Knowledge and attitudes of pain management by nurses in Saudi Arabian emergency departments : a mixed methods investigation

Upon arrival at the Emergency Department, nurses are typically the first healthcare providers whom patients encounter. Throughout the patient’s stay, registered nurses play the greatest role in pain management. This important role in managing pain is the focus of the present research project, which was set in the Emergency Department in the Kingdom of Saudi Arabia, where there is an absence of mixed methods research regarding nurses’ pain management. The research project investigated nurses’ knowledge and attitudes; barriers and facilitators to optimal pain management; and the influence of these upon pain management for patients who present to the Emergency Department in Saudi Arabia. A two-phase, sequential explanatory mixed methods design with quantitative emphasis was chosen. During Phase 1, a descriptive cross-sectional survey was distributed to 1440 ED nurses at 12 hospitals located in four Saudi Arabian cities, to which 629 valid responses were received, a response rate of 43.6%. In Phase 2, semi-structured interviews were conducted with a sub-group drawn from survey participants. Both data sets were analysed individually and then brought together to probe and better understand the survey findings in greater depth. Analysis of findings from Phase 2 indicated that, to a certain extent, interview participants relied on knowledge of best practice regarding pain management. Thus, in some instances, patients received adequate pain management in the ED. However, Phase 2 interview participants’ descriptions of their pain management practice also indicated the influence of numerous myths and misconceptions about pain and its management, and some pain management was therefore sub-optimal. As well, although participants revealed some positive attitudes in the interviews, they also described ways their practice was influenced by negative attitudes towards patients. For example, a commonly reported perception amongst interview participants was that numerous patients attending the Emergency Department over-report their pain and that in some such cases participants noted that they would deliberately withhold patient care and would not administer prescribed analgesia. Integrated analysis of Phase 1 results and Phase 2 findings revealed five key findings. These were: (1) participants prioritised ‘reading’ the way their patients reported their pain as a way to define such reports in terms of their perceived truthfulness; (2) participants were more likely to base their pain management on best practice for patients whom they perceived as truthful in their pain reports; (3) Emergency Department nursing unit cultures that supported participants to make clinical decisions based on intuition and accepted practice within the unit, even when such decisions were contrary to best practice; (4) participants may be at risk for both frustration and compassion fatigue, possibly due to the challenges of caring for patients with high pain levels in the emergency setting; and (5) participants tended to over-identify patients with pain as possible substance abusers and preferred to under-administer opioids, and that these practices apparently stemmed from a lack of clarity regarding best practice in the use of opioid analgesia. Recommendations for improvements in pain management arising from this research project include: for clinical practice, the development and consistent use of triage and pain assessment tools that include not only triage acuity levels but also emphasise the primacy of patient self-report of pain and pain intensity, and the development of standard protocols for pain management according to best practice guidelines; for education, the provision of ongoing short-course pain management education to ensure that all Emergency Department nurses have accurate, up-to-date knowledge and are made aware of misconceptions with respect to patients and analgesia as these can adversely affect optimal pain management. Finally, recommendations for further research are to develop operational definitions of nurses’ knowledge and attitudes regarding pain, and to design studies to test educational interventions aimed at reinforcing correct nursing knowledge while correcting misconceptions, and influencing nurses’ attitudes toward a more uniformly positive and empathetic view of patients in pain, in keeping with nursing’s core values