may not reflect current practice.
Conclusion
Despite chronic pain being an issue that affects patients globally, it still remains a topic that is insufficiently covered in health professionals' undergraduate education. There is some disagreement about whether chronic pain education is covered theoretically within the university setting, or whether students are expected to be educated on this within their clinical placements. Some students may not be exposed to chronic pain clinically as placements and clinicians' own knowledge on the subject can vary.
The IASP (2018) has produced guidelines for a curriculum on chronic pain but how much these guidelines have been used and how chronic pain education is taught has varied between UK universities. The guidance does not suggest an assessment method and currently undergraduate nursing students are assessed by their university lecturers and by health professionals in the clinical setting.
This review recommends that chronic pain needs to be specifically defined as a learning outcome for a generic undergraduate nursing module to ensure that all students are exposed to it. Theoretical assessment of knowledge could be assessed with the KASRP tool (Ferrell and MacCaffery, 2014). The PAD should specify an essential skill that demonstrates students' clinical skills when nursing patients with chronic pain. Chronic pain education should have an interprofessional approach, and there should be a designated leader on interprofessional education within universities.
This review has some limitations, such as the inclusion of dated literature. It is possible that chronic pain education is so integrated in undergraduate nursing programmes that it is difficult to understand the exact amount of teaching on the subject. More research is required into what factors are negatively affecting undergraduate education of nursing students on chronic pain and how to overcome them within UK universities.
KEY POINTS
- Treating patients with chronic pain can be difficult; it is recommended that chronic pain is covered within the undergraduate curricula of all healthcare courses
- The International Association for the Study of Pain (2018) has provided a free pain education curriculum for undergraduate healthcare courses. This resource does not provide guidance on how to assess students' knowledge
- A variety of factors affect the provision of pain education for undergraduate nurses, in particular on chronic pain, for example: confusion about whether it is taught by the university or by health professionals in a clinical placement; difficulty in including interprofessional learning in the curriculum; and disparity on how to assess a student's knowledge of pain education
- This review recommends that chronic pain needs to be specifically defined as a learning outcome with a recognised assessment on a generic undergraduate nursing module to ensure all students are exposed to it
CPD reflective questions
- What education and training have you received on chronic pain and its management? This could have been before or after you qualified. Is the education you received still current?
- Think about a patient with chronic pain for whom you have cared. How did you manage this patient? Did your nursing education adequately prepare you?
- When you work with students how do you educate them? Is it based on training that you have attended? Is this still current? Or do you base the education on your own clinical experience?