Pain Assessment in Critically Ill Patient: Knowledge and Practice among Nurses in Military Hospital Makkah

This research paper aims to understand the knowledge and practice skills of nursing professionals in Military Hospital Makkah, Saudi Arabia regarding pain assessment in critically ill patients. The study focuses on the use of pain assessment tools, adherence to guidelines, and understanding of standard precautions for infection control. The findings will contribute to improving pain management in healthcare facilities.

Running head: PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
.
Knowledge and Practice towards Pain Assessment in Critically Ill Patient among
Nurses in Emergency Room at Military Hospital Makkah, Saudi Arabia.
Name of the Student
Name of the University
Author’s Note:

1PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
Abstract
Introduction: Pain can be defined as an unpleasant sensory experience that occurs due to the
potential tissue damage due to which majority of the people suffers from distress and
restlessness. However, despite of advanced healthcare interventions and processes pain
assessment is one of the unmet aspects that the healthcare professionals are unable to achieve.
Moreover, the usage of pain assessment tools for pain management is also minimal and the
primary reason behind this incompetence is the inability of the healthcare professionals to
conduct accurate and relevant pain assessment practice using the guidelines and
recommendations. Hence, the primary intention of this research paper was to understand and
determine the knowledge of the nursing professionals of healthcare facilities in Military
Hospital Makkah, Saudi Arabia.
Methods: Quantitative, qualitative, and descriptive research methodology was chosen for this
investigation and research design that was selected for this investigation was cross sectional
research design. Total sample population for this investigation was 30.
Results: From the data presented in this investigation, it can be deduced that the all the
participants had same responses for the questions in Section II with same number of
frequency as the number of participants.
Discussion: The analysed data deduced from the responses of the present shows that the
nurses in the Military Hospital Makkah, Saudi Arabia have very high understanding of the
Standard of practice and high level of the knowledge regarding the pain assessment among
the chronically ill patients in emergency department. This investigation is limited by the
number of study population in which only the emergency nursing staff at Military Hospital
Makkah, Saudi Arabia participated and the reason behind this small number of sample size
and lack of diversity with regard to sample population.

2PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
Table of Contents
Chapter 1: Introduction..............................................................................................................5
1.1 Background of the study..................................................................................................5
1.2 Problem statement............................................................................................................6
1.3 Purpose of the study.........................................................................................................7
1.4 Research objectives..........................................................................................................8
1.4.1 General objectives.....................................................................................................8
1.4.2 Specific objectives....................................................................................................8
1.5 Research Questions..........................................................................................................9
1.6 Significance of the study..................................................................................................9
1.7 Definition of terms.........................................................................................................10
Chapter 2: Literature Review...................................................................................................11
2.1 Introduction on review of literature...............................................................................11
2.2 Review of literatures on level of knowledge of pain assessment in critically ill patients
..............................................................................................................................................12
2.2.1 Review of literature regarding standard of practice in pain management..............14
2.2.3 Review of literature on complications regarding the pain assessment among the
patients.............................................................................................................................16
2.3 Conceptual & Theoretical Framework...........................................................................18
2.3.1 Conceptual Framework...........................................................................................18
Chapter 3: Methodology..........................................................................................................19
3.1 Research Design.............................................................................................................19

3PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
3.2 Study Type.....................................................................................................................19
3.3 Study Settings.................................................................................................................20
3.4 Study Population............................................................................................................20
3.5 Sampling Size.................................................................................................................20
3.6 Sampling Method...........................................................................................................20
3.7 Sampling Criteria...........................................................................................................21
3.8 Research Instrument.......................................................................................................21
3.9 Data Collection...............................................................................................................22
3.10 Data Analysis...............................................................................................................22
3.11 Ethical Consideration...................................................................................................22
Chapter 4: Results....................................................................................................................23
4.1 Demographic Information of the Participants................................................................23
4.1.1 Gender.....................................................................................................................23
4.1.2 Range of Age Group...............................................................................................24
4.1.3 Years of Experience................................................................................................24
4.1.4 Level of Job Title....................................................................................................24
4.2 Level of knowledge and standards of practice among the Nurses with regards to the
pain assessments...................................................................................................................24
Chapter 5: Discussion and Conclusion....................................................................................28
5.1 Discussion......................................................................................................................28
5.2 Limitation of this Study.................................................................................................30
5.3 Conclusion......................................................................................................................30

4PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
5.4 Recommendation............................................................................................................31
References................................................................................................................................32
Appendix – 1............................................................................................................................39

5PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
Chapter 1: Introduction
1.1 Background of the study
The World Health Organisation mentions pain as an unpleasant sensory experience that
occurs due to the potential tissue damage due to which majority of the people suffers from
distress and restlessness (Glick et al. 2016). While providing critical care to the patients, pain
assessment and associated interventions are the most important care process that should be
conducted to provide the patients with effective relief (Burke, Mathias and Denson 2015).
However, despite of advanced healthcare interventions and processes pain assessment is one
of the unmet aspects that the healthcare professionals are unable to achieve (Watt-Watson
and Murinson 2013). As per Andersson, Otterstrom-Rydberg and Karlsson (2015) there are
several instances around the world, in which due to improper pain assessment and
management, patients suffer from several psychological and physiological consequences. As
per Chang et al. (2015), majority of the adverse events associated with improper pain
assessment and management is connected to enhanced rate of infection, increased duration of
mechanical ventilation, haemodynamic imbalance, affected immune system and the stress or
depression associated with delirium (Andersson, Otterstrom-Rydberg and Karlsson 2015).
Proper and accurate pain assessment is associated with systematic and comprehensive ways
of pain assessment and depending on these healthcare professionals are allowed to titrate the
amount of analgesia which could be used for the patients to relive their condition (Watt-
Watson and Murinson 2013). Further, in the research of Herr et al. (2015), it was noted that
despite developed and widely available pain management skills and guidelines, healthcare
professionals are unable to use the systematic or comprehensive ways of pain assessment.
Moreover, the usage of pain assessment tools for pain management is also minimal and as per
Attar (2014), the primary reason behind these incompetence is the inability of the healthcare

6PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
professionals to conduct accurate and relevant pain assessment practice using the guidelines
and recommendations, or widely available pain assessment tools (Burke, Mathias and Denson
2015).
Therefore, the study attempts to determine the knowledge and practice skills of healthcare
nursing professionals regarding the pain assessment among the critically ill patients, admitted
in the Emergency Room at Military Hospital Makkah, Saudi Arabia. Further, it would also
develop understanding about the knowledge of the professionals regarding the safety, security
and hygiene practices that should be conducted while pain assessment in critically ill patients
(Alqahtani and Jones 2015).
1.2 Problem statement
Healthcare facilities around the world are provided with governmental guidelines and
principles depending on which accurate and appropriate pain management and assessment
could be conducted. Further as per Khalaileh and Qadire (2013) there are several pain
assessment tools namely the Numeric rating Scale or the NRS, verbal descriptive scale, visual
analogue scale and others which is used extensively in the healthcare facilities around the
world. However, as per Darwish and Al-Zuhair (2014), the healthcare facilities in Saudi
Arabia do not have such specific protocols and guidelines that target the accurate and
appropriate pain assessment among the patients. Furthermore, very few researchers has
targeted this section of research and minimal research articles for pain assessment guidelines
in healthcare facilities of Saudi Arabia is available (Herr et al. 2015). Due to this, the
healthcare professionals working in ICU with terminally or critically ill patients required to
be assessed for their knowledge of pain assessment methods, tools and guidelines so that their
understanding related to the process could be assessed.

7PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
In another research which was conducted on a global perspective by Alqahtani and Jones
(2015), mentioned that majority of the healthcare or nursing professionals are unaware of the
accurate process and guidelines which should be used while conducting pain assessment
among critically ill patients. Duke et al. (2013) mentions about similar concept and mentions
that limited knowledge and negative attitude of the nursing professional regarding pain
assessment affect the holistic care of the patient by increasing obstacles in the care process.
The research by Ung et al. (2016) also indicated towards similar research finding as nursing
professionals behaviour and attitude while assessing pain affected the health and wellbeing
improvement of the patients by increasing hopelessness, impeding their responses to
healthcare interventions and ultimately hampering their quality of life (Duke et al. 2013).
As per the governmental data collected from the Institute for Health Metrics and Evaluation
(2019), pain is one of the most important aspects, due to which majority of the patients
suffered from disability. On an average, more than 89% people admitted in the healthcare
facilities with critical and chronic healthcare situations suffered from chronic and severe pain
and reported that their pain management and assessment was not done properly in the
healthcare facilities.
Further, lack of knowledge and practice skills related to pain assessment and management is
one of the crucial problems due to which the majority of cancer patients admitted in the
inpatient or outpatient service in healthcare facilities across Saudi Arabia suffered severe pain
as mentioned in (Al-Khawaldeh, Al-Hussami and Darawad 2013). Hence, this was the
primary problem focusing on which this paper has been developed.
1.3 Purpose of the study
The primary intention of this research paper was to understand and determine the knowledge
of the nursing professionals of healthcare facilities in Military Hospital Makkah, Saudi

8PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
Arabia so that while working with critically ill patients, they could conduct accurate pain
assessment process (Alqahtani and Jones 2015). Further, with this their understanding, their
knowledge, and their ability to practice the accurate and appropriate pain assessment and
management process could be assessed while working with patients who are critically or
terminally ill (Duke et al. 2013). It was also observed in the process, that majority of the
healthcare professionals were not able to conduct the care process effectively because the
healthcare facility they were working with did not provide them with intervention of facilities
as well as guidelines for pain assessment due to which majority of the healthcare issues were
faced by the patient in the care scenario. Further, it was also observed that the attitude and
behaviour of the healthcare professionals while conducting the pain assessment without any
recommendations and guidelines hence, it was observed that majority of the patients were
unable to mention the self-assessed pain score to the nursing professionals (Williams and
Craig 2016). Therefore, this was one of the limiting factors due to which the pain assessment
guidelines and practices developed and followed by the healthcare professionals should be
assessed (Fallatah 2017). Hence, this was the purpose of the study that was utilised for the
complete and detailed assessed of the research process.
1.4 Research objectives
1.4.1 General objectives
The general objective of this research project was to understand the knowledge of the nursing
professionals regarding pain assessment and pain management strategies, recommendations
and processes while working with critically and terminally ill patients in Military Hospital
Makkah, Saudi Arabia.
1.4.2 Specific objectives
a) To determine the level of understanding within healthcare nursing professionals of
Military Hospital Makkah, Saudi Arabia regarding pain assessment.

9PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
b) To determine their understanding of the concept of standard precaution for infection
control among critically ill patients
c) To assess their knowledge regarding personal protective agents so that the infection
among patients could be controlled
d) To assess their knowledge regarding the way regulations, guidelines and principles
help them to comply with the standard of practice for pain management and pain
assessment using several tools.
1.5 Research Questions
a) What is the status of knowledge of healthcare nursing professionals about the pain
assessment process so that they could conduct the process without any loophole?
b) What recommendations or practice guidelines the nurses follow while assessing the
level of pain among critically or terminally ill patients so that their understanding of
the critical healthcare situations could be assessed?
c) Is there any relationship between the knowledge of nursing principles and guidelines
with accurate implementation of pain assessment guidelines in the Military Hospital
Makkah, Saudi Arabia?
1.6 Significance of the study
The primary intention of this research project was to understand the level of knowledge or
practice skills the nursing professionals of Military Hospital Makkah, Saudi Arabia has
regarding pain assessment so that the successful pi assessment could be conducted. As per
Alqahtani and Jones (2015), very few research work has been done in this aspect and hence
to understand the type and extent of pain assessment guidelines which is used by the
healthcare professionals in the country (Williams and Craig 2016). Further, it was also
observed in the research processes that application of improper pain assessment is associated
with mental and physical ailments and was related to morbidity and mortality rates of the

10PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
patients. Further, the significance of the study is associated with the understanding of the pain
assessment method that is conducted by the healthcare professionals in the healthcare
facilities of Saudi Arabia so that the physical and mental trauma the patients suffer from
while undergoing the process could be understood (Jenkins et al. 2013). As per Pereira et al.
(2015), this was important to assess because the patients that undergone such serous health
complication and severe pain, required accurate and appropriate interventions to make the
care process accurate and provide the patient with effective pain management and assessment
for improved patient condition (Al-Quliti and Alamri 2015).
1.7 Definition of terms
1. Pain: unpleasant physical condition due to which patients suffer from sensation that
occurs due to tissue damages. Further it is also a type of emotional experiences due to
which the patient suffers from difficult situation and developed distress and agitation
(Williams and Craig 2016).
2. Pain assessment: pain assessment is the process using which the pain of the patient is
assessed using a multidisciplinary approach, this process helps the nursing
professionals to understand the level of pain the patients are suffering from in the
critical healthcare conditions (Andersson et al. 2015). As per Williams (2013), the
pain assessment is primarily based on the self-reporting methods and involvement of
patient is of higher importance in the process.
3. Nursing knowledge: the nursing knowledge is the detailed knowledge of the patients
depending on which they determine the healthcare interventions for the health and
wellbeing improvement among the critically ill patients. Further, in this aspect, they
include governmental recommendations, principles, guidelines, and other so that
ethical and professional codes of nursing care could be complied with (Fawcett and
Desanto-Madeya 2012).

11PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
4. Healthcare guidelines and recommendations: these guidelines and
recommendations are documents which are published by specific governmental
organisations or ministry of healthcare so that within a specific area or states,
healthcare professionals utilises similar process or interventions for healthcare
purpose (Jenkins et al. 2013).
5. Standard of practice: this standards are the guidelines or the benchmarks so that the
professional knowledge of the nursing professionals, their skills and attitudes could be
understood (Holmberg, Suryaprasad and Ward 2012).
6. Numeric rating Scale: the Numeric rating Scale is a pain assessment scale that
includes 11 points so that the self-reporting of the pain could be understood. This
assessment scale could only be applied on patients above the age of 10 as the patients
below that are unable to understand their level of pain and accordingly inaccurate
result is obtained (Oldenmenger et al. 2013).
7. Verbal Descriptive Scale: This is a type of pain assessment tool which is applied on
elders or adult patients so that their level of critical pain could be assessed. Further, it
was also seen in case of patients who can self- report their level of pain. Hence, this
assessment tool is used for patients who would be able to self- report the level of pain
in their healthcare condition (Pereira et al. 2015).
Chapter 2: Literature Review
2.1 Introduction on review of literature
The latest research articles that have been included in this literature review sections, were
collected from the search results from the reliable and easily available databases such as
Google Scholar and PubMed. Further, within these databases, several inclusion and exclusion
criteria were selected so that accurate and effective research articles could be collected for the
conduction of the literature review. The keywords, that were searched for the process was

12PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
pain assessment skills and knowledge, pain assessment and its importance, pain assessment
techniques and skills, pain assessment in healthcare facilities of Saudi Arabia was used
(Rantala et al., 2014).
Pain assessment is one of the crucial step or assessment method which is conducted with
patients suffering from critical healthcare conditions. As per Fallatah (2017), for majority of
the patients suffering from critical healthcare conditions require prioritized pain management
process and hence assessment of the pain should be acquired by the nursing professionals
around the world. Majority of the nations around the world has developed effective pain
management and assessment methods so that patients could be provided with effective and
accurate interventions for their pain management and assessment (Al-Atiyyat et al. 2018).
However, despite the urgency for such recommendations and policies, the Saudi Arabian
government does not provide its healthcare professionals with such guideline that help them
to conduct the pain assessment effectively (Abuelkheir et al 2014). Consequently, the amount
of research process focusing on pain assessment in Saudi Arabia and the knowledge of the
nursing professionals regarding the pain assessment strategies are minimal (Amenorpe 2017).
Which requires for extensive amount of research so that proper knowledge of the nursing
professionals of Saudi Arabia and their knowledge of pain assessment could be understood
(Mazoyer et al. 2017). Further, it was seen that improper and lack of awareness about the
pain assessment increases the patient morbidity and mortality, due to which conduction of
this research process requires latest and accurate understanding so that relation between
proper knowledge of pain assessment and adverse patient condition could be developed.
2.2 Review of literatures on level of knowledge of pain assessment in critically ill
patients
Researchers Eid et al. (2014) conducted a quantitative research among the nursing
professionals of Saudi Arabia so that the ability, attitude, and knowledge of the nursing

13PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
professionals regarding pain assessment methods could be understood. The researchers
distributed 775 questionnaires among the nursing professionals of Saudi Arabia and 593
responses were collected (Eid et al. 2014). The responses of the nursing professionals
indicated that majority of the nursing professionals were unaware of the pain assessment
methods (Eid et al. 2014). Further, it was seen that they refused to provide morphine to a
patient suffering from severe pain, because the patient was smiling Chang (2014). Therefore,
through the paper, it was determined that majority of the healthcare professionals in Saudi
Arabia are not aware of accurate pain assessment method (Eid et al. 2014). Further, the paper
recommends that government should implement pain assessment training programs for the
nursing professionals so that national and international level of healthcare process could be
achieved (Eid et al. 2014).
Another study conducted by Al-Quliti and Alamri (2015) utilised exploratory study under the
quantitative study so that the knowledge and attitude of nursing professionals regarding pain
assessment in the healthcare facilities of Almadinah Almunawwarah could be understood
(Al-Quliti and Alamri 2015). In this research, healthcare professionals of 7 hospitals were
included and they were assessed for their knowledge of pain assessment methodologies by
implementing the survey for the assessment of knowledge and assessment plan (Al-Quliti and
Alamri 2015). The data collected from January to April 2014 indicated that within 100
nursing professionals of these facilities, 77 participants scored 44% competency, and only 6%
nursing professionals were able to achieve 60% points. Therefore, through these processes, it
was identified that majority of the nursing professionals were unaware of the pain assessment
method (Al-Quliti and Alamri 2015). Further the paper recommended that healthcare
providers should provide the patients with effective knowledge and training so that with
increased competency, they could conduct accurate pain assessment among the patients (Al-
Quliti and Alamri 2015).

14PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
Another research should be discussed in this aspect that was conducted by Fallatah (2017), so
that the knowledge and growing awareness about the pain assessment in the healthcare
settings in Saudi Arabia could be understood. The objective of the research was to assess the
knowledge and understanding of the healthcare professionals and nurses in the healthcare
facilities in Saudi Arabia with assessment of their attitude while assessment of pain (Fallatah
2017). The researchers conducted a 3 month survey that included a 30 question questionnaire
and the primary assessment of the patient and their knowledge of pain assessment could be
understood (Fallatah 2017). Therefore, after the research it was observed that nursing
professionals in the Saudi Arabia lacks the knowledge and attitude which is required for the
patients that could be beneficial for the patients suffering from critical illness (Fallatah 2017).
Hence, the research recommends that the healthcare professionals in Saudi Arabia should
achieve proper education regarding pain management and learn the assessment method so
that accurate pain management could be implemented (Fallatah 2017).
2.2.1 Review of literature regarding standard of practice in pain management
The previous section of literature review assessed the lack of healthcare professionals
regarding the pain assessment interventions in healthcare facilities of Saudi Arabia. However,
the research regarding the type of practice followed by the healthcare professionals in the
healthcare facilities of Saudi Arabia should be mentioned (Moschinski et al. 2017). This
would help the research to understand the type and degree of pain assessment and therefore, it
helps to make the care process effective and accurate. In a research process by Chan and
Hamamura (2016), a cross sectional study under the quantitative research process was
conducted so that the negative effects of untreated pain among the patients and application of
pain assessment and management in such situations could be understood. In the process, the
researchers used a questionnaire with 247 questions so that the understanding of the patients
regarding pain management and understanding of pain assessment could be understood (Chan

15PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
and Hamamura 2016). Upon completion of the process, it was seen that 50% of the nursing
professionals not aware of their pain assessment or pain management education (Chan and
Hamamura 2016). Therefore, it was seen that majority of the nursing professionals not aware
of their pain management and hence, it was recommended in the pain education should be
provided in the healthcare facilities of Saudi Arabia so that they could be able to maintain the
pain assessment in the critical care of patients (Chan and Hamamura 2016). Another research
by Alqahtani and Jones (2015) was conducted to understand the type of pain assessment tool
the healthcare professionals in Saudi Arabia conducts so that the effectiveness of the
healthcare professionals in understanding the care process and pain assessment method could
be conducted. It was found that the nursing professionals were not aware of the widely
available assessment tools for pain assessment and were completely dependent on the
behaviour and ability of the patient to withstand the pain (N'Soundhat, Ndziessi and Bileckot
2015). Further, they just provided the patient with minimal morphine in higher and severe
pain situation. Therefore, through this research process, it was found that majority of the
nursing professionals lacked the knowledge about the pain assessment tools and process in
Saudi Arabia that indicated towards an alarming saturation (Rantala et al. 2015).
Another research was conducted by Bourdel et al. (2014), so that the ability of the nursing
professionals regarding the judgement of pain of patients while working in the healthcare
facilities of Saudi Arabia could be understood. It is seen that majority or more than 50% of
the patient’s undergone critical surgery suffers from moderate to critical pain and hence, the
nursing professionals should be aware of the pain assessment and management to provide
effective care to the patients (Bourdel et al. 2014). In this aspect the researchers conducted a
qualitative study and the visual analogue scale was used for the complete assessment and the
assessed or rated results were compared with the patients and their self- ratings (Bourdel et al.
2014). After completing the assessment, it was seen that majority of the nursing professionals

16PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
that assessed the pain level of patient, were wrong and required complete identification.
Hence, complete assessment and learning of pain assessment should be used for the pain
assessment method in Saudi Arabia healthcare facilities (Bourdel et al. 2014). Further, the
research process was able to understand the level of understanding of assessment tool usage
by the healthcare professionals in the healthcare facilities for the pain assessment and
management among the patients (Bourdel et al. 2014). Besides these, the researchers
indicated to the fact that due to the presence of serious language barriers among Arabian and
non-Arabian patients, the nursing professionals working in the healthcare facilities were
unable to provide effective treatment to the patients due to which the pain assessment method
also hampered and the decreased ability of the nursing professionals in conducting accurate
and proper pain assessment was observed (Alqahtani and Jones 2015). Hence, this was
conducted in the healthcare process of patients (Mohammed 2015).
2.2.3 Review of literature on complications regarding the pain assessment among the
patients
This aspect would focus on the global perspective as not only in Saudi Arabia, but also in
several sections of the world, nursing professionals suffer from complications while assessing
the pain among the critically ill patients (Chatchumni et al. 2016). Due to this, several
healthcare conditions are faced by the patients and their morbidity and mortality rates also
increases (Bouri et al., 2016). To understand the effect of this condition, the researchers
conducted a qualitative analysis so that the proper understanding of the effective nursing
interventions could be developed (N'Soundhat, Ndziessi and Bileckot 2017). Further, the
challenges included accurate and required healthcare aspects such as language and cultural
barriers, ideological barriers and others (N'Soundhat, Ndziessi and Bileckot 2015). Further
the data was collected by the healthcare facility after 20 nursing professionals were assessed
within the intensive care unit where the data was collected with the application of semi-

17PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
structured interview and inductive approach analysis was conducted so that accurate data
could be obtained (Amenorpe 2018). Hence after completion of the qualitative approach, it
was seen that the four aspects of the healthcare management would be barriers to knowledge
barriers to isolation, batters to ideology and barriers to attitude due to which patients with
effective healthcare conditions could be provided with improper or imbalanced pain
assessment. Therefore, this paper was included in the study (Colloca et al. 2017, Chatchumni
et al. 2016, Bourdel et al. 2014)
Another research articles by Samarkandi (2018) should be included in the care process so that
assessment of the pain and the management and the processing of the pain condition could be
done. As per Shahriary et al. (2015), adequate healthcare condition and accurate pain
assessment should be the target of the healthcare professional and in this aspect the ability of
the professionals should be assessed. However, in this aspect, if improper management is
conducted, then patients and their physical and emotional and psychological complication
increase. In this aspect, the researchers assessed the knowledge of the nursing professionals
regarding the healthcare pain assessment (Rantala et al. 2015). Hence, this aspect was
focused for the research aspect and in this aspect and therefore, this was determined that
majority of the nursing professionals were associated with improper knowledge of pain
assessment. Hence, it was assessed for the research process (Alotaibi, Higgins and Chan
2018).

18PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
The understanding of pain assessment among
nursing professionals of Saudi Arabia and
understanding their behaviour and attitude while
conducing healthcare process among the patients
suffering from severe pain condition.
Understanding the level of understanding and
the standard of practice regarding pain
assessment among the nursing professionals of
Saudi Arabia Military Hospital Makkah, Saudi
Arabia
Assessment of pain
among the critically ill
patients suffering from
healthcare conditions
Demographic Data
Nursing professionals their
understanding, their education level
and their professionals experience
Developed by the author
2.3 Conceptual & Theoretical Framework
2.3.1 Conceptual Framework

19PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
As per Inoue and Kent (2014), conceptual frame is the process using which researcher could
integrate, and explain their research process with a detailed explanation, prediction, and
understanding of the research question. Researchers are able to understand the process, as
they take both the variables dependent and independent variables. Hence, after complete and
detailed assessment of the process this platform of research was conducted (Gnyawali et al.
2016). Therefore, the complete structure of the framework was developed in the study
depending on the aim of the study.
Chapter 3: Methodology
3.1 Research Design
The research design that was selected for this investigation was cross sectional research
design. Cross sectional research design is a type of observational study and can be defined as
a study design in which a subset of representative population is selected for analysis for a
specific point of time (Charan and Biswas 2013). In this type of research design, variables
that were considered can be quantified and quantitative data can be obtained (Häuser et al.
2014). Due to the nature of quantitative data, it can be interpreted in a meaningful way which
is helpful for the deduction of research findings. Furthermore, straight forward close ended
questions were used for the questionnaires used in this investigation which was then analysed
using Microsoft excel.
3.2 Study Type
Quantitative, qualitative, and descriptive research methodology was chosen for this
investigation. Quantitative and qualitative data collection method was chosen, so that the data
will be readily available (due to numerical nature of the collected data) for the analysis for
this research investigation (Ingham-Broomfield 2014). This analysis will aid in the deduction
of the subsequent research findings. The Quantitative and descriptive methods was

20PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
implemented by the way of close ended and straight forward questions and different optional
choice instead of ‘Yes’ and ‘No’ represents the qualitative part of the analysis. The answers
of this questionnaires were categorized using Microsoft Excel and it was analysis in the same
platform as well.
3.3 Study Settings
The objective of this investigation was to investigate the knowledge and practice method of
the nurses in case of pain management for the critically ill patients in the Emergency Room at
Military Hospital Makkah, Saudi Arabia. Therefore, the study setting was set up among the
emergency nurses who work at the emergency department of the Military Hospital Makkah,
Saudi Arabia. The participants for this investigation were selected amongst them.
3.4 Study Population
Nurses who work at the emergency department of Military Hospital Makkah, Saudi Arabia
was selected for this study. Sample population was from the different hierarchy level as well
with different job title and experience. Amongst the sample population, nurses with five
different job title were selected and the job titles were head nurse (HN), RN 1 (registered
nurse 1), RN 2, RN 3, and PCA. Maximum experience level was 6 years while minimum
experience level was 1 years.
3.5 Sampling Size
The sampling size that was utilized in this assignment was 30 and these 30 nurses were used
for the data collection through close ended questionnaires.
3.6 Sampling Method
Simple random sampling method was used in this investigation as sampling method. The
sampling was conducted on the basis of voluntary participation. The reason behind the choice
of simple random sampling method was that it is a non- biased method of sample selection.

21PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
In the simple random sampling, all the member of the population has a similar chance for
selection possibilities which negates the chance of bias (Prasad, Kumar and Vaidaya 2016).
The participation was totally voluntary and no coercion techniques was used during the
selection process as well as during the answering process of the questionnaires used in this
investigation.
3.7 Sampling Criteria
During the sampling technique, inclusion and exclusion criteria were implemented. The
population in the study group included nurses working in the emergency department of
Military Hospital Makkah, Saudi Arabia. The study groups included nurses working in
emergency department only and this was treated as inclusion criteria. Exclusion criteria for
the sample group were nurses who were working as interns or on maternity leave, yearly
leave, and long periods of sick leave in the emergency department of the hospital.
3.8 Research Instrument
Questionnaires were the tool used as research instruments to collect data. The questionnaire
was built on the basis of prior research studies (Gallagher et al. 2014; Nimbalkar et al. 2014).
The questionnaires were tweaked to comply with the particular knowledge and awareness of
pain assessment in the patient with chronic illness who admitted to the emergency department
of the hospital. The questionnaire pattern is like a funnel where diverse issues like
demographics start at first (Fugard et al. 2015). Specific questions were addressed with
knowledge and understanding regarding pain assessment. The survey questionnaire consists
of three sections which are demographic questions, practice questions and examination
questions. Section I consisted of five demographic questions used for collection of
demographic information. This section collects data through open ended questions such as
age gender as well as multiple choice questions in order to address diverse experience level
of the participants. Section II comprises of six questions used to gather information at

22PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
practice and guidance level. Section III uses 5 questions for exams where in each question
one out of 5 options is right. These questions have been made to find the knowledge level of
the participants through examination score.
The survey questionnaire used in Section I, Section II and Section III for this investigation
have been presented in the Appendix 1.
3.9 Data Collection
This investigation began following written approval from the University. Recruitment was
conducted for two months after an approval from the unit manager, the nursing manager of
the emergency department was informed by electronic mail and data collection commenced
after the completion of the formalities. The investigators handed the questionnaire personally
to the participant for completion. The total participant had been informed before the
participation that the investigation was voluntary and they can withdraw at any time. The
whole participant concurred upon secured permission and received the survey questionnaire
during the course of the study.
3.10 Data Analysis
Collected data were recorded and archived using the platform Microsoft Excel and SPSS data
analysis software was also used for the analysis of the collected data. For demographical data
analysis and for developing scores from the examination the excel was used. The SPSS 2.0
software was used to analyse the correlation between the knowledge level, practice level and
nursing experiences. Data analyses were conducted for all the 30 participants who were
participated in the investigation.
3.11 Ethical Consideration
Ethical standards have been maintained in this experiment according to the standard norm
from the design of the research (research proposal) to the entire investigation process

23PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
and reporting of results. Consent of the University was acquired for the investigation. The
research instrument was taken from work published by previous researchers (Bigham et al.
2014). The confidentiality of the two parties were guaranteed and the confidentiality of the
participants, the researcher and the hospital was not be violated by any means. The
experiment is voluntary and respondents can withdraw from their participation without
any collateral impact.
Chapter 4: Results
4.1 Demographic Information of the Participants
The first part of the questionnaire was about the demographic information of the participants.
They were all total 30 participants and each of the participants were analysed based on their
age group, gender, years of experience, and job title. The details presentation and
segmentation of their difference in demographic information is presented in the Table 1
below.
Table 1: Demographic information of the participants
Participants Frequency Percentage of Sample
Population
Age Group
20 - 30 7 23.33
31 - 40 15 50.00
41 - 50 1 3.33
51 - 60 7 23.33
Gender Male 8 26.65
Female 22 73.35
Years of
Experience
1 to 5 16 53.33
5 to 10 11 36.67
10+ 3 10.00
Job Title
HN 1 3.33
RN 1 16 53.33
RN 2 8 26.67
RN 3 2 6.67
Intern 3 10.00

24PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
4.1.1 Gender
From the data presented in the Table 1, it can be seen that the gender of the participants in
predominantly female and out of 30 participants, 73% of them were female.
4.1.2 Range of Age Group
The age range of the participants varied from 20 years old to the 40 the years old. The
participants were segmented among the 4 different age groups. From the data presented in the
Table 1, it can be seen that maximum participants belong to the age group of 20 to 30 years
old and they are 50 per cent of the total participants. Participants belonging to the age group
of 20 to 25 years old and 36 to 40 years old were next with each of them having 7 participants
each which are around 23 per cent of the total participants. Only one participant belongs to
the age group of 31 to 35 years old.
4.1.3 Years of Experience
The participants that took the voluntary survey questionnaire had many different level of
experience. The levels of experience were divided in three groups. From the data presented in
the Table 1, it can be said that the around 54 per cent of participants had the experience level
of more than 5 years. The participants with less than or equal to 5 years of experience belongs
to the approximately 37 per cent of the total participants. Only 3 participants had the
experience level between these two categories which is between 3 to 4 years of experience.
4.1.4 Level of Job Title
Among the participants, the job title RN (level 1) was the most dominant. Almost, 54 per cent
(16 numbers of participants) of the total participants belongs to this job title. Apart from that,
they was one participants with job title Head Nurse, 8 participants with the job title RN (level
2), 3 participants with the job title intern and 2 participants with the job title RN (level 3).

25PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
4.2 Level of knowledge and standards of practice among the Nurses with regards
to the pain assessments
Section II of the survey questionnaire was used to evaluate the levels of knowledge and
standard of practice among the nurses with regard to the pain assessment. In these Section, all
total 6 questions were presented to the participants and each were equipped with multiple
choice and the participants had to choose one choice amongst them. The questionnaire
regarding the section is provided in the Appendix 1 section in detail manner. In this Section, a
trend has been noticed during analysis and arranging of the collected. All the participants had
the similar response to the question regarding the levels of knowledge and standard of
practice and each of the questions has a predominant answer. In the Table 2, all the
qualitative close ended questions were provided according the sequence the questions were
provided in the survey form and respective predominant response of the participants were
provided. Furthermore, the mean value of the response was provided as well along with the
standard deviation.
Descriptive Statistics
Mean Std. Deviation N
Regularity_PA 2.43 .858 30
Significance_PA 2.67 1.184 30
Received_training 2.50 1.106 30
Received_Guidance 2.60 1.248 30
Successful_PA 2.50 1.009 30
Exam_score 2.57 1.305 30
Training_needs 3.30 1.022 30
Table 2: Descriptive Statistics of training and standard of practice
From the descriptive statistics it has also been observed from the data that among all of the
participants (100 per cent), very few nurses took part in the pain assessment training session

26PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
provided by the hospital for health care professionals. The most predominant answer of the
each question and its frequency is lower than the moderate level which is 3. Most of the mean
values of the variables are less than 3 accept the value of training needs. The mean value 2.4
indicates that the nurses are not regularly using the pain assessment process. The mean value
2.6 indicates that the nurses are not aware enough about the significance of the pain
assessment as a nursing practice. The mean value 2.5 indicates that the nurses are not getting
enough on pain assessment procedure and significance. The mean value 2.6 indicates that the
nurses are not regularly guided and supported by their superior for using using the pain
assessment process. The mean value 2.5 indicates that the nurses are not successful enough to
manage the pain of a patient efficiently. The mean value 2.5 indicates that the most of the
nurses scores less than 50% in the nursing examination which shows the lack of knowledge
regarding pain management in nursing workforce. The mean value 3.3 indicates that the
nurses are very interested about having a proper training regularly using the pain assessment
process.
In the following table (Table 3) the correlations between the variables regarding the nursing
practice, knowledge and training are presented. The Pearson correlation values have been
accepted when the significant 2 tailed value is lower than the 0.05. The lower 2 tailed value
than probability test value signifies that the relation between to corresponding variable is
statistically significant.
Correlations
Regularity_
PA
Significance_
PA
Received_
training
Received_
Guidance
Successful_
PA
Exam_
score
Training
_needs
Regularity_P
A
Pearson
Correlation 1 .690** .672** .682** .896** .697** .043
Sig. (2-tailed) .000 .000 .000 .000 .000 .821
N 30 30 30 30 30 30 30
Significance
_PA
Pearson
Correlation .690** 1 .895** .886** .837** .818** .114
Sig. (2-tailed) .000 .000 .000 .000 .000 .549

27PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
N 30 30 30 30 30 30 30
Received_tra
ining
Pearson
Correlation .672** .895** 1 .949** .819** .920** .076
Sig. (2-tailed) .000 .000 .000 .000 .000 .689
N 30 30 30 30 30 30 30
Received_G
uidance
Pearson
Correlation .682** .886** .949** 1 .767** .927** -.038
Sig. (2-tailed) .000 .000 .000 .000 .000 .843
N 30 30 30 30 30 30 30
Successful_
PA
Pearson
Correlation .896** .837** .819** .767** 1 .773** .084
Sig. (2-tailed) .000 .000 .000 .000 .000 .660
N 30 30 30 30 30 30 30
Exam_score Pearson
Correlation .697** .818** .920** .927** .773** 1 .023
Sig. (2-tailed) .000 .000 .000 .000 .000 .903
N 30 30 30 30 30 30 30
Training_ne
eds
Pearson
Correlation .043 .114 .076 -.038 .084 .023 1
Sig. (2-tailed) .821 .549 .689 .843 .660 .903
N 30 30 30 30 30 30 30
**. Correlation is significant at the 0.01 level (2-tailed).
Table 3: Correlation of variables
From the data presented in the above section, it can be stated that the variables are mutually
correlated accept the training needs. The significant correlation value for the regular Pain
assessment practice and the exam score is 0.69, which indicates that the lower knowledge in
pain assessment is causing lower practice of pain assessment. The significant correlation
value for the regular Pain assessment practice and the awareness about the significance of
Pain assessment is 0.69, which indicates that the lower awareness of pain assessment is
causing lower practice of pain assessment.
The significant correlation value for the regular Pain assessment practice and the success rate
is 0.89. On the other hand, The significant correlation value for the success rate and the exam
score is 0.77. These correlation values indicate that the rate of successful management of pain
is directly depends on in pain assessment practice as well as knowledge in pain assessment.
Hence, it can be interpreted that the lower knowledge, practice and awareness in pain
management within nurses is causing lower practice of pain assessment.

28PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
Chapter 5: Discussion and Conclusion
5.1 Discussion
For this investigation, total 30 responses were collected from the voluntary participants. The
collection method for this survey was by person and each of the survey questionnaires were
delivered and collected from the participants by hand. Microsoft Excel as well as SPSS were
used for the organising and analysis of the collected data.
From the demographic information presented in the result section, it can be stated the
participants were predominantly female and they have contributed to the 100 per cent of the
total participants. Maximum number of the participants belongs to the age group of 26 to 30
years old and half of the participants were from this age group. It is also seen that the more
than 50 per cent of the participants were very experienced and 16 participants had more than
5 years of experience in the area of nursing. Additionally, predominant job title among the
participants was ‘Registered Nurse Level 1’.
From the data presented in the result section, it can be stated the Nurses in the Military
Hospital Makkah, Saudi Arabia follows a strict regime and guidelines and all the nurses abide
by it. The above statement is evident by the collected response as all the nurses responded
each question regarding levels of knowledge and standard of practice with same response.
This signifies that the nurses in the Military Hospital Makkah, Saudi Arabia have not been
trained thoroughly in the area of pain assessment and they are able to implement in
successfully in their professional activities. These findings denote a good adherence to the
standard of practice in the Military Hospital Makkah, Saudi Arabia by the nurses.
The analysed data deduced from the responses of the present shows that the nurses in the
Military Hospital Makkah, Saudi Arabia have very low understanding of the Standard of
practice and low level of the knowledge regarding the pain assessment among the chronically

29PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
ill patients in emergency department. Thus, it can be deduced that they have followed strict
guidelines and all the nurses are abiding by it. This is in clear contrast with the findings
presented in the literature review section of this investigation. In the literature review section,
most of the literature review said that the nurses lack the knowledge regarding pain
assessment. This information also bolsters the statement made in the first line of this
paragraph.
Studies have shown that the management of training and development should train the nurses
adequately so that they can understand the process and significance of pain assessment. It
will also allow them to utilise the pain assessment practice in their regular treatment and
assessment (Patel et al. 2016). In this area the nurses in the Military Hospital Makkah, Saudi
Arabia have shown excellent competency. All the questions have provided a response of 100
per cent which signifies that the all of the nurses are aware of the fact that pain management
has paramount importance in the every department.
According to the recent publications, it has been reported that standard of practice and
adherence to the guidelines is also quite important in case nursing practice (Odell 2015). This
aspect was also considered among the questionnaires. For this reason, ‘Do you know the
concept of standard precaution?’ was specifically placed in the survey questionnaire. All the
response to this question was ‘I know it well’. Therefore, it can be deduced that the nurses in
the Military Hospital Makkah, Saudi Arabia are well aware of the fact about the standard of
the practice related to the nursing management with the patient admitted in the emergency
department due to painful illness and procedural pain.
However, they do have some gap in their practice regarding the control of severe pain the rate
of fatality could be increase for anxiety level, stress, higher blood pressure, elevated heart
rate and others (World Health Organization 2014). Therefore, Military Hospital Makkah,

30PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
Saudi Arabia should review this particular standard of practice for enhancement of control of
regular pain assessment implementation, knowledge, awareness and training among the
nurses and caregivers.
5.2 Limitation of this Study
As per the shortcomings and limitations of the research can be defined as the inaccuracy of
the findings which are beyond the control of the researcher. This study is restricted by the
study population in which only the emergency nursing staff at Military Hospital Makkah,
Saudi Arabia participated in. Due to small number of sample size and lack of diversity with
regard to sample population, the findings of this investigation cannot as a result be
generalized beyond this group to the sample population.
5.3 Conclusion
This investigative study has been able to attain its goals which were to evaluate
the knowledge, practice standards, and the relation between emergency nurses with regard to
pain assessment in the Military Hospital Makkah, Saudi Arabia. From the background study
and literature review it has been evident that there is a significant gap with regard to the pain
assessment and management among the nurses. Although the results presented in this study
provided a stark contrast in this regard. This findings of this study reports that the nurses in
the Military Hospital Makkah, Saudi Arabia have very low understanding of the Standard of
practice and low level of the knowledge regarding the pain assessment. Even though, there is
minor gap in their practice regarding their assessment. Efforts must be made to iron out the
minor glitch which is present in the otherwise strong and excellent standards of practice
which will make quality of health care service provided by Military Hospital Makkah, Saudi
Arabia even better.

31PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
5.4 Recommendation
This research shows that although many nurses have a high level of knowledge on
pain assessment in the emergency department, the standard of practice does not comply 100
per cent with the regulation and it should be looked after as discussed in the discussion
section. Continued training in pain assessment techniques is therefore critical for the new and
interim nurses which could consist of many young and novice adults in this environment.
Secondly, a hands-on workshop on the pain assessment using the practical equipment should
be held to educate the staff on pain assessment.
Thirdly, to avoid mistakes in the emergency department, a checklist should be set up for all
the nurses who are on duty in the department.
Finally, further research is needed in this area with a much bigger sample size, so that the
findings can be generalised with the general population.

32PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
References
Abuelkheir, M., Alsourani, D., Al-Eyadhy, A., Temsah, M.H., Meo, S.A. and Alzamil, F.,
2014. EMLA® cream: A pain-relieving strategy for childhood vaccination. Journal of
International Medical Research, 42(2), pp.329-336.
Al-Atiyyat, N., Salim, N.A., Tuffaha, M.G., Nigim, H.A.A., Mah'd Saleh, M., Alkhodary,
M.E. and Brant, J.M., 2018. A Survey of the Knowledge and Attitudes of Oncology Nurses
toward Pain in United Arab Emirates Oncology Settings. Pain Management Nursing.
Al-Khawaldeh, O.A., Al-Hussami, M. and Darawad, M., 2013. Knowledge and attitudes
regarding pain management among Jordanian nursing students. Nurse Education
Today, 33(4), pp.339-345.
Alotaibi, K., Higgins, I. and Chan, S., 2018. Nurses’ Knowledge and Attitude toward
Pediatric Pain Management: A Cross-Sectional Study. Pain Management Nursing.
Alqahtani, M. and Jones, L.K., 2015. Quantitative study of oncology nurses' knowledge and
attitudes towards pain management in Saudi Arabian hospitals. European Journal of
Oncology Nursing, 19(1), pp.44-49.
Al-Quliti, K.W. and Alamri, M.S., 2015. Assessment of pain: Knowledge, attitudes, and
practices of health care providers in Almadinah Almunawwarah, Saudi
Arabia. Neurosciences, 20(2), p.131.
Amenorpe, F.D., 2017. Chronic Pain Experiences Among Advanced Cancer Patients In The
Accra Metropolis (Doctoral dissertation, University of Ghana).
Andersson, V., Otterstrom-Rydberg, E. and Karlsson, A.K., 2015. The importance of written
and verbal information on pain treatment for patients undergoing surgical interventions. Pain
Management Nursing, 16(5), pp.634-641.

33PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
Andersson, V., Otterstrom-Rydberg, E. and Karlsson, A.K., 2015. The importance of written
and verbal information on pain treatment for patients undergoing surgical interventions. Pain
Management Nursing, 16(5), pp.634-641.
Attar, S.M., 2014. Frequency and risk factors of musculoskeletal pain in nurses at a tertiary
centre in Jeddah, Saudi Arabia: a cross sectional study. BMC research notes, 7(1), p.61.
Bigham, B.L., Jensen, J.L., Tavares, W., Drennan, I.R., Saleem, H., Dainty, K.N. and Munro,
G., 2014. Paramedic self-reported exposure to violence in the emergency medical services
(EMS) workplace: a mixed-methods cross-sectional survey. Prehospital emergency
care, 18(4), pp.489-494.
Bourdel, N., Alves, J., Pickering, G., Ramilo, I., Roman, H. and Canis, M., 2014. Systematic
review of endometriosis pain assessment: how to choose a scale?. Human reproduction
update, 21(1), pp.136-152.
Bouri, F., El Ansari, W., Mahmoud, S., Elhessy, A., Al-Ansari, A. and Al-Dosari, M., 2018,
September. Orthopedic Professionals’ Recognition and Knowledge of Pain and Perceived
Barriers to Optimal Pain Management at Five Hospitals. In Healthcare (Vol. 6, No. 3, p. 98).
Multidisciplinary Digital Publishing Institute.
Burke, A.L., Mathias, J.L. and Denson, L.A., 2015. Psychological functioning of people
living with chronic pain: A meta‐analytic review. British Journal of Clinical
Psychology, 54(3), pp.345-360.
Chan, J.C. and Hamamura, T., 2016. Emotional intelligence, pain knowledge, and attitudes of
nursing students in Hong Kong. Pain Management Nursing, 17(2), pp.159-168.

34PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
Chang, J., Versloot, J., Fashler, S. R., McCrystal, K. N., & Craig, K. D. (2015). Pain
assessment in children: validity of facial expression items in observational pain scales. The
Clinical journal of pain, 31(3), 189-197.
Charan, J. and Biswas, T., 2013. How to calculate sample size for different study designs in
medical research?. Indian journal of psychological medicine, 35(2), p.121.
Chatchumni, M., Namvongprom, A., Eriksson, H. and Mazaheri, M., 2016. Thai Nurses’
experiences of post-operative pain assessment and its’ influence on pain management
decisions. BMC nursing, 15(1), p.12.
Colloca, L., Ludman, T., Bouhassira, D., Baron, R., Dickenson, A.H., Yarnitsky, D.,
Freeman, R., Truini, A., Attal, N., Finnerup, N.B. and Eccleston, C., 2017. Neuropathic
pain. Nature reviews Disease primers, 3, p.17002.
Darwish, M.A. and Al-Zuhair, S.Z., 2013. Musculoskeletal pain disorders among secondary
school Saudi female teachers. Pain research and treatment, 2013.
Duke, G., Haas, B.K., Yarbrough, S. and Northam, S., 2013. Pain management knowledge
and attitudes of baccalaureate nursing students and faculty. Pain Management Nursing, 14(1),
pp.11-19.
Eid, T., Manias, E., Bucknall, T. and Almazrooa, A., 2014. Nurses' knowledge and attitudes
regarding pain in Saudi Arabia. Pain Management Nursing, 15(4), pp.e25-e36.
Fallatah, S.M., 2017. Pain knowledge and attitude survey among health-care professionals at
a university hospital in Saudi Arabia. Saudi journal of medicine & medical sciences, 5(2),
p.155.
Fawcett, J. and Desanto-Madeya, S., 2012. Contemporary nursing knowledge: Analysis and
evaluation of nursing models and theories. FA Davis.

35PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
Fugard, A.J., Stapley, E., Ford, T., Law, D., Wolpert, M. and York, A., 2015. Analysing and
reporting UK CAMHS outcomes: an application of funnel plots. Child and Adolescent
Mental Health, 20(3), pp.155-162.
Gallagher, R., Fry, M., Chenoweth, L., Gallagher, P. and Stein‐Parbury, J., 2014. Emergency
department nurses’ perceptions and experiences of providing care for older people. Nursing
& health sciences, 16(4), pp.449-453.
Glick, M., Williams, D.M., Kleinman, D.V., Vujicic, M., Watt, R.G. and Weyant, R.J., 2016.
A new definition for oral health developed by the FDI World Dental Federation opens the
door to a universal definition of oral health. British dental journal, 221(12), p.792.
Gnyawali, D.R., Madhavan, R., He, J. and Bengtsson, M., 2016. The competition–
cooperation paradox in inter-firm relationships: A conceptual framework. Industrial
Marketing Management, 53, pp.7-18.
Häuser, W., Wolfe, F., Henningsen, P., Schmutzer, G., Brähler, E. and Hinz, A., 2014.
Untying chronic pain: prevalence and societal burden of chronic pain stages in the general
population-a cross-sectional survey. BMC public health, 14(1), p.352.
Herr, K., St Marie, B., Gordon, D.B., Paice, J.A., Watt-Watson, J., Stevens, B.J., Bakerjian,
D. and Young, H.M., 2015. An interprofessional consensus of core competencies for
prelicensure education in pain management: curriculum application for nursing. Journal of
Nursing Education, 54(6), pp.317-327.
Holmberg, S.D., Suryaprasad, A. and Ward, J.W., 2012. Updated CDC recommendations for
the management of hepatitis B virus–infected health-care providers and students. Morbidity
and Mortality Weekly Report: Recommendations and Reports, 61(3), pp.1-12.

36PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
Ingham-Broomfield, R., 2014. A nurses' guide to quantitative research. Australian Journal of
Advanced Nursing, The, 32(2), p.32.
Inoue, Y. and Kent, A., 2014. A conceptual framework for understanding the effects of
corporate social marketing on consumer behavior. Journal of business ethics, 121(4), pp.621-
633.
Jenkins, T.C., Stella, S.A., Cervantes, L., Knepper, B.C., Sabel, A.L., Price, C.S., Shockley,
L., Hanley, M.E., Mehler, P.S. and Burman, W.J., 2013. Targets for antibiotic and healthcare
resource stewardship in inpatient community-acquired pneumonia: a comparison of
management practices with National Guideline Recommendations. Infection, 41(1), pp.135-
144.
Khalaileh, M.A. and Qadire, M.A., 2013. Pain management in Jordan: nursing students'
knowledge and attitude. British Journal of Nursing, 22(21), pp.1234-1240.
Mazoyer, J., Sastre, M.T.M., Sorum, P.C. and Mullet, E., 2017. Mapping French people and
health professionals’ positions regarding the circumstances of morphine use to relieve cancer
pain. Supportive Care in Cancer, 25(9), pp.2723-2731.
Mohammed, N., 2015. Knowledge and attitudes of pain management by nurses in Saudi
Arabian emergency departments: a mixed methods investigation.
Moschinski, K., Kuske, S., Andrich, S., Stephan, A., Gnass, I., Sirsch, E. and Icks, A., 2017.
Drug-based pain management for people with dementia after hip or pelvic fractures: a
systematic review. BMC geriatrics, 17(1), p.54.
Nimbalkar, A.S., Dongara, A.R., Phatak, A.G. and Nimbalkar, S.M., 2014. Knowledge and
attitudes regarding neonatal pain among nursing staff of pediatric department: an Indian
experience. Pain Management Nursing, 15(1), pp.69-75.

37PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
N'Soundhat, N.E.L., Ndziessi, G. and Bileckot, R., 2017. Connaissances et pratiques de la
prise en charge de la douleur rhumatismale dans les centres de santé intégrés de
Brazzaville. Douleurs: Évaluation-Diagnostic-Traitement, 18(6), pp.269-273.
Odell, M., 2015. Detection and management of the deteriorating ward patient: an evaluation
of nursing practice. Journal of clinical nursing, 24(1-2), pp.173-182.
Oldenmenger, W.H., Pleun, J., de Klerk, C. and van der Rijt, C.C., 2013. Cut points on 0–10
numeric rating scales for symptoms included in the Edmonton Symptom Assessment Scale in
cancer patients: a systematic review. Journal of pain and symptom management, 45(6),
pp.1083-1093.
Patel, V., Chisholm, D., Parikh, R., Charlson, F.J., Degenhardt, L., Dua, T., Ferrari, A.J.,
Hyman, S., Laxminarayan, R., Levin, C. and Lund, C., 2016. Addressing the burden of
mental, neurological, and substance use disorders: key messages from Disease Control
Priorities. The Lancet, 387(10028), pp.1672-1685.
Pereira, L.V., Pereira, G.D.A., Moura, L.A.D. and Fernandes, R.R., 2015. Pain intensity
among institutionalized elderly: a comparison between numerical scales and verbal
descriptors. Revista da Escola de Enfermagem da USP, 49(5), pp.804-810.
Prasad, K.D.V., Kumar, V.A. and Vaidaya, R., 2016. Optimization of Human Resources
Using Simple Random Sampling Without Replacement: A Case Study using C and
CSCAPE. Optimization, 4(5).
Rantala, M., Hartikainen, S., Kvist, T. and Kankkunen, P., 2015. Registered nurses'
knowledge about adverse effects of analgesics when treating postoperative pain in patients
with dementia. Pain Management Nursing, 16(4), pp.544-551.

38PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
Samarkandi, O.A., 2018. Knowledge and attitudes of nurses toward pain management. Saudi
journal of anaesthesia, 12(2), p.220.
Shahriary, S., Shiryazdi, S.M., Shiryazdi, S.A., Arjomandi, A., Haghighi, F., Vakili, F.M. and
Mostafaie, N., 2015. Oncology nurses knowledge and attitudes regarding cancer pain
management. Asian Pac J Cancer Prev, 16(17), pp.7501-6.
Ung, A., Salamonson, Y., Hu, W. and Gallego, G., 2016. Assessing knowledge, perceptions
and attitudes to pain management among medical and nursing students: a review of the
literature. British journal of pain, 10(1), pp.8-21.
Watt-Watson, J. and Murinson, B.B., 2013. Current challenges in pain education. Pain
management, 3(5), pp.351-357.
Williams, A.C.D.C. and Craig, K.D., 2016. Updating the definition of pain. Pain, 157(11),
pp.2420-2423.
Williams, D.A., 2013. The importance of psychological assessment in chronic pain. Current
opinion in urology, 23(6), p.554.
World Health Organization, 2014. Interim infection prevention and control guidance for care
of patients with suspected or confirmed filovirus haemorrhagic fever in health-care settings,
with focus on Ebola (No. WHO/HIS/SDS/2014.4 Rev. 1). World Health Organization.

39PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
Appendix – 1
Survey Questionnaire:
1. Your age group 20 to 30 31 to 40 41 to 50 51 to 60 More than
60
2. Gender Male Female
3. Years of Experience Below 1 year 1 to 5 years 5 to 10 years More than
10
4. Your Job position Intern RN1 RN2 RN3 HN
5. Department Medical and
Primary Care
Mother and
child care
Emergency Surgical ICU
6. Rate pain assessment as a
part of your regular job
role
Very low Low Moderate High Very High
7. Significance of pain
assessment in nursing
practice
Very low Low Moderate High Very High
8. How much pain
assessment training you
received in past 3 years
Very low Low Moderate High Very High
9. Rate how much do you
need a pain assessment
training
10
.
How much do you
receive guidance and
support regularly from
your superior regarding
pain assessment
Very low Low Moderate High Very High
11
.
As per your experience
how do you rate your
success in successfully
understanding and
managing your patient’s
pain
Very low Low Moderate High Very High
Examination on pain assessment: choose the correct answer
Questions Options
EQ1 Procedural pain
associated with
Burn care and
Wound care
Appendicitis Cardiac pain
care
All of them None of
them
EQ2 Wong-Baker FACES
scale consists of
5 faces 6 faces 10 faces All of them None of
them
EQ3 Which pain scale is
the most sensitive to
gender and ethnic
differences?
Visual Verbal Numerical Flacc None of
them
EQ4 Which pain scale Visual Verbal Numerical Flacc None of

40PAIN ASSESSMENT IN CRITICALLY ILL PATIENT
would be the most
appropriate for a
patient who is unable
to communicate their
pain or in an
unconscious state?
them
EQ5 Pain is considered as
the vital sign with the
position of
2st 3rd 4th 5th None of
them