Nurses' Knowledge of Pain Assessment ... - SAGE Journals

CLINICAL Coyne et al. NURSING / NURSES’ RESEARCH KNOWLEDGE / MayOF 1999 PAIN MANAGEMENT

This study compared differences in knowledge of pain assessment and pharmacologic and nonpharmacologic pain management strategies among 232 L.P.N.s and R.N.s from three hospitals. Twenty-three adult medical, surgical, and special care units were represented. The “Knowledge of Pain Management” tool measured knowledge of pain assessment, drug and nondrug strategies, and was based on AHCPR guidelines. Scores ranged from 24% to 92%. There were significant differences in scores across hospitals and between R.N.s and L.P.N.s. The mean score was 72% for L.P.N.s and 75% for R.N.s. There was a significant difference in pharmacologic scores between L.P.N.s versus A.D./A.A.-R.N.s, B.S.N-R.N.s, and M.S.N.-M.S.-R.N.s but not between L.P.N.s and diploma-R.N.s. There were significant differences in overall knowledge scores between L.P.N.s versus B.S.N.-R.N.s but not A.D./A.A.-R.N.s, diploma-R.N.s, and M.S.N./M.S-R.N.s. Findings suggest the need for aggressive nursing education programs offered in academic and clinical settings to assist nurses in effectively managing the universal phenomenon of pain.

Nurses’ Knowledge of Pain Assessment, Pharmacologic and Nonpharmacologic Interventions MARY LOUISE COYNE BONITA REINERT KAY CATER WANDA DUBUISSON JANE F. H. SMITH MADELYN M. PARKER CYNTHIA CHATHAM University of Southern Mississippi

Although surgical patients expect health providers to accurately assess and effectively manage their pain, less than 50% of CLINICAL NURSING RESEARCH, Vol. 8 No. 2, May 1999 153-165 © 1999 Sage Publications, Inc.

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patients report experiencing adequate pain management during their postoperative period (Agency for Health Care Policy and Research [AHCPR], 1992a, 1992b). The general public assumes, and patients hope, that nurses and physicians, by virtue of their education and experience, possess a comprehensive knowledge of pain management that is readily translated into clinical practice. To honor the public’s trust and effect positive patient outcomes, health professionals and educational institutions are committed, on an ongoing basis, to examine their knowledge base and practice patterns related to pain management to ensure that they are congruent with current standards of practice and reflect innovative approaches obtained from clinical research studies. Knowledge deficits are inevitable in an evolving science and, although initially disconcerting, provide future directions for professional growth and development for nurses and curricular revisions for nursing programs. Pain is a universal patient phenomenon. Likewise, effective pain management should be a universal response by health professionals. Standards of clinical practice contained in Acute Pain Management in Adults: Operative Procedures have been established by the Agency for Health Care Policy and Research (AHCPR, 1992a, 1992b) provide research-based insight into how individual health professionals and health care agencies may maximize pain management and minimize iatrogenic factors contributing to ineffective pain control. Essential components of these guidelines include knowledge of the nature of pain; various assessment tools that capture the patient’s pain experience; the frequency of monitoring pain and pain relief patterns; the types, use, and timing of nonsteroidal antiinflammatory and opioid agents; and the types, uses, and benefits of nonpharmacological interventions as adjunctive therapy. These guidelines provide a basis for sound clinical decision making. Authors’ Note: Acknowledgment of colleagues at The University of Southern Mississippi include Lindy Hoover, M.S., R.N., C., C.N.S., nurse educator, Memorial Hospital at Gulfport, Gulfport, MS, and Rebecca Clark, B.S.N., R.N., graduate student, Community Health Program. Funding was provided by Gamma Lambda Chapter, Sigma Theta Tau International. Reprint requests should be addressed to Mary Louise Coyne, College of Nursing, University of Southern Mississippi, Long Beach, Mississippi 39560.

Coyne et al. / NURSES’ KNOWLEDGE OF PAIN MANAGEMENT

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Pain management education is lacking in schools of nursing and medicine. Frankel (1998) reported that 40% of recent U.S. medical school graduates indicated that they received no instruction in pain management during medical school and had limited clinical experience in managing patients experiencing acute or chronic pain. Ferrell (as cited in Batten, 1995) estimated that during 1995, top U.S. medical schools dedicated 1 hour to pain content, whereas top U.S. nursing schools had 3.9 hours of pain management content in the curricula. Watt-Watson and Watson (as cited in Ferrell, McGuire, & Donovan, 1993) found that 48% of Canadian nursing schools reported that pain content in the curricula ranged from zero to 3.5 total hours and 78% of Canadian medical schools reported minimal to no pain-related content in the curricula. Several authors posit that schools of nursing have not adequately educated nurses to comprehensively assess, critically analyze, and make sound clinical decisions about pain management (Ferrell et al., 1993; Ferrell, Whedon, & Rollins, 1995; McDonald, 1993; Zalon, 1995). Graffam (1990) noted that less than 8% of schools of nursing employed faculty members possessing advanced knowledge and expertise in pain management. Knowledge deficits regarding pain management occur in clinical settings and are well documented (AHCPR, 1992a, 1992b; Ferrell, McCaffery, & Ropchan, 1992; Gujol, 1994; Jacox, Ferrell, Heidrich, Hester, & Miaskowki, 1992; McCaffery & Ferrell, 1996; McCaffery, Ferrell, O’Neil-Page, & Lester, 1990). Coyne, Smith, Stein, Hieser, and Hoover (1998) surveyed patterns of pain management on a postsurgical unit and concluded that nurses demonstrated wide variations in the implementation of pain assessment and management strategies. These authors found that nurses, within and across shifts, used different pain assessment tools with the same patient, and reassessment of pain was either randomly conducted or randomly recorded. Management approaches used by nurses were limited to pharmacological versus nonpharmacological interventions and selection of analgesics did not correspond with patients’ self-report of pain intensity. According to the literature, failure to assess and document pain and pain relief patterns, knowledge deficits regarding pharmacological and nonpharmacological pain reduction interventions, and fear of addiction have contributed to the undertreatment of acute pain

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by nurses (American Pain Society, 1992; Jackson, 1995; Jacox et al., 1992; McCaffery et al., 1990). Wallace, Graham, Ventura, and Burke (1997) examined the effect of a pain management education program on the knowledge level and attitudes toward pain management among 17 registered and licensed practical nurses in an acute care setting. AHCPR pain guidelines for clinical practice served as the basis for the education program. Findings revealed no significant differences in knowledge of and attitudes toward pain management within or between different types of providers following a pain management education program. Although some research provides insight into nurses’ preparedness and knowledge of pain management, these studies have been limited by sample size and single settings of care. The purpose of this study was to compare differences in knowledge of pain assessment and pharmacologic and nonpharmacologic pain management strategies among 232 medical and surgical nurses from three acute care hospitals in Southern Mississippi. The study addressed the following questions: “Is there a difference among nurses’ knowledge of pain management, by type of licensure status?” and “Is there a difference among nurses’ knowledge of pain management, by type of nursing education?”

METHOD DESIGN

A nonexperimental design and descriptive-comparative approach were used to examine differences in knowledge of pain assessment, pharmacologic pain management strategies, and nonpharmacologic pain management strategies among registered and licensed practical nurses from three hospitals. Subjects were selected using a nonprobability, convenience sampling plan. SAMPLE AND SETTING

The sample for this study consisted of 232 medical and surgical nurses from three hospitals. Each participant met the following eligibility criteria: licensed as a registered nurse (R.N.)


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or licensed practical nurse (L.P.N.) in Mississippi, employed on a full-time or part-time basis, and provided direct nursing care to adult patients. The study was conducted in 23 adult medical, surgical, and special care inpatient units across three acute care hospitals located in southern Mississippi. A profile of the units participating in the study is as follows: Hospital A, a private, for-profit facility, had six units comprising 160 inpatient beds; Hospital B, a public, nonprofit facility, had nine units totaling 249 inpatient beds; and Hospital C, a public, nonprofit facility, had eight units comprising 152 inpatient beds. Three hospitals were selected to obtain an adequate sample size representative of nursing staff mix, that is, L.P.N.s and R.N.s, providing direct care to adult patients on medical and surgical units. PROCEDURE

Prior to conducting the study, approval was obtained from the Human Subjects Protection Review Committee (HSPRC) at The University of Southern Mississippi and the Institution Review Board at each hospital. A member of the research team provided an oral and written presentation concerning conditions of participation in the study to groups of interested nurses from each of the selected units. At the end of the oral presentation, the researcher invited nurses to participate in the study, entertained questions, distributed questionnaires to interested persons, notified subjects that a private room near the unit was available for completion of the questionnaire, and directed participants to deposit completed questionnaires in a secured box labeled “Pain Questionnaires” located on the unit. At the end of the shift, the researcher collected questionnaires from each of the units. All of the distributed questionnaires were returned, and one was not completed. Completion of the questionnaire was construed as willingness to participate in the study. INSTRUMENTATION

The “Knowledge of Pain Management” questionnaire (Coyne et al., 1998) was based on AHCPR guidelines and was used in this study. Section I contains demographic questions regarding participants’ age, unit, and level of nursing education.

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Section II contains a 50-item tool with true-false and multiplechoice responses that measure three major concepts pertinent to effective pain management: nurses’ knowledge of pain assessment (10 questions), nurses’ knowledge of pharmacologic interventions pertinent to pain management (30 questions), and nurses’ knowledge of nonpharmacologic interventions pertinent to pain management (10 questions). In the pain assessment section, nurses are queried regarding their knowledge of the prevalence of pain, reliable indicators of pain and pain assessment, and frequency of conducting pain assessments. In the pharmacologic section, questions address nurses’ knowledge of the purpose, actions, side effects, contraindications, and standards of practice regarding the use of nonsteroidal anti-inflammatory agents (NSAIDs) and opioids. In the nonpharmacologic section, nurses are asked questions about the use of various types of cognitive-behavioral techniques and physical agents used in pain management. The instrument was pilot tested prior to use in this study. The entire tool took approximately 20 minutes to complete. STATISTICAL ANALYSES

Demographic data were summarized, using descriptive statistics. A traditional grading system was used to interpret scores from the “Knowledge of Pain Management” questionnaire: (a) 90-100 indicated superior knowledge of the topic, (b) 80-89 indicated excellent knowledge of the topic, (c) 70-79 indicated average knowledge of the topic, and (d) 60-69 indicated inferior knowledge of the topic. Data derived from the “Knowledge of Pain Management” portion of the questionnaire were analyzed using analysis of variance (ANOVA). Tukey’s HSD multiple comparison test was used to identify specific group differences. Levene’s test was used to examine homogeneity of group variances. The level of significance for all tests was p ≤ .05. RESULTS The majority of participants (64%) were between the ages of 20 and 41 years, 88% (n = 200) were employed on a full-time basis, 45 subjects (19%) were L.P.N.s and 187 (81%) were R.N.s. The highest level of nursing educational preparation for


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Table 1 Demographic Profile of Participants by Hospital Hospital Characteristics Age category 20-30 31-41 42-52 53-63 64+ Licensure type Licensed practical nurse Registered nurse Employment status Full-time Part-time Highest degree L.P.N. R.N.: Diploma R.N.: A.A. or A.D. R.N.: B.S.N. R.N.: M.S. or M.S.N.

A

B 25 31 30 11 3

(25.0) (31.0) (30.0) (11.0) (3.0)

Total

13 (28.8) 26 (50.0) 8 (15.4) 2 (3.8) 1 (1.9)

22 29 20 7 0

15 (28.8) 37 (71.2)

17 (21.3) 63 (78.8)

13 (13.0) 87 (87.0)

45 (19.4) 187 (80.6)

49 (96.1) 2 (3.9)

70 (90.9) 6 (7.8)

81 (81.0) 19 (19.0)

200 (87.7) 27 (11.8)

15 0 19 17 1

17 (21.3) 3 (3.8) 29 (36.3) 31 (38.8) 0 (0)

13 6 38 34 9

(28.8) (0) (36.5) (32.7) (1.9)

(28.2) (37.2) (25.6) (9.0) (0)

C

(13.0) (6.0) (38.0) (34.0) (9.0)

60 86 58 20 4

45 9 86 82 10

(27.0) (37.4) (25.2) (8.7) (1.7)

(19.4) (3.9) (37.1) (35.3) (4.3)

NOTE: Entries are frequencies and percentages are in parentheses. A.A. = Associate of arts; A.D. = Associate degree; B.S.N. = Bachelor of science in nursing; L.P.N. = Licensed practical nurse; M.S. = Master of science; M.S.N. = Master of science in nursing; R.N. = Registered nurse.

the R.N. sample was as follows: 9 (3.9%) were prepared at the diploma level, 86 (37%) were prepared at the associate degree (A.D./A.A.) level, 82 (35%) at the bachelor of science in nursing (B.S.N.) level, and 10 (4%) at the master’s in nursing (M.S.N./M.S.) level. A demographic profile of participants by hospital is found in Table 1. KNOWLEDGE SCORES BY HOSPITAL

An analysis of variance (ANOVA) revealed no significant differences among hospitals in “Knowledge of Pain Assessment” scores and “Knowledge of Pharmacologic Pain Management” scores. There was a significant difference in “Knowledge of Nonpharmacologic Pain Management” scores among hospital groups, F (2, 231) = 28.187, p = .000. Findings from a Tukey’s HSD analysis procedure indicated that the significant difference in “Knowledge of Nonpharmacologic Pain Management”

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Table 2 Summary of “Knowledge of Pain Management” Scores by Type of Licensure Type of License L.P.N. (n = 45) R.N. (n = 187) Knowledge Scores Pain assessment scores Number of correct responses Percentage of correct responses Pharmacologic pain management scores Number of correct responses Percentage of correct responses Nonpharmacologic pain management scores Number of correct responses Percentage of correct responses Overall knowledge of pain management scores Number of correct responses Percentage of correct responses

Mean (SD)

Mean (SD)

6.6 (1.4) 66.0

6.9 (1.5) 69.0

20.5 (3.6) 68.2

22.5 (2.6) a 74.9

8.0 (1.2) 80.3

8.5 (1.1) b 85.1

35.9 (3.3) 71.8

37.9 (3.8) c 75.1

a. t(230) = –4.362, p = 0.000. b. t(189) = –2.189, p = 0.030 c. t(189) = –2.938, p = 0.004

scores existed between Hospital B versus Hospitals A (p = .000) and C (p = .000); that is, Hospital B had lower scores than did Hospitals A and C. There was also a significant difference in “Overall Knowledge of Pain Management” scores among hospital groups, F (2, 231) = 8.316, p = .000. Tukey’s HSD analysis procedure indicated that the significant difference in “Overall Knowledge of Pain Management” scores was between Hospital B versus Hospital A (p = .025) and C (p = .000); that is, Hospital B had significantly lower scores than Hospitals A and C. KNOWLEDGE SCORES BY LICENSURE

Table 2 provides a summary of “Knowledge of Pain Management” scores by type of licensure. There was no significant difference in “Knowledge of Pain Assessment” scores between R.N. and L.P.N. groups, t(230) = –1.162, p = 0.246. The R.N. group did score significantly higher than L.P.N.s in the following: (a) “Knowledge of Pharmacologic Pain Management,” t(230) = –4.362, p = 0.000, (b) “Knowledge of Nonpharmacologic Pain Management,” t(189) = –2.189, p = 0.030, and (c) “Overall Knowledge of Pain Management,” t(189) = –2.938, p = 0.004.


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KNOWLEDGE SCORES BY EDUCATION

An analysis of variance (ANOVA) revealed no significant differences in “Knowledge of Pain Assessment” scores among L.P.N., diploma-R.N., A.D./A.A.-R.N., B.S.N.-R.N., and M.S.N./M.S.-R.N. groups, F(4, 231) = 0.990, p = .414, and “Knowledge of Nonpharmacologic Pain Management” scores among these groups, F(4, 190) = 1.740, p =.143. In contrast, there were significant differences in “Knowledge of Pharmacologic Pain Management” scores, F(4, 231) = 6.175, p =.000, and ”Overall Knowledge of Pain Management” scores among education groups, F(4, 190) = 3.211, p = .014. Tukey’s HSD analysis yielded a significant difference in “Knowledge of Pharmacologic Pain Management” scores between the L.P.N. group versus the A.D./A.A.-RN group (p =.005), B.S.N.-R.N. group (p = .000), and M.S.N./M.S.-R.N. group (p = .002); that is, the L.P.N. group had lower scores than these educational groups. When the scores were broken down by R.N. educational level there were no significant differences in “Knowledge of Pharmacological Pain Management” scores between the L.P.N. group and the diploma-R.N. group (p = .870). A Tukey’s HSD analysis procedure indicated that the significant difference in “Overall Knowledge of Pain Management” scores existed between the L.P.N. group versus the B.S.N.-R.N. group (p = .028); that is, the L.P.N. group had lower scores than the B.S.N.-R.N. educational group. There were no significant differences in “Overall Knowledge of Pain Management” scores when comparing the L.P.N. group with the diploma-R.N. group (p = .995), the A.D./A.A.-R.N. group (p = .095), and the M.S.N./M.N.-R.N. group (p = .107). A multiple comparison of differences among means by type of nursing education is provided in Table 3. ITEM ANALYSIS

An item analysis revealed that 17 items were missed by 33% to 46% of the participants and 9 items were missed by 50% to 70% of the participants (Table 4). The largest percentage of missed items were in the pain assessment section of the tool. Two items were missed by 70% of the subjects. These items included, “Demerol produces clinical analgesia for at least 4-6 hours” (True or False) and “If opioid analgesia is going to be needed for 48 hours, morphine should be ordered___” (every 4

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Table 3 Multiple Comparison of Differences Among Means by Type of Education

Mean L.P.N. Scores

Diploma-R.N. Mean Diff. (p)

Assessment –0.51 Pharmacologic –0.98 Nonpharmacologic 3.30 Overall 0.68

(0.895) (0.870) (1.000) (0.995)

A.D./A.A. Mean Diff. (p) –0.26 –1.75 –0.50 –1.90

(0.891) (.005)* (0.239) (0.095)

B.S.N. Mean Diff. (p) –0.40 –2.22 –0.45 –2.28

M.S.N./M.S. Mean Diff. (p)

(0.632) 0.40 (0.947) (.000)* –3.53 (.002)* (0.353) –0.87 (0.225) (0.028)* –3.22 (0.107)

NOTE: Mean Diff. = Mean difference from mean L.P.N. score. *p ≤ .05.

Table 4 Item Analysis of Percentage of Missed Questions Percentage of Missed Questions Knowledge of Pain Subscales Pain assessment subscale Items 1-10 Pharmacologic subscale Items 11-40 Nonpharmacologic subscale Items 41-50

1 3

Missed

1 2

Missed

6 (60%)

2 (20%)

8 (27%)

5 (17%)

3 (30%)

2 (20%)

hours or PRN). Many items that were missed related to effects and side effects of medications.

DISCUSSION AND IMPLICATIONS Although acute pain often has a protective function, persistent and unrelieved pain can result in exhaustion, suffering, and debilitation. Review of the literature has shown that the cornerstone of pain management is a strong clinical knowledge base composed of three general areas: pain assessment techniques, pharmacologic pain management strategies, and nonpharmacological management strategies. Despite major breakthroughs in pain management, the literature suggests that undertreatment or ineffective treatment of pain remains a critical problem for hospitalized patients. Furthermore, questions have been raised about the adequacy of nurses’ pain


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management knowledge. Four major findings emerged from this study. Overall knowledge of pain management scores ranged from 24% to 92%, and there were significant differences in these scores across hospitals and between R.N.s and L.P.N.s. Second, there was a significant difference in knowledge of pharmacologic pain management scores between the L.P.N. group versus the A.D./A.A.-R.N. group, the B.S.N.-R.N. group, and M.S.N./M.S.-R.N. group, but not between the L.P.N. group and diploma-R.N. group. Third, there were significant differences in overall knowledge of pain management scores between the L.P.N. group versus the B.S.N.-R.N. group but not the A.D./A.A.-R.N., diploma-R.N., and M.S.N./ M.S.-R.N. groups. Last, the mean knowledge of pain management score was 72% for L.P.N.s and 75% for R.N.s. Scores in the 72% to 75% range indicate that nurses answered one out of four questions incorrectly, although there was not a pattern of missed questions in any section. Although nurses are in a unique position to assess and reverse the deleterious effects of pain, findings from this study suggest that both L.P.N.s and R.N.s possess less than adequate knowledge of pain assessment and management strategies. An unexpected finding that emerged during data analysis was a significant difference in knowledge of nonpharmacological pain management strategies across hospitals. Additional exploration is needed to explain why this difference occurred. Future research may examine the impact of part-time versus full-time employment status on nurses’ knowledge of pain management. AHCPR Pain Management Guidelines (1992a) indicate that effective pain assessment and management strategies must be rooted in scientific knowledge and research and systematically applied in the nursing care of patients. Without such a foundation, staff efforts to treat pain may become sporadic, ineffectual, or both. Patients who are ineffectively treated for pain become stressed, anxious, physiologically compromised, and emotionally dissatisfied with their care. Comprehensive pain management education must begin in academic settings. Nursing and medical curricula must reflect a commitment to aggressively educate students in understanding the universal patient phenomenon of pain, unique expressions of pain by each patient, variances in pain manifestations,

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and the judicious use of pharmacological and nonpharmacological strategies to eliminate or at least effectively manage pain. Faculty members possessing expertise in pain management must provide students with didactic and clinical experiences in caring for patients experiencing acute and chronic pain. Curricular attentiveness to pain management education, including assessment, pharmacology, and nonpharmacological interventions, must occur regardless of the length of nursing programs. Pain education must not be limited to educational settings or curtailed upon graduation. Ongoing pain education for nurses and physicians must also occur within clinical settings. Specialized education programs must be offered to ensure that these clinicians understand the pain experience and current research-based standards of practice. Both nurses and physicians must understand that ineffective pain management is not an acceptable patient outcome.

REFERENCES Agency for Health Care Policy and Research. (1992a). Acute pain management: Operative or medical procedures and trauma. Clinical practice guidelines (AHCPR Publication No. 92-0032). Rockville, MD: Department of Health and Human Services. Agency for Health Care Policy and Research. (1992b). Acute pain management: Operative or medical procedures and trauma. Quick reference guide for clinicians (AHCPR Publication No. 92-0019). Rockville, MD: Department of Health and Human Services. American Pain Society. (1992). Principles of analgesic use in the treatment of acute and cancer pain (3rd ed.) [Booklet]. Skokie, IL: Author. Batten, M. (1995, January/February). Taking charge of your pain. Modern Maturity, pp. 35-37, 80-81. Coyne, M. L., Smith, J.F.H., Stein, D., Hieser, M. J., & Hoover, L. (1998). Describing pain management documentation. MEDSURG Nursing, 7(1), 45-51. Ferrell, B., McCaffery, M., & Ropchan, R. (1992). Pain management as a clinical challenge for nursing administration. Nursing Outlook, 40(6), 263-268. Ferrell, B. R., McGuire, D. B., & Donovan, M. I. (1993). Knowledge and beliefs regarding pain in a sample of nursing faculty. Journal of Professional Nursing, 9(2), 79-88. Ferrell, B., Whedon, M., & Rollins, B. (1995). Pain and quality assessment/improvement. Journal of Nursing Care Quality, 9(3), 69-85. Frankel, D. (1998, May 2). Pain management poorly taught in USA. Lancet, 351(9112), 1334.


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Graffam, S. (1990). Pain content in the curriculum: A survey. Nurse Educator, 15, 20-23. Gujol, M. C. (1994). A survey of pain assessment and management practices among critical care nurses. American Journal of Critical Care, 3(2), 123-128. Jackson, A. (1995). Acute pain: Its physiology and the pharmacology of analgesia. Nursing Times, 91(16), 27-28. Jacox, A., Ferrell, B., Heidrich, G., Hester, N., & Miaskowki, C. (1992). A guideline for the nation: Managing acute pain. American Journal of Nursing, 92(5), 49-55. McCaffery, M., & Ferrell, B. R. (1996). Correcting misconceptions about pain assessment and use of opioid analgesics: Educational strategies aimed at public concerns. Nursing Outlook, 44(4), 184-190. McCaffery, M., Ferrell, B., O’Neil-Page, E., & Lester, M. (1990). Nurses’ knowledge of opioid analgesic drugs and psychological dependence. Cancer Nursing, 13(1), 21-27. McDonald, D. D. (1993). Post-operative narcotic analgesic administration. Applied Nursing Research, 6(3), 106-110. Wallace, K. G., Graham, K. M, Ventura, M. R., & Burke, R. (1997). Lessons learned in implementing a staff education program in pain management in the acute care setting. Journal of Nursing Staff Development, 13(1), 24-31. Zalon, M. L. (1995). Pain management instruction in nursing curricula. Journal of Nursing Education, 34(6), 262-267.

Mary Louise Coyne, D.N.Sc., R.N., C.S., is an associate professor at the College of Nursing, University of Southern Mississippi. Bonita Reinert, Ph.D., R.N., is an associate professor at the College of Nursing, University of Southern Mississippi. Kay Cater, M.N., R.N., is an instructor at the College of Nursing, University of Southern Mississippi. Wanda Dubuisson, M.N., R.N., is an assistant professor at the College of Nursing, University of Southern Mississippi. Jane F. H. Smith, B.S.N., R.N., is a graduate student in the Adult Health Program, University of Southern Mississippi. Madelyn M. Parker, B.S.N., R.N., C., is a graduate student in the Family Nurse Practitioner Program, University of Southern Mississippi. Cynthia Chatham, R.N.C., D.S.N., is an associate professor at the College of Nursing, University of Southern Mississippi.