Pain Assessment Knowledge and Practice in Emergency Room Nurses

This report investigates the knowledge and practices of nurses regarding pain assessment for critically ill patients in the Emergency Room at Military Hospital Makkah, Saudi Arabia. The study aims to address the gap in research concerning pain management in critical care settings, where pain is often underestimated or inadequately addressed. The research employs a descriptive cross-sectional design to evaluate nurses' understanding and application of pain assessment guidelines, with the goal of improving patient-centered care and minimizing discomfort. The findings are expected to inform the development of strategies and protocols to enhance nurses' pain assessment skills and ultimately improve the quality of life for critically ill patients. The study acknowledges limitations such as reliance on self-reports and potential non-response, while emphasizing the significance of improved pain assessment in optimizing patient recovery.

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Knowledge and practice towards pain assessment in critically ill patient among Nurses in
Emergency Room at Military Hospital Makkah, Saudi Arabia.
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Table of Contents
CHAPTER 1: INTRODUCTION...........................................................................................3
1.1 Background of the Study..................................................................................................3
1.2 Problem Statement............................................................................................................3
1.3 Objective of the Study......................................................................................................4
1.4 Research Questions..........................................................................................................4
1.5 Significance of the Study..................................................................................................4
1.6 Limitations of the Study...................................................................................................5
1.7 Operational Definitions....................................................................................................5
CHAPTER 2: REVIEW OF LITERATURE........................................................................6
2.1 Search Strategy.................................................................................................................6
2.2 Overview on Basic Life Support and Level of Knowledge of Basic Life Support among
Nurses.....................................................................................................................................6
CHAPTER 3: METHODOLOGY..........................................................................................9
3.1 Research Design...............................................................................................................9
3.2 Setting of the Study..........................................................................................................9
3.3 Population.........................................................................................................................9
3.5 Sampling Criteria............................................................................................................10
3.6 Sample and Its Size........................................................................................................10
3.7 Variables.........................................................................................................................11
3.8 Instrument.......................................................................................................................11
3.9 Validity and Reliability..................................................................................................11
3.10 Pilot Study....................................................................................................................12
3.11 Data Collection Procedure............................................................................................12
3.12 Data Analysis................................................................................................................13
3.13 Ethical Considerations..................................................................................................13
CHAPTER 4: DATA ANALYSIS........................................................................................13
CHAPTER 5: DISCUSSION AND CONCLUSION...........................................................13
References...............................................................................................................................14
Appendices..............................................................................................................................18
Appendix 1: Gantt Chart...................................................................................................18

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CHAPTER 1: INTRODUCTION
1.1 Background of the Study
The International Association for the study of pain as defined pain as a hostile sensory and
passionate experience that is related to potential tissue injury (Loeser and Treede, 2008).
Pasero (2009) describes pain assessment as a necessary procedure which involves examining
the location and intensity of pain. The role of providing the most appropriate ease for
severely sick patients is an overall aim for doctors and nurses since pain is an experience that
makes a patient uncomfortable. Pain can be caused by already existing illness, invasive
procedures or distress (Arif-Rahu and Grap, 2010). Buttes et al. (2014) observe that pain
assessment is the initial step towards pain management, and is very significant in patient care.
The inadequate management of critical pain negatively affects the normal functioning of the
organ system, in addition to physical and psychological outcomes (Bennett and Hurford,
2011). Studies indicate that critically ill adult patients (CIAP) experience pain while in a
restful position and during usual care (Barr et al., 2013). The magnitude of CIAP is a
drawback to the efforts being made in the improvement of knowledge and technology aimed
at optimal pain assessment (Cogan, 2010). Based on the foregoing evidence, improved pain
assessment for acute pain is an essential aspect in addressing the needs of patients and
optimizing the possibility of recovery (Li et al., 2014). Therefore, evaluating Nurses
knowledge and practice of guidelines associated with acute pain assessment and management
is therefore fundamental to adequate pain relief.
1.2 Problem Statement
Severely sick patients often undergo average to extreme pain, and in instances of deadly
sickness, the alleviation of pain is overlooked, or at least not adequately esteemed by the
health care providers (Barr et al., 2013). Studies have pointed out that 64% of patients

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remember having undergone pain and term it as the most stressful encounter during their
critical stay (Puntillo et al., 2009). Even though pain is a crucial issue in critical care settings,
the matter hasn’t sufficiently been researched by critical care nurses.
The hindrances faced by the nurses such as knowledge shortfalls about pain assessment,
failure to evaluate and appreciate the presence of pain, individual and social preference have
substantially contributed to inadequate pain evaluation among severely sick patients (Pasero
et al., 2009). Thomas (2008) found out that the incorrect pain assessment alongside the
outcomes of inadequate pain alleviation in critically ill adults causes grievous physiological
and psychological effect. However, there is limited literature on the nurses’ knowledge and
practices on pain assessment notwithstanding the increased awareness on the same (Pasero et
al., 2009). There exists no study focusing on the knowledge and practices of nurses in pain
assessment among critically ill in the Emergency Room at Military Hospital Makkah.
1.3 Objective of the Study
To explore the knowledge and practices of nurses in pain assessment for critically ill patients
in the Emergency Room at Military Hospital Makkah, Saudi Arabia.
1.4 Research Questions
1. What are the pain assessment practices among nurses caring for critically ill patients
in the Emergency Room at Military Hospital Makkah?
2. What is the level of knowledge related to pain assessment among nurses caring for
critically ill patients in the Emergency Room at Military Hospital Makkah?
1.5 Significance of the Study
The findings of this study will enable nurses to adequately assess the condition of the patients
and provide patient-centered care and thus minimize discomfort and improve the quality of
life.

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The study will enable the designing and implementation of strategies to enhance the
knowledge and practices of pain assessment among nurses with an objective of reducing
patient suffering.
The study is likely to influence the formulation of protocols and policy guidelines aimed at
enhancing nursing practice.
1.6 Limitations of the Study
Since the study will be based on nurses’ self-reports, this will not possibly allow the
assessment of the actual practice with regard to pain assessment. Additionally, the allotted
time for the study may not permit the use of important techniques of data collection such as
observation of the routine practices. It is likely that some of the study participants may not
return the questionnaires; an aspect that will lead to a low rate of non-response.
1.7 Operational Definitions
ANOVA – Analysis of Variance
CIAP- Critically ill adult patients
BLS- Basic life support
CPR- Pulmonary resuscitation
AED- Accident and Emergency department
ERC- Ethics and Research Committee
SPSS- Statistical Packages for Social Sciences

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CHAPTER 2: REVIEW OF LITERATURE
2.1 Search Strategy
The researcher critically examined relevant articles and books to the research title. Search
engines such as Google Scholar, PMC, and PubMed were used to conduct systematic
research. Only articles published within the last eight years were included in the review. 40
studies were retrieved from the database after a quality check. 20 studies were included in the
critical review. Ten of the studies were excluded due to duplication, and the other ten of them
had restricted access. The specific key term used in the search are pain, pain assessment,
nurse, critical care, nursing knowledge, and basic life support.
2.2 Overview on Basic Life Support and Level of Knowledge of Basic Life Support
among Nurses
Basic life support (BLS) is an emergency procedure that comprises of ascertaining an arrest
and initiating appropriate cardiac, pulmonary resuscitation (CPR) methods to sustain life until
the recovery of the patient or access to the medical facility (Berg et al., 2010). Bajracharya
and Nagarkoti (2016) resuscitation as the practice of restoring life or consciousness of one
who is seemingly unconscious. Some of the vital elements of BLS include airways,
circulation, and breathing. Inadequate circulation for approximately 200 seconds will result in
permanent damage to the brain. The most prevalent type of emergencies include accidents
and cardiac arrests with severe impacts. However, basic practices and skills can enhance the
results, in addition to CPR which can increase survival chances (Berg et al., 2010). Ewy
(2009) indicated that most of the patients that undergo pre-hospital cardiac arrest do not
receive adequate and prompt resuscitation by healthcare experts. For each delay of
resuscitation by a minute in case of cardiac arrest, the possibility of efficacious resuscitation
is decreased by 10% (Rubertsson et al., 2014). Studies have also shown that there is over

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49% survival rate when the timely administration of CPR with defibrillation is administered
within five minutes of collapsing.
The first healthcare providers to witness a cardiac arrest in any medical facility and call for
help are the nurses. Therefore, there is a need for the nurses to be in possession of current
technological know-how and practical skills to help in effectively addressing matters of
cardiac arrest among others (Ewy, 2009). Furthermore, studies have shown that knowledge of
BLS is a significant factor in the ultimate result of critical emergencies. Devishree, Mahesh,
and Jain (2018) carried out a cross-sectional descriptive study of 150 dental students on the
knowledge regarding BLS in a pediatric patient. The authors evaluated the knowledge of the
students on BLS in a pediatric patient using self-administered questionnaires and found out
that all the participants did not possess adequate BLS knowledge. Awareness of the meaning
of the BLS abbreviation among the respondents was 76%, whereas 62 percent of them were
knowledgeable regarding the position of chest compressions in unresponsive adults. The
outcomes of the study indicate that there was an inadequacy among the dental community
students regarding the preparedness to handle such issues.
Similarly, Bajracharya and Nagarkoti (2016) undertook a descriptive cross-sectional study on
the knowledge of BLS among 50 nurses engaged in different care units in the referral hospital
of Nepal. The authors gathered data using self-semi structured questionnaires and found out
that all of them were aware of BLS. However, 86 percent had no training in BLS. The authors
concluded that there was an inadequacy in BLS knowledge in most of the nurses. Vasudevan
et al. (2016) carried out a cross-sectional analytic study on the knowledge of simple BLS
algorithm among nursing and medical students in teaching hospital and found out that the
nursing students had a higher median knowledge score of 8.5 with the highest being reported
amongst those that had experienced BLS before or attended a seminar on BLS. The nursing

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student had higher BLS knowledge when compared to medical students. Despite the
existence of a knowledge gap in BLS, the nursing students have been found to outperform
other students in healthcare regarding BLS or CPR knowledge (Josipovic, Webb, and
McGrath, 2009). Xanthos et al. (2009) also found out that nurses were more effective in
teaching other nurses about BLS knowledge than doctors.
Salameh et al. (2018) carried out a cross-sectional descriptive study of 150 nursing students
and 150 nursing professionals with the aim of comparing their knowledge on BLS. The
outcomes indicated that the registered nurses had higher BLS knowledge (56.7%) compared
to the nursing students. Xanthos et al. (2012) assessed the theoretical knowledge of nurses in
BLS and found out that there was an alarmingly low level (10.3%) of BLS knowledge which
was also not affected by the refresher BLS course and former experience.

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CHAPTER 3: METHODOLOGY
3.1 Research Design
The research will adopt a descriptive cross-sectional study approach. The researcher settled
for a quantitative approach because it allows the collection of statistical data and carrying out
quantitative assessment using statistical methods, so as to ascertain the knowledge level of
nurses and explore the practices associated to pain evaluation for severely sick patients
among the nurses in Emergency Room at Military Hospital Makkah. A cross-sectional design
best fits the study because it will allow the investigator to analytically assess and record the
knowledge level and practices in the actual manner among different nurses at the same time.
3.2 Setting of the Study
The study will be carried out at Military Hospital Makkah. Makkah armed forces hospital is
located at Makkha centre opposite the King Abdullah Rd in Saud Arabia making it easily
accessible to incidences of immediate emergency care. The hospital comprises of 200 beds
for critical medical care providing healthcare services to military personnel and families. The
hospital is one among the average military hospitals in the Kingdom and has approximately
564 healthcare providers with nurses being the majority (40%). The nurses have varying
qualifications from masters, bachelors’ degree to diplomas. The researcher chose Military
Hospital Makkah because it is one of the hospitals dealing with cardiac issues and burns unit.
Based on its location it is believed that most of the nurses there deal with critically ill patients
with different conditions.
3.3 Population
The study population comprises of nurses employed at Military Hospital Makkah. The
facility has 226 nurses tasked with the role of attending critically ill patients. The nurses that

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make up the study population include those attached to the intensive care unit, neurological
and emergency units.
3.5 Sampling Criteria
The study will adopt purposive sampling approach in the selection of the facility and the
respective units which the nurses are allocated. Purposive sampling will be used in the
selection of the units to make sure that those involved in the study have expertise in handling
critically ill patients and pain assessment. Each of the potential participants will individually
be approached by the researcher and the objective of the study explained to them after which
a request for their participation will be made. The willingness of the nurses to participate in
the study will be expressed through reading and signing the consent form.
3.6 Sample and Its Size
The Cronchran’s (1977) formula will be used to estimate the sample size as shown below:
Where; n = the estimated sample size
N = the study population and
e= approximate margin of error: 0.05 (95% C.I)
e2 = (0.05)2 = 0.0025
(n) = 226/(1+0.3) = 226/ (1.3)
n= 173

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3.7 Variables
Independent Variables
The independent variables include demographic profile namely age, job position, gender,
education level, work experience, and training in pain assessment.
Dependent Variables
The dependent variables include practices associated to pain assessment and knowledge level
associated to pain assessment.
3.8 Instrument
A semi-structured questionnaire will be used to collect quantitative data. The researcher will
individually design the semi-structured questionnaire and it will comprise of close and open-
ended questions. The questions will be categorised into three areas namely knowledge,
practices and demographic profile. The tool will be given to three professionals in critical
care and entreated to assess the appropriateness and relevance of the specific items. The
experts will be required to rate the items on a four-point Likert scale regarding their bearing
to knowledge and practices of pain assessment.
3.9 Validity and Reliability
Validity
Validity has been defined by Sayer (2010) as the precision and relevance of inferences
arrived at on the basis of the study outcomes. This involves asking an appropriate question in
the most understandable manner. The study will use content validity to measure the validity
of the research tool to be used. Content validity will be determined on two stages. Each item
was critically assessed for its appropriateness to measure the expected content. The
questionnaire was then submitted to three experts for evaluation.

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Reliability
Orodho (2009) defines reliability as extent to which the tool yields similar outcomes on
repeated trials. In order to achieve reliability, two professionals in critical care will be
requested to carry out a pilot study to find out the completeness, uncertainty and determine
the time taken for data collection using the proposed semi-structured questionnaire. Cronbach
Alpha statistical tests will be used in testing the variables for reliability. Reliability
coefficients of 0.90 will be regarded as exceptional, 0.80 as very good and those around 0.70
as satisfactory (Koul, 2009).
3.10 Pilot Study
An approval to conduct the research will be obtained from the Ethics and Research
Committee (ERC) of the institution. A pilot study will be carried out at Duqm Lint medical
services centre. Seventeen questionnaires will be administered to nurses assigned to the
Accident and Emergency department (AED) to ascertain the validity and reliability of the
research tool. Duqm Lint medical services centre has been preferred because it is near
Military Hospital Makkah and deals with critical ill patients. Pain casualties that seek for
services in both facilities have relatively the same cause.
3.11 Data Collection Procedure
The questionnaire will be amended accordingly based on the outcomes of the pilot study. The
researcher will individually drop the questionnaires at the offices of the various units where
the potential nurses have been allocated and then picked at the end of the day. Each
questionnaire will be attached to an introductory letter with details on the objective of the
study