International Emergency Nursing 23 (2015) 75–80
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International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
Emergency nurses’ knowledge, attitude and clinical decision making skills about pain Meral Ucuzal PhD (Assistant Professor) a,*, Runida Doğan Msc (Nursing) b a b
Malatya School of Health, Inonu University, Campus 44280, Malatya, Turkey Health, Culture and Sport Department, Inonu University, Campus 44280, Malatya, Turkey
A R T I C L E
I N F O
Article history: Received 4 July 2014 Received in revised form 23 November 2014 Accepted 25 November 2014 Keywords: Pain Knowledge Attitude Skills Clinical decision-making Emergency Nurse
A B S T R A C T
Introduction: Pain is the most common reason that patients come to the emergency department. Emergency nurses have an indispensable role in the management of this pain. Aim: The aim of this study was to examine emergency nurses’ knowledge, attitude and clinical decisionmaking skills about pain. Methods: This descriptive study was conducted in a state and a university hospital between September and October 2012 in Malatya, Turkey. Of 98 nurses working in the emergency departments of these two hospitals, 57 returned the questionnaires. The response rate was 58%. Data were collected using the Demographic Information Questionnaire, Knowledge and Attitude Questionnaire about Pain and Clinical Decision Making Survey. Frequency, percentage, mean and standard deviation were used to evaluate data. Results: 75.4% of participant nurses knew that patients’ own statement about their pain was the most reliable indicator during pain assessment. Almost half of the nurses believed that patients should be encouraged to endure the pain as much as possible before resorting to a pain relief method. The results also indicate that most of nurses think that a sleeping patient does not have any pain and pain relief should be postponed as it can influence the diagnosis negatively. It is determined that the pain scale was not used frequently. Only 35.1% of nurses reported keeping records of pain. Conclusion: Despite all the recommendations of substantial past research the results of this study indicate that emergency nurses continue to demonstrate inadequate knowledge, clinical decision-making skills and negative attitudes about pain. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Pain is a common symptom in many emergency department cases. However, patients may be discharged either with unchanged or increased levels of pain (Berben et al., 2008; Todd et al., 2007). A previous study conducted in Turkey reported that all adult trauma patients admitted to the emergency department experienced pain, with 51.7% of them describing their pain as very severe and 62.9% indicating that they still had pain despite treatment (Eti Aslan et al., 2008). Effective pain management requires accurate knowledge, positive attitudes, and clinical decision-making skills about pain (Kuzeyli Yıldırım et al., 2008). Many nurses gain their perceptions about pain from their knowledge. However, knowledge deficits in this area of practice may yield negative attitudes that can interfere with their clinical decision-making skills and add to the complexity of the pain management issue (El-Rahman et al., 2013; Young et al., 2006).
* Corresponding author. Malatya School of Health, Inonu University, Campus 44280, Malatya, Turkey. Tel.: +90 (422) 341 02 20/1127; fax: +90 (422) 341 02 19. E-mail address: [email protected] (M. Ucuzal). http://dx.doi.org/10.1016/j.ienj.2014.11.006 1755-599X/© 2014 Elsevier Ltd. All rights reserved.
Incorrectly evaluating pain as less severe than it is, believing that the patient exaggerates his/her pain, lack of knowledge regarding pain medications, concerns regarding addiction, beliefs that pain treatment would delay the diagnostic tests, and effects of age and gender result in inadequate pain management in emergency departments (Wheeler et al., 2010). Furthermore, effective pain management in emergency departments is hampered by reasons including concerns that it could mask primary symptoms and cause respiratory depression, not adopting multidisciplinary team work, and a lack of widespread use of new pain control methods (Eren Çevik et al., 2011; Eti Aslan et al., 2008; Karaçay et al., 2006). In previous studies on this subject, emergency nurses stated that a lack of knowledge about pain assessment and relief, lack of time, inadequate pain management until after a diagnosis was obtained, and a patient’s use of alcohol or other stimulant substances were important factors that hampered pain management (Duignan and Dunn, 2009; Tanabe and Buschmann, 2000). Nurses have an indispensable role in providing effective pain management. The important factors that differentiate nurses in pain control from the other team members are that nurses have learned patients’ previous pain experiences and methods to deal with pain and use them when necessary, they spend more time with
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patients, they teach patients strategies to cope with pain, they observe the efficiency and results of the planned treatments, and they have an emphatic approach (Çöçelli et al., 2008). From an ethical standpoint, a patient should not be left to suffer if his/her pain can be relieved. Patients have the right to receive treatment and care for relieving or alleviating their pain (Çöçelli et al., 2008). For correct management of pain, which is a universal, complex, and subjective experience, nurses must use a proper pain scale to assess pain appropriately, believe the level of pain reported by patients is accurate and support them in this regard, use pain relief methods, and evaluate the efficacy of these methods (McGuire, 2006; Smeltzer et al., 2008). Through these techniques, nurses can contribute to decrease morbidity and mortality rates, reduce hospitalisation periods, and increase patient satisfaction (Eren Çevik et al., 2011; Eti Aslan et al., 2008; Karaçay et al., 2006; Özer et al., 2006; Yılmaz and Gürler, 2011). However, in some studies conducted in Turkey, it has been determined that nurses have insufficient knowledge of, attitudes, and clinical decision-making skills about pain (Özer et al., 2006; Yılmaz and Gürler, 2011). Despite the numerous studies about pain reported in international literature, only a limited number evaluate emergency nurses’ knowledge of, attitudes, and clinical decision-making skills about pain. A study has examined triage nurses’ clinical decision-making (Gerdtz and Bucknall, 2001), but little is known about emergency nurses’ attitudes and clinical decision-making skills regarding pain. In Turkey, although these issues have been investigated among nurses working in different clinics, they have not previously been studied with emergency nurses. Therefore, this research will form the basis for future studies with emergency nurses in Turkey. In addition, we believe that the results of the current study will provide useful information to the body of literature regarding what emergency nurses know and their attitudes and clinical decision-making skills about patients’ pain.
tion Questionnaire included six questions for determining the descriptive characteristics of the nurses (age, gender, education level, employed institution, total number of years working, and total number of years working in an emergency department). The Knowledge and Attitude Questionnaire about Pain was developed by study authors in the light of previous research in order to determine nurses’ knowledge and attitudes about pain (Al-Shaer et al., 2011; Bernardi et al., 2007; Erkes et al., 2001; Kuzeyli Yıldırım et al., 2008; Özer et al., 2006; Tanabe and Buschmann, 2000; Tsai et al., 2007). The questionnaire consisted of 15 items: 10 false and five true. These 15 questions are answered as “true” or “false”. In addition, nurses were also asked to evaluate their confidence in the responses they had given to questions in the questionnaire using a 5-point scale. The Clinical Decision Making Survey was used to determine the nurses’ clinical decision-making skills about pain. The Clinical Decision Making Survey was developed by Ferrell et al. (2012). Studies of The Clinical Decision Making Survey for Turkish adaptation were performed by Özer et al. (2006). This survey consisted of 14 questions answered with a “yes” or a “no” (Özer et al., 2006). 2.4. Data collection Investigators managed the data-collection process: there were no managers or supervisors. There were three shifts per day in these clinics: 0800–1600, 1600–2400, and 1600–0800. Data were collected at the end of the 0800–1600 shift. The nurses were given information about the purpose, time, and how the study was going to be conducted. They were also told that their personal information would be protected. Data collection tools were explained and distributed, the participants were asked to fill them in, and then the tools were taken back. No incentives were given to the nurses. The mean time to fill in data collection tools was 15–20 minutes. 2.5. Data analysis
2. Methods 2.1. Design This descriptive study was carried out to determine the knowledge, attitudes, and clinical decision-making skills of emergency nurses regarding pain. 2.2. Sample and setting Almost all hospitals in Turkey offer emergency care, and also most of these hospitals are run by the state, universities or by private hospitals that exist in many cities. The data were collected in emergency departments of a state (Malatya State Hospital) and a university (Turgut Ozal Medical Center of Inonu University) hospital in Malatya between September and October 2012. Ninety-eight nurses were employed in the emergency departments of these two hospitals. The shortage of nurses is an important issue in Turkey. This problem, especially with the rapid increase in the number of private health institutions, began to show itself significantly. The presence of 98 nurses in clinics where the study was applied is a reflection of this situation. In this study, no sampling method was made, and all of the nurses could be reached. However, 31 nurses refused to participate in the study and 10 nurses did not complete the survey; therefore, the study sample consisted of 57 nurses. The response rate was 58%.
The study data were analysed by Statistical Package of Social Science (SPSS) 15.0 software. For the evaluation of the study data, descriptive statistical methods (frequency, percentage, mean, and standard deviation) were used. 2.6. Ethical considerations The study was started after obtaining the necessary written permissions from the Malatya Clinical Researches Ethical Committee, the Malatya Health Provincial Directorate, and the head physician of Turgut Ozal Medical Center of Inonu University. Verbal permissions were received after giving information about the research to nurse managers in study hospitals. In addition, participants were informed about the purpose of the study, and their verbal permissions were obtained. 3. Results 3.1. Descriptive characteristics of nurses According to the descriptive characteristics of nurses, 84.2% were between 18 and 37 years of age, 87.7% were female, 63.2% had Bachelor/Master’s degrees, 77.2% were employed in the state hospital, and 29.8% had worked for five years or less. The mean amount of time that the nurses had worked in the emergency departments was 3.28 ± 3.39 years (Table 1).
2.3. Instruments 3.2. Nurses’ knowledge and attitudes about pain The data were collected using the Demographic Information Questionnaire, Knowledge and Attitude Questionnaire about Pain, and Clinical Decision Making Survey. The Demographic Informa-
The correct answer rates of nurses to knowledge and attitude questions about pain are shown in Table 2. The statement “Patient’s
M. Ucuzal, R. Doğan Msc/International Emergency Nursing 23 (2015) 75–80
Table 3 Nurses’ responses to clinical decision making survey (n = 57).
Table 1 Descriptive characteristics of nurses (n = 57). Nurse Characteristics Age, year 18–27 28–37 ≥38 Gender Female Male Educational level Senior High School-Associate Degree Bachelor/Master’s degree Institution University Hospital State Hospital Work year ≤5 6–10 11–15 ≥16 Time of work in emergency departments:
77
n
%
20 28 9
35.1 49.1 15.8
50 7
87.7 12.3
21 36
36.8 63.2
13 44
22.8 77.2
17 14 13 13 3.28 ± 3.39
29.8 24.6 22.8 22.8
own statement of pain is the most reliable indicator in pain assessment” had the highest number of correct answers, whereas the statement “Non-pharmacological interventions are more effective for moderate pain, but not as effective for severe pain” received the fewest correct answers. The self-confidence of the nurses that they had given the correct answers to statements was determined to be 3.68 ± 0.91. 3.3. Nurses’ skills of clinical decision making When the nurses’ responses to the Clinical Decision Making Survey were investigated, it was observed that 48.4% of the nurses use the behaviour of the patient in defining the severity of pain, 80.7% do not use the pain scale for pain assessment, and 64.9% do
Responses Criteria for defining the severity of paina I observe a patient’s behaviours I ask a patient how much pain he/she feels I review the information in the physician notes I consider the information verbally given by other nurses The use of pain scale No Yes Record the identifications related to pain No Yes Administration route of painkillers Intramuscular Intravenous Intramuscular + intravenous The administration methods the drugs ordered as “as needed” I give them as ordered I give them less frequently than ordered I give another drug (antiemetic, sedative, etc.) Issues discussed with physician about pain I report the changes in pain I discuss the necessity for increasing drug dose I discuss the necessity for altering the drug or administration route I discuss the side-effects of the drugs (e.g. nausea) Conditions for which nurses should decide related to paina Assessment of the patient’s pain Drugs to be given to the patient and administration time Professional/ethical dilemma in pain relief Most important dilemma is worry/fear of administering overdose Least important dilemma is conflict with patient or patient’s family Knowledge most needed for pain management Pain assessment Pharmacological management of pain Non-pharmacological interventions Other (technical issues such as analgesic pumps, psychosocial issues and pain management in special populations) a
Table 2 Nurses’ knowledge and attitudes about pain (n = 57). Knowledge and attitudes
Correct answer %
Patient’s own statement of pain is the most reliable indicator in pain assessment (T) Before applying a pain relief method, the patient should be encouraged to endure the pain as much as possible (F) Unrelieved pain increases mortality and morbidity rates in emergency patients (T) It is recommended that a patient use non-pharmacological methods alone, they should not be used in combination with painkillers (F) The use of a pain scale increases the application frequency of analgesics (T) Non-steroid anti-inflammatory drugs should be the first preferred pharmacological agent in emergency departments (F) A single analgesic agent should be used for patients in pain rather than combined drug groups (F) If a patient’s attention can be distracted from the pain, this means that patient pain is not as severe as he/she defines (F) A patient can sleep despite his/her moderate or severe pain (T) Opioids rarely cause respiratory depression (T) Drugs with sedative effect are effective in reducing pain (F) If a patient’s pain is relieved by a placebo, his/her pain is not real (F) Changes observed in life signs are important indicator for defining the severity of patient’s pain (F) As pain relief interventions negatively affect the diagnosis, they should be postponed in the emergency departments (F) Non-pharmacological interventions are more effective on moderate pains, but not as effective on severe pains (F)
75.4 54.4 49.1 49.1
38.6 35.1 33.3 28.1 21.1 19.3 15.8 14.0 12.3 12.3 7.0
The correct answers (T: true, F: false) for each item are given between brackets.
n
%
31 16 11 1
48.4 25.0 17.0 1.6
46 11
80.7 19.3
37 20
64.9 35.1
33 2 22
57.9 3.5 38.6
46 10 1
80.7 17.5 1.8
23 13 13
42.6 24.1 24.1
5
9.2
58 13
81.7 18.3
15
26.3
1
1.8
40 8 6 3
70.1 14.0 10.5 5.4
More than 1 option has been marked.
not record the pain assessments. Among the most common ethical dilemmas in pain relief, the item “Worrying about giving overdose drug” came first with 26.3% of nurses choosing this item. On the other hand, 70.1% of nurses were determined to need assistance for “Pain assessment” in the first place (Table 3). 4. Discussion Pain assessment begins with the patient’s self-report, which is the most reliable indicator of pain. The majority of participant nurses (75.4%) knew that the patient’s own statement about their pain was the most reliable indicator during pain assessment. This result is largely compatible with the results of previous studies performed with emergency nurses (Tanabe and Buschmann, 2000; Tsai et al., 2007) and other reports in the literature (Çöçelli et al., 2008; McCaffery and Robinson, 2002). On the contrary, another study that was conducted in Turkey found that only 30.7% of nurses stated that they believed a patient’s statements about pain (Özer and Bölükbaş, 2001). In this study, the majority of nurses stated that they believed that the most reliable indication in pain analysis was the patient’s own statement; however, only 25% of them said that they asked the patient their level of pain, which is a contradiction. The patients in the emergency service might not be able to express their pain for certain reasons, such as being unconscious or under the effect of alcohol or drugs. Therefore, it appears that nurses
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do not ask patients about their pain because they have difficulty communicating. Unrelieved pain is known to cause physical, psychological, family, and social complications (Brennan et al., 2007). However, we determined that only half of the nurses believed that unrelieved pain in emergency patients increased mortality and morbidity rates. In addition, almost half of the nurses wrongly believed that patients should be encouraged to endure the pain as much as possible before resorting to a pain relief method. In contrast, oncology nurses in Turkey (Kuzeyli Yıldırım et al., 2008) and emergency nurses in Taiwan (Tsai et al., 2007) asserted that they encouraged patients to endure the pain less. These results indicate that a significant number of nurses leave the patients to face relievable pain. The use of pharmacological methods together with nonpharmacological methods provides effective pain control, especially for severe pain (Smeltzer et al., 2008). However, it should be noted that non-pharmacological methods are not to be used instead of analgesic medicines, but to increase their influence. Research conducted in Turkey found that oncology nurses are not well-informed about this subject (Kuzeyli Yıldırım et al., 2008). Again, in this study, almost half of the nurses thought that non-pharmacological methods should be used alone, which is incorrect. This situation is regarded as an important barrier for effective pain management in emergency services. In the study, most of the nurses thought that the preferred firstline pain management agent was non-steroidal anti-inflammatory drugs (NSAIDs). It has been reported that NSAIDs do not show the desired rapid effect in emergency situations (Eti Aslan et al., 2008), and that opioids should be used for the treatment of acute pain due to their quick and strong analgesic effects (Eren Çevik et al., 2011). Some researchers have developed the first grade-based recommendations for improving analgesia in the emergency department and suggested the use of opioids in intravenous therapy for a patient with acute pain (Lipp et al., 2013). The finding that emergency nurses primarily choose NSAIDs for pain relief does not correlate with this information. A significant number of nurses (71.9%) believe that if a patient’s attention can be distracted from the pain, it means that the pain is not as severe as the patient described it to be. In a previous a study, it was determined that 96.6% of nurses disagree in this thought (Erkes et al., 2001). The patient protects himself/herself from feeling the pain through the technique of addressing his/her attention elsewhere. It is wrong to think that a patient who can apply this technique does not have intolerable pain. These results show that emergency nurses in Turkey do not have sufficient information about distraction techniques, and do not believe in the patient’s statement about his/her pain, as suggested above. It has been reported in the literature that patients can sleep even if they have pain (Özer et al., 2006; Tsai et al., 2007). Yet, the results also indicate that most emergency nurses think that a sleeping patient does not have any pain. This inference might have a negative influence on the attitude of nurses. As, on the contrary, another study claims that 83.3% of critical care nurses believe a patient who has pain might be able to sleep (Erkes et al., 2001). It has been reported that frequency of respiratory depression related to opioids is less than 1% (Eti Aslan et al., 2008), and respiratory depression could be seen especially in the use of morphine, but this is quite rare with the use of recommended doses (Eren Çevik et al., 2011). An extensive review of the electronic medical records of patients with sudden onset, life-threatening, critical respiratory events during opioid therapy for surgical pain between 2000 and 2007 showed an incidence of 0.038% (Ramachandran et al., 2011). This research found that the majority of nurses are misinformed about opioids causing respiratory depression. Although the rate of correct answers in this study is lower than in other studies (Al-Shaer et al., 2011; Tanabe and Buschmann, 2000), it has been reported
elsewhere that emergency nurses worry about the use of opioids (Puntillo et al., 2003; Rampanjato et al., 2007). This information suggests that one of the most important reasons for inadequate pain management in emergency departments is avoidance of opioid use. Naloxone is used to reverse the effects of narcotic drugs used to treat pain and also may be used to treat narcotic drug overdose. If this knowledge is highlighted in basic pharmacology courses, it can reduce the worry about the use of opioids of nurses. If the reason for the pain is unknown, the diagnosis has the precedence; however, symptomatic treatment of pain should be made and the severity of the pain should be decreased to an acceptable level (Eren Çevik et al., 2011; Tanabe and Buschmann, 2000). In Tanabe and Buschmann’s research (2000), emergency nurses thought that the most common barrier in pain management was postponing treatment until diagnosis (Tanabe and Buschmann, 2000). In this research, the majority of nurses think that pain relief should be postponed as it can negatively influence the diagnosis. This belief, which was very widespread for a long period of time, has changed in recent years. The current thinking is that analgesic treatment can decrease the patient’s stress; thus, the doctors and nurses will be able to undertake a more accurate physical examination. The results of this research indicate that nurses have an incorrect attitude towards postponing treatment. An evaluation of attitudes and information of nurses (about pain) participating in this research implies that the statement with the lowest number of correct responses is the one about nonpharmacological methods. Non-pharmacological methods are known to be effective for moderate and severe pain management (Demir, 2013). A slight percentage of the nurses (7.0%) know that these methods are effective in intense pain situations. This rate is close to other study results (Bernardi et al., 2007; Özer et al., 2006), and is lower than some (Al-Shaer et al., 2011; Tsai et al., 2007). The results show that the nurses do not prefer to use non-pharmacological methods for severe pain. The two most common methods of measuring verbal and nonverbal pain behaviours are through self-reporting and direct observation (Labus et al., 2003). In this study, it was determined that nurses primarily observed patients’ behaviours and asked how much pain the patient was in to assess the severity of their pain. Similarly, it has been previously reported in other studies conducted in Turkey that patients’ behaviours are observed for pain assessment (Özer and Bölükbaş, 2001; Özer et al., 2006). Pain rating scales have a fundamental place in clinical practice. Pain scales should be used to turn a subjective pain expression into an objective condition in order to comprehend the perceived pain by the patient and determine the response of the patient to treatment (Eren Çevik et al., 2011; Williamson and Hoggart, 2005). In this research, it is determined that the pain scale was not used frequently, which is similar to other research (Özer et al., 2006) conducted in Turkey. The results of both studies show that one of the reasons for inadequate pain management is a lack of use of pain measurement tools for pain assessment in emergency departments in Turkey. The American Pain Society identified pain as the fifth sign of life (Smeltzer et al., 2008) and set guidelines delineating that a first step in improving the treatment of pain is the assessment and recording of the patients’ reports of pain (Mularski et al., 2006). Nurses do not record pain in the observation form and do not assess it as the fifth sign of life, which causes inadequate pain management (Eti Aslan et al., 2008). In this study, only 35.1% of nurses reported keeping records of pain. This rate was 71.5% in a similar study (Özer et al., 2006). This result shows that emergency nurses have a low awareness about the importance of recording and controlling pain. Varieties of routes for administering analgesia are needed in an emergency. The gold standard is the intravenous route, as it is the most efficient and direct, the drug can be titrated, and it can be given
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intermittently or continuously (Balfour, 2004). The intravenous route is preferred because tissue perfusion is too strong, especially in trauma patients, and repeated intramuscular injections could cause pain and trauma. In addition, it is reported that intramuscular injections may cause erratic absorption of the drug and delay its effect (Karaçay et al., 2006). In this and another study carried out in an emergency department in Turkey, analgesics largely were reported to be administered intramuscularly (Karaçay et al., 2006). The results indicate that emergency patients are subjected to pain for a long time. A nurse who is competent in pain assessment and analgesic administration can safely interpret and properly implement “as needed” orders for analgesic medications (Gordon et al., 2004). According to the results of our study, 17.5% of nurses give an incorrect clinical decision that they administered the analgesic medications that were ordered “as needed” less frequently than ordered. In this study, the most important professional/ethical dilemma that nurses face in pain relief was determined to be “fear of administering overdose drug”, while the least important dilemma was determined to be “conflict with patient and patient’s family”. In another study, “worrying about respiratory depression” was reported as the most important dilemma, and “conflict with patient and patient’s family” as the least important ethical dilemma (Özer et al., 2006). The worries about overdose during drug administration could be caused by the lack of knowledge about the effects and side effects of the medicines. Apparently, this concern will have a negative influence on nurses’ clinical decisions about pain management. Pain assessment and knowledge are the basis for nursing interventions and a critical component of effective pain management (Al-Shaer et al., 2011). At the end of the Clinical Decision Making Survey, nurses were asked about their three most important needs for pain management, and accordingly, pain assessment ranked first (70.1%). Similarly, pain assessment ranked first (39.6%) in a previous study (Özer et al., 2006). 5. Conclusions Pain is a unique and subjective experience that is difficult to assess and manage. Patients have the right to appropriate assessment and management of their pain. Accurate and adequate knowledge about pain and applications for pain management are essential components in clinical nursing practices and can positively influence patient outcomes. However, despite this and past study results, emergency nurses in these two facilities continue to demonstrate inadequate knowledge, attitudes, and clinical decision-making skills related to pain. 6. Limitations The first limitation of this study is that the results cannot be generalised to all emergency nurses due to the small sample size. Another limitation in the research is that, in the Knowledge and Attitude Questionnaire about Pain, nurses are compelled to select between the “true” or “false” choices. 7. Implications for emergency nurses The results of this study indicate that compulsory and organised hospital education programmes about pain assessment and management for emergency nurses need to be a high priority. The information gathered in this study is useful for planning educational programmes, and the least correctly answered items could act as a guide for the educators. Advanced future studies conducted with larger sample groups will provide results that are more definitive.
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Rampanjato, R.M., Florence, M., Patrick, N.C., Finucane, B.T., 2007. Factors influencing pain management by nurses in emergency departments in Central Africa. Emergency Medicine Journal : EMJ. 24, 475–476. Smeltzer, S.C., Bare, B.G., Hinkle, J.L., Cheever, K.H., 2008. Pain Management: Textbook of Medical Surgical Nursing. Lippincott Williams & Wilkins, Philadelphia. Tanabe, P., Buschmann, M., 2000. Emergency nurses’ knowledge of pain management principles. Journal of Emergency Nursing. 26, 299–305. Todd, K.H., Ducharme, J., Choiniere, M., Crandall, C.S., Fosnocht, D.E., Homel, P., et al., 2007. Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI) multicenter study. The Journal of Pain. 8, 460– 466.
Tsai, F.C., Tsai, Y.F., Chien, C.C., Lin, C.C., 2007. Emergency nurses’ knowledge of perceived barriers in pain management in Taiwan. Journal of Clinical Nursing. 16, 2088–2095. Wheeler, E., Hardie, T., Klemm, P., Akanji, I., Schonewolf, E., Scott, J., et al., 2010. Level of pain and waiting time in the emergency department. Pain Management Nursing. 11, 108–114. Williamson, A., Hoggart, B., 2005. Pain: a review of three commonly used pain rating scales. Journal of Clinical Nursing. 14, 798–804. Yılmaz, M., Gürler, H., 2011. Nursing approaches toward postoperative pain in patients: patients’ opinions. Pain. 23, 71–79. Young, J.L., Horton, F.M., Davidhizar, R., 2006. Nursing attitudes and beliefs in pain assessment and management. Journal of Advanced Nursing. 53, 412–421.
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International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
Emergency nurses’ knowledge, attitude and clinical decision making skills about pain Meral Ucuzal PhD (Assistant Professor) a,*, Runida Doğan Msc (Nursing) b a b
Malatya School of Health, Inonu University, Campus 44280, Malatya, Turkey Health, Culture and Sport Department, Inonu University, Campus 44280, Malatya, Turkey
A R T I C L E
I N F O
Article history: Received 4 July 2014 Received in revised form 23 November 2014 Accepted 25 November 2014 Keywords: Pain Knowledge Attitude Skills Clinical decision-making Emergency Nurse
A B S T R A C T
Introduction: Pain is the most common reason that patients come to the emergency department. Emergency nurses have an indispensable role in the management of this pain. Aim: The aim of this study was to examine emergency nurses’ knowledge, attitude and clinical decisionmaking skills about pain. Methods: This descriptive study was conducted in a state and a university hospital between September and October 2012 in Malatya, Turkey. Of 98 nurses working in the emergency departments of these two hospitals, 57 returned the questionnaires. The response rate was 58%. Data were collected using the Demographic Information Questionnaire, Knowledge and Attitude Questionnaire about Pain and Clinical Decision Making Survey. Frequency, percentage, mean and standard deviation were used to evaluate data. Results: 75.4% of participant nurses knew that patients’ own statement about their pain was the most reliable indicator during pain assessment. Almost half of the nurses believed that patients should be encouraged to endure the pain as much as possible before resorting to a pain relief method. The results also indicate that most of nurses think that a sleeping patient does not have any pain and pain relief should be postponed as it can influence the diagnosis negatively. It is determined that the pain scale was not used frequently. Only 35.1% of nurses reported keeping records of pain. Conclusion: Despite all the recommendations of substantial past research the results of this study indicate that emergency nurses continue to demonstrate inadequate knowledge, clinical decision-making skills and negative attitudes about pain. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Pain is a common symptom in many emergency department cases. However, patients may be discharged either with unchanged or increased levels of pain (Berben et al., 2008; Todd et al., 2007). A previous study conducted in Turkey reported that all adult trauma patients admitted to the emergency department experienced pain, with 51.7% of them describing their pain as very severe and 62.9% indicating that they still had pain despite treatment (Eti Aslan et al., 2008). Effective pain management requires accurate knowledge, positive attitudes, and clinical decision-making skills about pain (Kuzeyli Yıldırım et al., 2008). Many nurses gain their perceptions about pain from their knowledge. However, knowledge deficits in this area of practice may yield negative attitudes that can interfere with their clinical decision-making skills and add to the complexity of the pain management issue (El-Rahman et al., 2013; Young et al., 2006).
* Corresponding author. Malatya School of Health, Inonu University, Campus 44280, Malatya, Turkey. Tel.: +90 (422) 341 02 20/1127; fax: +90 (422) 341 02 19. E-mail address: [email protected] (M. Ucuzal). http://dx.doi.org/10.1016/j.ienj.2014.11.006 1755-599X/© 2014 Elsevier Ltd. All rights reserved.
Incorrectly evaluating pain as less severe than it is, believing that the patient exaggerates his/her pain, lack of knowledge regarding pain medications, concerns regarding addiction, beliefs that pain treatment would delay the diagnostic tests, and effects of age and gender result in inadequate pain management in emergency departments (Wheeler et al., 2010). Furthermore, effective pain management in emergency departments is hampered by reasons including concerns that it could mask primary symptoms and cause respiratory depression, not adopting multidisciplinary team work, and a lack of widespread use of new pain control methods (Eren Çevik et al., 2011; Eti Aslan et al., 2008; Karaçay et al., 2006). In previous studies on this subject, emergency nurses stated that a lack of knowledge about pain assessment and relief, lack of time, inadequate pain management until after a diagnosis was obtained, and a patient’s use of alcohol or other stimulant substances were important factors that hampered pain management (Duignan and Dunn, 2009; Tanabe and Buschmann, 2000). Nurses have an indispensable role in providing effective pain management. The important factors that differentiate nurses in pain control from the other team members are that nurses have learned patients’ previous pain experiences and methods to deal with pain and use them when necessary, they spend more time with
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patients, they teach patients strategies to cope with pain, they observe the efficiency and results of the planned treatments, and they have an emphatic approach (Çöçelli et al., 2008). From an ethical standpoint, a patient should not be left to suffer if his/her pain can be relieved. Patients have the right to receive treatment and care for relieving or alleviating their pain (Çöçelli et al., 2008). For correct management of pain, which is a universal, complex, and subjective experience, nurses must use a proper pain scale to assess pain appropriately, believe the level of pain reported by patients is accurate and support them in this regard, use pain relief methods, and evaluate the efficacy of these methods (McGuire, 2006; Smeltzer et al., 2008). Through these techniques, nurses can contribute to decrease morbidity and mortality rates, reduce hospitalisation periods, and increase patient satisfaction (Eren Çevik et al., 2011; Eti Aslan et al., 2008; Karaçay et al., 2006; Özer et al., 2006; Yılmaz and Gürler, 2011). However, in some studies conducted in Turkey, it has been determined that nurses have insufficient knowledge of, attitudes, and clinical decision-making skills about pain (Özer et al., 2006; Yılmaz and Gürler, 2011). Despite the numerous studies about pain reported in international literature, only a limited number evaluate emergency nurses’ knowledge of, attitudes, and clinical decision-making skills about pain. A study has examined triage nurses’ clinical decision-making (Gerdtz and Bucknall, 2001), but little is known about emergency nurses’ attitudes and clinical decision-making skills regarding pain. In Turkey, although these issues have been investigated among nurses working in different clinics, they have not previously been studied with emergency nurses. Therefore, this research will form the basis for future studies with emergency nurses in Turkey. In addition, we believe that the results of the current study will provide useful information to the body of literature regarding what emergency nurses know and their attitudes and clinical decision-making skills about patients’ pain.
tion Questionnaire included six questions for determining the descriptive characteristics of the nurses (age, gender, education level, employed institution, total number of years working, and total number of years working in an emergency department). The Knowledge and Attitude Questionnaire about Pain was developed by study authors in the light of previous research in order to determine nurses’ knowledge and attitudes about pain (Al-Shaer et al., 2011; Bernardi et al., 2007; Erkes et al., 2001; Kuzeyli Yıldırım et al., 2008; Özer et al., 2006; Tanabe and Buschmann, 2000; Tsai et al., 2007). The questionnaire consisted of 15 items: 10 false and five true. These 15 questions are answered as “true” or “false”. In addition, nurses were also asked to evaluate their confidence in the responses they had given to questions in the questionnaire using a 5-point scale. The Clinical Decision Making Survey was used to determine the nurses’ clinical decision-making skills about pain. The Clinical Decision Making Survey was developed by Ferrell et al. (2012). Studies of The Clinical Decision Making Survey for Turkish adaptation were performed by Özer et al. (2006). This survey consisted of 14 questions answered with a “yes” or a “no” (Özer et al., 2006). 2.4. Data collection Investigators managed the data-collection process: there were no managers or supervisors. There were three shifts per day in these clinics: 0800–1600, 1600–2400, and 1600–0800. Data were collected at the end of the 0800–1600 shift. The nurses were given information about the purpose, time, and how the study was going to be conducted. They were also told that their personal information would be protected. Data collection tools were explained and distributed, the participants were asked to fill them in, and then the tools were taken back. No incentives were given to the nurses. The mean time to fill in data collection tools was 15–20 minutes. 2.5. Data analysis
2. Methods 2.1. Design This descriptive study was carried out to determine the knowledge, attitudes, and clinical decision-making skills of emergency nurses regarding pain. 2.2. Sample and setting Almost all hospitals in Turkey offer emergency care, and also most of these hospitals are run by the state, universities or by private hospitals that exist in many cities. The data were collected in emergency departments of a state (Malatya State Hospital) and a university (Turgut Ozal Medical Center of Inonu University) hospital in Malatya between September and October 2012. Ninety-eight nurses were employed in the emergency departments of these two hospitals. The shortage of nurses is an important issue in Turkey. This problem, especially with the rapid increase in the number of private health institutions, began to show itself significantly. The presence of 98 nurses in clinics where the study was applied is a reflection of this situation. In this study, no sampling method was made, and all of the nurses could be reached. However, 31 nurses refused to participate in the study and 10 nurses did not complete the survey; therefore, the study sample consisted of 57 nurses. The response rate was 58%.
The study data were analysed by Statistical Package of Social Science (SPSS) 15.0 software. For the evaluation of the study data, descriptive statistical methods (frequency, percentage, mean, and standard deviation) were used. 2.6. Ethical considerations The study was started after obtaining the necessary written permissions from the Malatya Clinical Researches Ethical Committee, the Malatya Health Provincial Directorate, and the head physician of Turgut Ozal Medical Center of Inonu University. Verbal permissions were received after giving information about the research to nurse managers in study hospitals. In addition, participants were informed about the purpose of the study, and their verbal permissions were obtained. 3. Results 3.1. Descriptive characteristics of nurses According to the descriptive characteristics of nurses, 84.2% were between 18 and 37 years of age, 87.7% were female, 63.2% had Bachelor/Master’s degrees, 77.2% were employed in the state hospital, and 29.8% had worked for five years or less. The mean amount of time that the nurses had worked in the emergency departments was 3.28 ± 3.39 years (Table 1).
2.3. Instruments 3.2. Nurses’ knowledge and attitudes about pain The data were collected using the Demographic Information Questionnaire, Knowledge and Attitude Questionnaire about Pain, and Clinical Decision Making Survey. The Demographic Informa-
The correct answer rates of nurses to knowledge and attitude questions about pain are shown in Table 2. The statement “Patient’s
M. Ucuzal, R. Doğan Msc/International Emergency Nursing 23 (2015) 75–80
Table 3 Nurses’ responses to clinical decision making survey (n = 57).
Table 1 Descriptive characteristics of nurses (n = 57). Nurse Characteristics Age, year 18–27 28–37 ≥38 Gender Female Male Educational level Senior High School-Associate Degree Bachelor/Master’s degree Institution University Hospital State Hospital Work year ≤5 6–10 11–15 ≥16 Time of work in emergency departments:
77
n
%
20 28 9
35.1 49.1 15.8
50 7
87.7 12.3
21 36
36.8 63.2
13 44
22.8 77.2
17 14 13 13 3.28 ± 3.39
29.8 24.6 22.8 22.8
own statement of pain is the most reliable indicator in pain assessment” had the highest number of correct answers, whereas the statement “Non-pharmacological interventions are more effective for moderate pain, but not as effective for severe pain” received the fewest correct answers. The self-confidence of the nurses that they had given the correct answers to statements was determined to be 3.68 ± 0.91. 3.3. Nurses’ skills of clinical decision making When the nurses’ responses to the Clinical Decision Making Survey were investigated, it was observed that 48.4% of the nurses use the behaviour of the patient in defining the severity of pain, 80.7% do not use the pain scale for pain assessment, and 64.9% do
Responses Criteria for defining the severity of paina I observe a patient’s behaviours I ask a patient how much pain he/she feels I review the information in the physician notes I consider the information verbally given by other nurses The use of pain scale No Yes Record the identifications related to pain No Yes Administration route of painkillers Intramuscular Intravenous Intramuscular + intravenous The administration methods the drugs ordered as “as needed” I give them as ordered I give them less frequently than ordered I give another drug (antiemetic, sedative, etc.) Issues discussed with physician about pain I report the changes in pain I discuss the necessity for increasing drug dose I discuss the necessity for altering the drug or administration route I discuss the side-effects of the drugs (e.g. nausea) Conditions for which nurses should decide related to paina Assessment of the patient’s pain Drugs to be given to the patient and administration time Professional/ethical dilemma in pain relief Most important dilemma is worry/fear of administering overdose Least important dilemma is conflict with patient or patient’s family Knowledge most needed for pain management Pain assessment Pharmacological management of pain Non-pharmacological interventions Other (technical issues such as analgesic pumps, psychosocial issues and pain management in special populations) a
Table 2 Nurses’ knowledge and attitudes about pain (n = 57). Knowledge and attitudes
Correct answer %
Patient’s own statement of pain is the most reliable indicator in pain assessment (T) Before applying a pain relief method, the patient should be encouraged to endure the pain as much as possible (F) Unrelieved pain increases mortality and morbidity rates in emergency patients (T) It is recommended that a patient use non-pharmacological methods alone, they should not be used in combination with painkillers (F) The use of a pain scale increases the application frequency of analgesics (T) Non-steroid anti-inflammatory drugs should be the first preferred pharmacological agent in emergency departments (F) A single analgesic agent should be used for patients in pain rather than combined drug groups (F) If a patient’s attention can be distracted from the pain, this means that patient pain is not as severe as he/she defines (F) A patient can sleep despite his/her moderate or severe pain (T) Opioids rarely cause respiratory depression (T) Drugs with sedative effect are effective in reducing pain (F) If a patient’s pain is relieved by a placebo, his/her pain is not real (F) Changes observed in life signs are important indicator for defining the severity of patient’s pain (F) As pain relief interventions negatively affect the diagnosis, they should be postponed in the emergency departments (F) Non-pharmacological interventions are more effective on moderate pains, but not as effective on severe pains (F)
75.4 54.4 49.1 49.1
38.6 35.1 33.3 28.1 21.1 19.3 15.8 14.0 12.3 12.3 7.0
The correct answers (T: true, F: false) for each item are given between brackets.
n
%
31 16 11 1
48.4 25.0 17.0 1.6
46 11
80.7 19.3
37 20
64.9 35.1
33 2 22
57.9 3.5 38.6
46 10 1
80.7 17.5 1.8
23 13 13
42.6 24.1 24.1
5
9.2
58 13
81.7 18.3
15
26.3
1
1.8
40 8 6 3
70.1 14.0 10.5 5.4
More than 1 option has been marked.
not record the pain assessments. Among the most common ethical dilemmas in pain relief, the item “Worrying about giving overdose drug” came first with 26.3% of nurses choosing this item. On the other hand, 70.1% of nurses were determined to need assistance for “Pain assessment” in the first place (Table 3). 4. Discussion Pain assessment begins with the patient’s self-report, which is the most reliable indicator of pain. The majority of participant nurses (75.4%) knew that the patient’s own statement about their pain was the most reliable indicator during pain assessment. This result is largely compatible with the results of previous studies performed with emergency nurses (Tanabe and Buschmann, 2000; Tsai et al., 2007) and other reports in the literature (Çöçelli et al., 2008; McCaffery and Robinson, 2002). On the contrary, another study that was conducted in Turkey found that only 30.7% of nurses stated that they believed a patient’s statements about pain (Özer and Bölükbaş, 2001). In this study, the majority of nurses stated that they believed that the most reliable indication in pain analysis was the patient’s own statement; however, only 25% of them said that they asked the patient their level of pain, which is a contradiction. The patients in the emergency service might not be able to express their pain for certain reasons, such as being unconscious or under the effect of alcohol or drugs. Therefore, it appears that nurses
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do not ask patients about their pain because they have difficulty communicating. Unrelieved pain is known to cause physical, psychological, family, and social complications (Brennan et al., 2007). However, we determined that only half of the nurses believed that unrelieved pain in emergency patients increased mortality and morbidity rates. In addition, almost half of the nurses wrongly believed that patients should be encouraged to endure the pain as much as possible before resorting to a pain relief method. In contrast, oncology nurses in Turkey (Kuzeyli Yıldırım et al., 2008) and emergency nurses in Taiwan (Tsai et al., 2007) asserted that they encouraged patients to endure the pain less. These results indicate that a significant number of nurses leave the patients to face relievable pain. The use of pharmacological methods together with nonpharmacological methods provides effective pain control, especially for severe pain (Smeltzer et al., 2008). However, it should be noted that non-pharmacological methods are not to be used instead of analgesic medicines, but to increase their influence. Research conducted in Turkey found that oncology nurses are not well-informed about this subject (Kuzeyli Yıldırım et al., 2008). Again, in this study, almost half of the nurses thought that non-pharmacological methods should be used alone, which is incorrect. This situation is regarded as an important barrier for effective pain management in emergency services. In the study, most of the nurses thought that the preferred firstline pain management agent was non-steroidal anti-inflammatory drugs (NSAIDs). It has been reported that NSAIDs do not show the desired rapid effect in emergency situations (Eti Aslan et al., 2008), and that opioids should be used for the treatment of acute pain due to their quick and strong analgesic effects (Eren Çevik et al., 2011). Some researchers have developed the first grade-based recommendations for improving analgesia in the emergency department and suggested the use of opioids in intravenous therapy for a patient with acute pain (Lipp et al., 2013). The finding that emergency nurses primarily choose NSAIDs for pain relief does not correlate with this information. A significant number of nurses (71.9%) believe that if a patient’s attention can be distracted from the pain, it means that the pain is not as severe as the patient described it to be. In a previous a study, it was determined that 96.6% of nurses disagree in this thought (Erkes et al., 2001). The patient protects himself/herself from feeling the pain through the technique of addressing his/her attention elsewhere. It is wrong to think that a patient who can apply this technique does not have intolerable pain. These results show that emergency nurses in Turkey do not have sufficient information about distraction techniques, and do not believe in the patient’s statement about his/her pain, as suggested above. It has been reported in the literature that patients can sleep even if they have pain (Özer et al., 2006; Tsai et al., 2007). Yet, the results also indicate that most emergency nurses think that a sleeping patient does not have any pain. This inference might have a negative influence on the attitude of nurses. As, on the contrary, another study claims that 83.3% of critical care nurses believe a patient who has pain might be able to sleep (Erkes et al., 2001). It has been reported that frequency of respiratory depression related to opioids is less than 1% (Eti Aslan et al., 2008), and respiratory depression could be seen especially in the use of morphine, but this is quite rare with the use of recommended doses (Eren Çevik et al., 2011). An extensive review of the electronic medical records of patients with sudden onset, life-threatening, critical respiratory events during opioid therapy for surgical pain between 2000 and 2007 showed an incidence of 0.038% (Ramachandran et al., 2011). This research found that the majority of nurses are misinformed about opioids causing respiratory depression. Although the rate of correct answers in this study is lower than in other studies (Al-Shaer et al., 2011; Tanabe and Buschmann, 2000), it has been reported
elsewhere that emergency nurses worry about the use of opioids (Puntillo et al., 2003; Rampanjato et al., 2007). This information suggests that one of the most important reasons for inadequate pain management in emergency departments is avoidance of opioid use. Naloxone is used to reverse the effects of narcotic drugs used to treat pain and also may be used to treat narcotic drug overdose. If this knowledge is highlighted in basic pharmacology courses, it can reduce the worry about the use of opioids of nurses. If the reason for the pain is unknown, the diagnosis has the precedence; however, symptomatic treatment of pain should be made and the severity of the pain should be decreased to an acceptable level (Eren Çevik et al., 2011; Tanabe and Buschmann, 2000). In Tanabe and Buschmann’s research (2000), emergency nurses thought that the most common barrier in pain management was postponing treatment until diagnosis (Tanabe and Buschmann, 2000). In this research, the majority of nurses think that pain relief should be postponed as it can negatively influence the diagnosis. This belief, which was very widespread for a long period of time, has changed in recent years. The current thinking is that analgesic treatment can decrease the patient’s stress; thus, the doctors and nurses will be able to undertake a more accurate physical examination. The results of this research indicate that nurses have an incorrect attitude towards postponing treatment. An evaluation of attitudes and information of nurses (about pain) participating in this research implies that the statement with the lowest number of correct responses is the one about nonpharmacological methods. Non-pharmacological methods are known to be effective for moderate and severe pain management (Demir, 2013). A slight percentage of the nurses (7.0%) know that these methods are effective in intense pain situations. This rate is close to other study results (Bernardi et al., 2007; Özer et al., 2006), and is lower than some (Al-Shaer et al., 2011; Tsai et al., 2007). The results show that the nurses do not prefer to use non-pharmacological methods for severe pain. The two most common methods of measuring verbal and nonverbal pain behaviours are through self-reporting and direct observation (Labus et al., 2003). In this study, it was determined that nurses primarily observed patients’ behaviours and asked how much pain the patient was in to assess the severity of their pain. Similarly, it has been previously reported in other studies conducted in Turkey that patients’ behaviours are observed for pain assessment (Özer and Bölükbaş, 2001; Özer et al., 2006). Pain rating scales have a fundamental place in clinical practice. Pain scales should be used to turn a subjective pain expression into an objective condition in order to comprehend the perceived pain by the patient and determine the response of the patient to treatment (Eren Çevik et al., 2011; Williamson and Hoggart, 2005). In this research, it is determined that the pain scale was not used frequently, which is similar to other research (Özer et al., 2006) conducted in Turkey. The results of both studies show that one of the reasons for inadequate pain management is a lack of use of pain measurement tools for pain assessment in emergency departments in Turkey. The American Pain Society identified pain as the fifth sign of life (Smeltzer et al., 2008) and set guidelines delineating that a first step in improving the treatment of pain is the assessment and recording of the patients’ reports of pain (Mularski et al., 2006). Nurses do not record pain in the observation form and do not assess it as the fifth sign of life, which causes inadequate pain management (Eti Aslan et al., 2008). In this study, only 35.1% of nurses reported keeping records of pain. This rate was 71.5% in a similar study (Özer et al., 2006). This result shows that emergency nurses have a low awareness about the importance of recording and controlling pain. Varieties of routes for administering analgesia are needed in an emergency. The gold standard is the intravenous route, as it is the most efficient and direct, the drug can be titrated, and it can be given
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intermittently or continuously (Balfour, 2004). The intravenous route is preferred because tissue perfusion is too strong, especially in trauma patients, and repeated intramuscular injections could cause pain and trauma. In addition, it is reported that intramuscular injections may cause erratic absorption of the drug and delay its effect (Karaçay et al., 2006). In this and another study carried out in an emergency department in Turkey, analgesics largely were reported to be administered intramuscularly (Karaçay et al., 2006). The results indicate that emergency patients are subjected to pain for a long time. A nurse who is competent in pain assessment and analgesic administration can safely interpret and properly implement “as needed” orders for analgesic medications (Gordon et al., 2004). According to the results of our study, 17.5% of nurses give an incorrect clinical decision that they administered the analgesic medications that were ordered “as needed” less frequently than ordered. In this study, the most important professional/ethical dilemma that nurses face in pain relief was determined to be “fear of administering overdose drug”, while the least important dilemma was determined to be “conflict with patient and patient’s family”. In another study, “worrying about respiratory depression” was reported as the most important dilemma, and “conflict with patient and patient’s family” as the least important ethical dilemma (Özer et al., 2006). The worries about overdose during drug administration could be caused by the lack of knowledge about the effects and side effects of the medicines. Apparently, this concern will have a negative influence on nurses’ clinical decisions about pain management. Pain assessment and knowledge are the basis for nursing interventions and a critical component of effective pain management (Al-Shaer et al., 2011). At the end of the Clinical Decision Making Survey, nurses were asked about their three most important needs for pain management, and accordingly, pain assessment ranked first (70.1%). Similarly, pain assessment ranked first (39.6%) in a previous study (Özer et al., 2006). 5. Conclusions Pain is a unique and subjective experience that is difficult to assess and manage. Patients have the right to appropriate assessment and management of their pain. Accurate and adequate knowledge about pain and applications for pain management are essential components in clinical nursing practices and can positively influence patient outcomes. However, despite this and past study results, emergency nurses in these two facilities continue to demonstrate inadequate knowledge, attitudes, and clinical decision-making skills related to pain. 6. Limitations The first limitation of this study is that the results cannot be generalised to all emergency nurses due to the small sample size. Another limitation in the research is that, in the Knowledge and Attitude Questionnaire about Pain, nurses are compelled to select between the “true” or “false” choices. 7. Implications for emergency nurses The results of this study indicate that compulsory and organised hospital education programmes about pain assessment and management for emergency nurses need to be a high priority. The information gathered in this study is useful for planning educational programmes, and the least correctly answered items could act as a guide for the educators. Advanced future studies conducted with larger sample groups will provide results that are more definitive.
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