Dissertation on Persistence of Undertreated Pain

 Acknowledgment on Persistence of Undertreated Pain

First of all, I am grateful to Allah for giving me knowledge, patience, and health for completing this project. I thank Allah for the greatest gift, my parents who supported me all this time. I would be unable to carry this project out if my parents were not there to help me when I didn’t know what to do. No matter how much I thank them, I wouldn’t be able to pay them back for the care they showed when I needed. A major part of this project solely belongs to my parents. Their unconditional love has always been a pillar of support to me. I would also like to thank all of my friends, siblings, and relative who did their all to assist me in this project so I could successfully complete it. They have supported me through their wishes and letting me know that they were always praying for my success.

Furthermore, I express my gratitude to my supervisors, Dr. Feryal and Dr. Rana for their encouragement, support, and wisdom. Whenever I was confused, they would offer me their assistance and a direct that eventually lead me to a solution. I would also like to thank Dr. Omnia and Dr. Remma for their consistent support and guidance. I sincerely dedicate a part of this project to my teachers and supervisors.

I am also grateful to the Hospital for allowing me to collect data. All those who participated in the project, faculties, and nurses, I thank all of them because of their support and efforts. They have also helped me significantly in completing this project.

I am also thankful to my senior colleagues who also guided me and offered their support during my graduate degree. Again, I thank my parents and dedicate this project to them and my teachers. 

Abstract on Persistence of Undertreated Pain

It has been reported that around 5 million patients are being admitted to the critical care unit each year around the globe (Klein et al., 2010). Around 77% of these patients complained of feeling pain during their stay in critical care units. Among these patients, 32% reported severe pain while 60% reported moderate to severe pain. Approximately 80 % of the pain was associated with critical care units’ procedures such as endotracheal tube insertion, tracheostomy, incision, drainage, positioning, suctioning, intravenous cannulation, and wound dressing, etc. (Chanques et al., 2010; Klein et al., 2010 & Shuaib, 2018). Undertreated pain leads to psychological, hemodynamic, metabolic, and neuroendocrine responses that increase morbidity and length of stay in critical care units (Muhammad, 2018). Undertreated pain aggravates anxiety, sleep deprivation, agitation, delirium, and depression that often lead to a chronic condition (Carrillo-Torres et al., 2016 & Mindy, 2013). There are various barriers to the recognition and proper management of pain such as sedation and the presence of endotracheal tube etc. (Herr et al., 2011& Pasero et al., 2009). Therefore, it becomes essential for nurses to have the required knowledge related to types of pain in critical care units, valid pain assessment tools, and proper pain management. Devoting an accurate and reliable pain assessment is the key to reduce suffering and successful pain management (Kozier, 2008 & Al-Shaer et al., 2011). Although pain is a significant challenge within the critical care environment, the problem has not been addressed quietly in Kingdom of Saudi Arabia (Issa, 2017; Thurayya et al., 2014; Summayah, 2017 & Nihad, 2015). This study aims to assess critical care nurses’ knowledge and attitude regarding pain management at a university hospital in Saudi Arabia. Design: A cross-sectional design. Settings: Data will be collected from 112 nurses of the critical care units including Surgical Intensive Care Unit (SICU), Medical Intensive Care Unit (MICU), Coronary Care Unit (CCU), and Emergency Room (ER) at the University Hospital in Saudi Arabia. Tool: A modified nurses’ knowledge and attitude survey (NKAS) regarding pain will be adopted in this study. The survey was developed by McCaffery & Ferrell in 1987 and was modified with the permission of Al-Shaer, Hill, & Anderson 2011 (Herr & McCaffery, 2011). Method: Ethical approval to conduct the study will be obtained. Data will be coded & analyzed using statistical package SPSS version 25.

Keywords: Knowledge, Attitude, Pain management, Critical care

Chapter 1

Introduction of Persistence of Undertreated Pain

It has been reported that around five million patients are admitted to the critical care units yearly around the globe (Klein et al., 2010). Around 77% of these patients complained of pain during their hospitalization. Among these patients, 32% reported severe pain while 60% reported moderate to severe pain. Around 80% of the pain is associated with critical care units' procedures such as endotracheal tube insertion, tracheostomy, incision, drainage, positioning, suctioning, intravenous cannulation and wound dressing, etc. (Chanques et al., 2010; Klein et al., 2010; Shuaib, 2018). 

Persistence undertreated pain may lead to serious physiological and psychological effects. It interferes with cardiovascular and respiratory physiology, and can, therefore, impair a patient’s recovery and discharge. Immune, musculoskeletal, genitourinary, respiratory, gastrointestinal, and cardiovascular systems are influenced by the above physiological changes. An increment in the breathing and heart rates seem to facilitate the rising demand of nutrients and oxygen in integral organs. Vomiting can also be induced by physiological changes and can also pre-empt conditions of chronic pain. It can be said that cognitive and psychological negative impacts are relatively common and can be found (Sessler, 2009).

In the ICU patients, negative psychological outcomes can be increased by severe pain including PTSD or post-traumatic stress disorder, depression, and anxiety (Sessler, 2009). Actually, these effects are capable of leading to sleep deprivation, depression, anxiety, and distress (McCarberg et al., 2008). There is a positive correlation among pain and anxiety. People expressing anxiety at high levels tend to have a higher occurrence of noxious stress at an early stage. Hormonal changes induced by acute stress described here are similar to the complex symptom of depression, anxiety, and hypercortisolism, an anxiety physiology’s consistent feature. That is why, stressor impacts of unrelieved pain are capable of increasing the levels of anxiety and hamper the daily activities like leisure activities, work, exercise, and diet. It even is able to cause insomnia at different levels. Such type of pain can even result in a person suffering from reduced concentration ability, mental confusion, and disorientation (Sessler, 2009).

There are various barriers toward recognition and proper management of pain in the ICU such as sedation, the presence of endotracheal tube, etc. (Herr, Coyne, McCaffery, Manworren, & Merkel, 2011; Puntillo et al., 2009). It is important to assess and manage pain properly to prevent adverse effects of undertreated pain such as prolonged mechanical ventilation, hemodynamic derangements, delirium and compromised immunity (Puntillo et al., 2009; Skrobik et al., 2010). Undertreated pain aggravates anxiety, sleep deprivation, agitation, delirium, and depression that often lead to a chronic condition (Carrillo-Torres, Ramirez-Torres & Mendiola-Roa, 2016; Stites, 2013). It also leads to psychological, hemodynamic, metabolic and neuroendocrine responses that increase morbidity and length of stay in critical care units (Mohammed, 2015).

Literature synthesis over the past decade shows that one reason patients continue to suffer from undertreated pain is improper management by healthcare providers (Wells et al., 2008). Effective pain management requires adequate knowledge and positive attitudes of healthcare providers. Superior on healthcare providers, nurses have a vital role in pain management for patients as they spend the most time with them (Kwon, 2014; Alqahtani & Jones, 2015). In the management of pain, the part of nurses is quite significant. They are capable of assessing pain and can determine the impacts of pain on an individual. They also have the ability of advocating individuals and educating the family of patient about the side effects of a certain medication (Habich et al., 2012), motivate the patient, and make sure that every patient is receiving the required pain medication (D’Arcy, 2007).

Therefore, nurses’ knowledge and attitude regarding pain is the key for enhancing practice, which enables nurses to manage pain in the best way possible and to prevent physiological and psychological distress (Matthew JG Sigakis & Edward A Bittner, 2015).

Despite the importance of nurses’ knowledge and attitude toward management of pain, several studies have been conducted internationally and highlighted that nurses have inadequate knowledge toward pain management (Shuaib, 2018; Wang & Tsai, 2010; Wilson. 2007; Al-Shaer, Hill, & Anderson, 2011; Lui, So, & Fong, 2008; Yildirim, Cicek, & Uyar, 2008; Teixeira & Durão, 2016; Mondol, Muhammad & Chowdhury, 2018; Mohamed, 2015; Rose et al., 2012). Although pain is a significant challenge within the critical care environment, the problem has not been addressed adequately in Kingdom of Saudi Arabia (Rasmi Issa, Awaje H & Khraisat, 2017; Eid, Manias, Bucknall, & Almazrooa, 2014; Fallatah, 2017; Mohammed, 2015). In the context of KSA, there are few studies that examined nurses’ knowledge and attitude regarding pain management faced limitation of the small sample size which mandate further studies with a larger sample size.

All of the previous studies agreed that there is a severe lack of knowledge and poor attitudes among critical care nurses towards pain management. Rasmi Issa and colleagues (2017) conducted a study about knowledge and attitude about pain and pain management among critical care nurses in a tertiary hospital. The study showed a severe lack of knowledge and poor attitudes among nurses in the intensive care unit (ICU) towards pain management. The results showed that around 60% of the knowledge questions were answered incorrectly by more than 50% of the nursing staff participated in the study, 65% of attitude questions were answered incorrectly by more than 50% of the nursing staff. Similarly, Eid (2014) conducted a study to examine nurses’ knowledge and attitudes toward pain in Saudi Arabia. The study target nurses working in acute care, intensive care, and nursing education and administration settings (n= 775). It showed a lack of knowledge regarding appropriate pain management practices in a tertiary hospital located in Jeddah on the western coast of Saudi Arabia (Eid et al., 2014). Additionally, Fallatah (2017) conducted a study to get an overview of the knowledge and attitude among health‑care professionals (n= 346) toward pain management in the King Fahd Hospital of the University. Questionnaires were distributed in the hospital to nursing units and clinical departments. The author concluded that there is a lack of knowledge and a negative attitude among health‑care professionals in Saudi Arabia in terms of pain management. There is also a strong need to improve their knowledge to achieve better patient care.

This study's aim was to explore critical care nurses' knowledge and attitude regarding pain management at a university hospital in Saudi Arabia. Research questions include:

1.   What is the current knowledge of critical care nurses regarding pain management?

2.   What is critical care nurses attitude toward pain management?

Justification of the Research on Persistence of Undertreated Pain

 Critically ill patients experience various stressors within intensive care units and pain is one of the most predominant stressors (Morton & Fontaine, 2009). Pain is associated with illness and also can result from the treatment itself that requires painful procedures (Ufashingabire, Nsereko, Njunwa & Brysiewicz, 2016). Endotracheal tube insertion, tracheostomy, incision, drainage, positioning, suctioning, intravenous cannulation, and wound dressing have been addressed in research contributing 80% of pain (Chanques et al., 2010).

Persistence pain induces many harmful effects which worsen early recovery from the critical illness (Morton & Fontaine, 2009). Studies have documented negative effect of pain on endocrine, metabolic system, cardiovascular system, gastrointestinal system, and immune system (Wells et al., 2008). The endocrine system reacts by releasing excessive amounts of hormones as a physiologic effect of severe pain. Initially, severe pain causes hyperarousal of the hypothalamic–pituitary–adrenal system which elevates levels of serum hormone. Hormones such as adrenocorticotropin, cortisol, and pregnenolone lead to catabolism of carbohydrate, protein and fat and poor glucose utilization (Wells et al., 2008).

Untreated pain has a harmful impact on patients’ quality of life including both physiological psychological quality (Bartoszczyk & Gilbertson-White, 2015). In a study, Brennan, Carr and Cousins (2007) argued that undertreated pain is due to poor practice. Authors point out that undertreated pain causes increased heart rate, systemic vascular resistance, and increased risk of myocardial ischemia, stroke, bleeding, and other complications. Also, it can result in pain syndromes that may present with immobility, weakness, sleep disturbance, immune impairment, and increased risk to diseases. Author concluded that, persistent pain may affect all body systems also cause various types of pain including physical, psychosocial, spiritual, and emotional pain (Brennan, Carr, & Cousins, 2007)

In purpose to prevent the negative impact of pain, it is important to consider pain management in the management of patients (Bartoszczyk & Gilbertson, 2015). Pain management is an essential element for all healthcare providers when treating critically ill patients. Among them all, nurses play an important role due to spending the majority of time beside patients. Nurses in critical care units owe the duty to take care of all patients who need help; moreover nurses have responsibility and accountability to maintain patients’ integrity and safety when patients have pain (Morton & Fontaine, 2009). Therefore, nurses in critical care areas should be competent, knowledgeable and well trained to deal with critically ill patients (Shannon & Bucknall, 2003). It’s important as well for nurses to have a clear meaning of the concept of pain assessment to achieve effective pain control (Morton & Fontaine, 2009).

Definition of Terms on Persistence of Undertreated Pain

 Persistence of Undertreated Pain

International Association for the Study of Pain (1979) seems to define pain as “an emotional and unpleasant sensory experience which related to the potential or actual damage or explained with respect such type of damage” (P. 250).

Pain attitude of Persistence of Undertreated

The definition of pain attitude is as a persisting group of values and beliefs that impact just how one reacts or responds under the involvement of pain (McMillian, Tittle, Hagan, Laughlin, & Tabler, 2000).

Nursing attitude of Persistence of Undertreated Pain

Nursing attitude can be either perceived as negative or positive. The positive one refers to an attitude that is capable of enhancing the dignity and quality of profession and nurse while the negative one belittle and denigrate both of them (Mason & Whitehead, 2003, p. 104).

Knowledge about Persistence of Undertreated Pain

It can be said that knowledge is simplified as a condition or fact of understanding something with a familiarity that is gained through association or experience (Merriam-Webster Online Dictionary, 2012).

Nursing knowledge of Persistence of Undertreated Pain

The concept of knowledge is multifaceted and complex. It is obtained through various ways and it is predicted to be a precise reflection of the actual globe. Historically, nurses have obtained information and knowledge through research, reasoning, intuition, mentorship, borrowing, and training (Burns & Grove, 2009, p. 706).

Pain Management of Persistence of Undertreated Pain

 The management of pain is simplified as interventions which are utilized in easing and understanding pain while alleviating its origin according to Quality of Care Task Force of American Pain Society (Gordon et al., 2005).

Chapter 2

Literature Review of Persistence of Undertreated Pain

Review of Lecture of Persistence of Undertreated Pain

 Paraphrase (ONLY Underline)

Pain History of Persistence of Undertreated

 As long as humans have experienced pain, they have given explanations for its existence and discovered methods to stop or lessen painful sensations (Meldrum, 2003). In the 2nd century, Galen in ancient time (130-201) recognized the brain as the site of sensation by closely observing patients suffering from various pain sources. Science didn’t support Galen’s assumption at that time and refused that brain is the site of sensation (Merskey, Loeser, Dubner, & Iasp; Perl, 2007). In the 5th century, the term of pain appeared in the literature of occidental medicine in the Hippocratic Collection (Rey, 1998).

In the 8th century, the explanation of pain explored for the first time in Western countries. It was mentioned in ancient Greece in the Iliad and the Odyssey book by Homer’s epics (Rey, 1998).  During this century, science still not believes that brain is the core of sensation. According to Aristotle’s postulate, the heart was the core of sensations instead. It was believed that heart is responsible for hearing, vision, smell, taste, and pain, as well as emotions and mental functions (Rey, 1998; Merskey, et al., 2007).

In the period of 14th to 17th century, resistance developed against the idea of making heart the core of sensation. The resistance started when systematic autopsies were carried out by Andreas Vesalius, the founder of modern human anatomy, who published the classical book on the subject, ‘On the Fabric of the Human Body’ (Rey, 1998; Merskey, et al., 2007).

In the 17th century, the functions of the brain were significantly promoted by René Descartes, Thomas Willis and Thomas Sydenham (Rey, 1998; Merskey, et al., 2007). Rene Descartes (1596–1650) showed the transmission of pain information through the peripheral nerves and the spinal cord to the brain. Thomas Willis is the discoverer of the ‘Circle of Willis’ in brain anatomy. In response to this finding, Cerebri Anatome (1664) provided strong evidence supporting the roles of the brain in the perception of pain (Rey, 1998).

Before the 18th century, the term of pain appeared for the first time in Traditional Chinese Medicine (TCM). It was mentioned in the ancient medical book Huang Di Nei Jing. In 1966, the book was translated into English by Veith with a title of The Yellow Emperor’s Classic of Internal Medicine (Veith, 1966). In 2001, it got translated by Zhu to The Medical Classic of the Yellow Emperor (Zhu, 2005). The book described that pain is a result of imbalance between yin and yang whereas, the majority of yin results in hypothermia or cold causes damage to tissues and leads to swelling. Meanwhile, yang results in hyperthermia or heat causes damage which leads to pain. That was probably the first description of nociceptive and inflammatory pain’s signs and symptoms in the medical literature. In the 19th century, physicians used pain as a diagnostic tool (Meldrum, 2003). In 2000, Joint Commission on Accreditation on Healthcare Organizations (JCAHO) started to consider pain as the 5th vital sign (Phillips, 2000).

Pain Theory of Persistence of Undertreated

 Theories excessively focused on the causes of pain and how is it function within the body. Even within limited groups, such as the ancient Greeks, there were competing theories to proof causes of pain. Aristotle enumerated the five senses without including pain and agreed with Plato that pain is emotion not a sensation (Dallenbach, 1939). Alternatively, Hippocrates believed that pain is a sensation caused by an imbalance in the human vital fluids. Neither Aristotle nor Hippocrates believed that the brain had a role to pain sensation. Both of them believed that heart is the central organ for pain sensation (Linton, 2005).

In the 11th century, Avicenna explained in a theory that there is a group of feelings consider as sense including touch, pain and titillation (Dallenbach, 1939). Pain was not well understood and it was believed that pain occur outside of the body. It was explained as a punishment from God and can only cured by prayers (Meldrum, 2003). Rene Descartes (1664), stated in a theory that the body is similar to a machine and pain is a disturbance that transmit along nerve fibers until reached the brain (Linton, 2005; Melzack & Katz, 2004). The theory transformed the perception of pain from a spiritual experience to a physical sensation. This proved that there is a cure for pain that may be found by locating pain fibers within the body rather than searching forgiveness from God. Also, it proved that the center of pain sensation and perception is the brain and not the heart.

In 19th century, the specificity theory states that pain is "a specific sensation, with its own sensory apparatus independent of touch and other senses," (Bonica, 1990). Charles Bell (1811), proposed different types of sensory receptors and each has a response to one specific stimulus. Wilhelm Erb (1874), developed the intensive theory that proposed that pain can be generated by any stressor stimulus (Dallenbach, 1939). Goldscheider (1894), extended the intensive theory through explaining that each nerve fiber can trigger three different qualities of sensation. These sensations include tickle, touch, and pain based on the intensity of stimulation. Edward Titchener (1896) addressed in textbook, "excessive stimulation of any sense organ or direct injury to any sensory nerve occasions the common sensation of pain" (Dallenbach, 1939). DC Sinclair and G Weddell's (1955) developed a pattern theory and proposed that all skin fiber endings are identical. Furthermore, pain is produced by powerful stimulation of these fibers (Bonica, 1990).

Ronal Melzack and Patrick Wall (1965) came up with a theory regarding pain which was referred as the gate control. Psychological and physiological knowledge was used by authors for proposing it. They also described transmission impulses to spinal cord from the afferent fibers to T-cells which are then modulated by a mechanism of gating. Different fibers were classified by authors that impact this mechanism. Fibers have two types; large and small fibers. It was presented by authors that a thin diameter is classified by the nerve fibers which present pain while the large diameter seems to present vibration, pressure, and touch. Information is carried by both diameters to spinal cord form injury site. Through cells, transmission passes which contain signals of pain towards brain. Normally, transmission is attempted to be inhibited by large fibers by closing gates. Meanwhile, the gate is attempted to be opened by the small fibers. They also try to facilitate impulse transmission. The mechanism of spinal gating is highly affected by the impulses of nerve that travel from the brain. When the production of T-cells go over the critical level, an action system is activated by it due to which, pain is experienced by the person (Melzack & Wall, 1965).

In 1979 the International Association for the Study of Pain (IASP), defined pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" as the final definition (P. 250).

Pain Pathway

Trigeminal pathway and spinothalamic pathway are included in the pathway of central pain. For pain transmission. For the transmission of pain to brain from body, there are 5 prime nerve routes.

The spinothalamic pathway of Persistence of Undertreated Pain

Spinal cord is entered by nerve fibers through dorsal root and signals are sent to 1-2 branch segments down and up the spinal cord. Before entering the gray matter of spinal cord and making contact with innervate, the nerve cells in lamina II and lamina I are present.  Fibers of Aδ innervate the cells in marginal zone and cells are mainly innervated by C fibers in the spinal cord’s substantia gelatinosa layer. In nucleus proprius, cells are innervated by these nerve cells. Throughout delivering nerve fibers across ascend and spinal midline, nerve cells are actually located in some certain parts of thalamus. In thalamic pathways, dysfunctions might cause pain, as it is observed in patients after a stroke with thalamic pain in the part of paralysis (Patel, 2010).

The trigeminal pathway of Persistence of Undertreated Pain

From the area of face, noxious stimuli are actually transmitted in nerve fibers which are originating from nerve cells in cardinal nuclei X, IX, VII, and trigeminal ganglion. Nerve fibers seems to enter brainstem before descending to medulla where trigeminal nuclear complex’s subdivision is innervated by them. Neural midline is crossed by nerve fibers and ascend for innervating nerve cells which are thalamic on contralateral side. It can be said that spontaneous firing of ganglion of trigeminal nerve might be trigeminal neuralgia’s etiology. Thalamus’s area that seems to receive the information pain form the trigeminal nuclei and spinal cord is also a part receiving information regarding normal stimuli of sensory such as pressure and touch. Nerve fibers from this part are sent to the brain’s surface layer.

That is why, by having somatic sensory and nociceptive information on cortical area that is same, information about the intensity and location of pain can be used to be a painful and localized feeling. This body’s cortical representation is explained in the homunculus of Penfield, might be a source of pain as well. In some specific circumstances, cortical representation might alter which will cause non-painful and painful sensations like the telescoping phenomenon. Understanding pain pathway’s complexity can actually contribute the recognition of difficulty in analyzing the source of pain in patients and in providing relief (Patel, 2010).

Types of Pain of Persistence of Undertreated Pain

ASP in 1994 defined neuropathic pain as the pain which was initiated by a primary dysfunction in the NS or nervous system. It was also noted by a task force by IASP that there was a need to determine nociepetive pain from the neuropathic pain which arose indirectly from the pain conditions and neurological disorders with secondary changes which are neuroplastic taking place in nociceptive system and a new definition was proposed by it that omitted pain that arose as a direct result of a disease that affected the somatosensory system. IASP Taxonomy Committee proposed a new version of this simplification and was accepted: pain which was caused by a disease or a lesion of SNS. Neuropathic and nociceptive are prime types of pain (Hallenbeck, 2003).

Contraceptive Pain of Persistence of Undertreated

The source of nociceptive pain is tissue damage referred as inflammatory pain and can be subdivided into visceral and somatic pain. The latter one refers joint pain and the former one refers to smooth muscle and hollow organs. It is actually characterized as dull and sharp aching. Visceral pain might be radiated by this kind of pain but not in the direct distribution of nerve (Hallenbeck, 2003).

Neuropathic Pain Persistence of Undertreated

Neuropathic pain results from nerve damage or dysfunction in the peripheral or central nervous system. It can be either peripheral (outside the central nervous system) or central. Neuropathic pain frequently coexists with nociceptive pain. Examples include trauma that damages tissue and nerves, burns (4th degree), and external nerve compression (Hallenbeck, 2003).

Prevalence of Pain in Emergency Department

International Association for the Study of Pain (2011) addressed that there is a high prevalence of pain in the emergency department (ED). The Middle East Region (MER) associated with acute pain variously based on clinical settings. Patients who are presented to ED with acute pain showed a higher prevalence by 40% among hospitalization patients. There are no epidemiological surveys reporting year’s prevalence of acute pain in the MER (Marinangeli et al., 2009; Galinski et al., 2010). In Saudi Arabia, there is no epidemiology which shows the prevalence of acute pain among population.

Cordell and colleagues (2002) seemingly assessed the presence of pain in the ED which was carried out in the Methodist Hospital’s department, Indianapolis, IN. During a period of seven days, charts from consecutive 1,655 ED visits were analyzed and pain was simplified as the pain equivalent to the word or word pain. Of all the visits, 61.2 percent had pain documented almost anywhere on the chart and was the chief compliant for 52.2 percent of visits. It was commented by authors that it may be underdetermined prevalence because of the lack of consistency in the pain assessments. ED records were reviewed by Chang and colleagues (2014) to 2010 from 2000 in a large multi-style study. It was concluded that 45.4 percent of patients proposed pain prevalence with just pain as the main as the primary symptom.

With respect to the Study of Pain’s International Association, there is an important finding about severe pain. It was shown that severe pain’s prevalence actually increased in 2003-8 to 40 percent form 25 percent. It is agreed by reports that pain prevalence is increasing internationally (International Association for the Study of Pain, 2011).

There is only an individual research in which Rehmani (2010) analyzed pain scores from medical records of 2199 adult patients.  Those patients presented to the ED complain of pain. The author presents that (23.5%) patients complained of severe pain while (76.5%) of them reported mild to moderate pain. 

Prevalence of Pain in Intensive Care Units

The incidence of significant pain is still (50%) or higher in both medical and surgical ICU patients (de Jong et al., 2013). Recently, more than (80%) of the ICU-discharged patients described painful memories and discomfort associated mostly to endotracheal tube. Around (38%) of patients stated that pain was their worst intensive care memory even after 6 months of discharge. Granja and colleagues (2008) found that (17%) of discharged patients remembered experiencing severe pain 6 months later. The prevalence rates of moderate to extreme pain conditions after critical care range between (36%) and (60%) (Granja, Dias, Costa-Pereira, & Sarmento, 2004; Orwelius et al., 2013).

Gelinas, Fortier, Viens, Fillion and Puntillo (2004) determined that in 152 patients, 183 episodes of pain were present and they had gotten medical ventilation. Time’s observable indicators were recorded. Self-reports of the pain of patients were recorded at only 29 percent of the time, a practice which is opposing recommendations for the assessment of pain. In comparison to non-pharmacological interventions, pharmacological interventions were utilized more for the management of pain. Observable indicators (66 percent) for reassessments of the time were recorded and self-reports of patents were recorded only at 8 percent of the time.

Vazquez et al. (2011) in another study analyzed the intensity of pain during changing positions (330) for 96 surgical and medical ventilated patients. A significant increment in the pain score by the author between changing and rest positions. CPOT or Critical-Care Pain Observation Tool was used by the author for investigating the differences in physiological and behavioral responses to the pain after and during changing positions. On the CPOT scale, the overall mean score prior to changing the position was just 0.27 and during the changing of positions was 1.93, and it reached 0.10 after the changing of position. Expressions were the indicators that rose followed by the movements of body: muscle tension, and compliance with ventilators. In physiological variables, there were slight variations during the position alteration. On the scale of CPOT, the overall mean score during surgical patients’ changing position was almost 2.02 while it was 1.80 for the medical patients.

Consequence of Persistence of Under treated Pain 

Pain leads to many harmful effects that adversely affect healing and recovery from critical illness. With the impinging of noxious stimuli on the body from an internal or external source, information about the harmful effect of these stimuli is transduced on bodily tissues through the neural pathways and is transmitted through the PNS to ANS and CNS (Garland, 2012). Vasoconstriction is caused by the ANS or autonomic nervous system while increasing the heart contractility and it increases cardiac output together with pulse (Suzanne, 2005). As a result, myocardial workload and the demand of oxygen is increased which might lead to myocardial ischemia in critically ill patients. It can be said respiratory changes resulting from the pain that includes decreased pulmonary flow and respiratory effort etc. Intestinal motility and gastric emptying in gastrointestinal system decrease which might cause ileus and impaired function. Musculoskeletal system is also negatively affected by pain by causing muscle rigidity, spasms, and contractions. Patients might hesitate to cough, breathe, or move since pain is caused by movement. Patients with uncontrolled pain during an acute illness are at the risk for delayed development and recovery of syndromes of chronic pain after a discharge. Immune functions are suppressed by the pain while predisposing to sepsis, wound infections, and pneumonia. Meanwhile, patients having controlled pain have better recovery and outcomes (Suzanne, 2005).

Pain Assessment

The first step in relieving pain for ICU patients is appropriate assessment. Pain assessment is done by using different scales based on the patient condition (Suzanne, 2005). The purpose of evaluating pain intensity in ICU is to relieve patient suffering and prevent serious complications related to pain. The Numeric Rating Scale (NRS) is a visually linear from 0 to 10. It has been determined as the most valid and reliable scale for patients who can self-report pain intensity in ICU (Chanques et al., 2010). On the other hand, there are behavioral scales customized for patients who are unable to self-report pain intensity. Two of them were identified to be the most valid and reliable for monitoring pain in medical, surgical, and non-brain injured trauma patients (Barr et al., 2013). These include the Behavioral Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT) (J.-F. Payen et al., 2001; Gélinas, Fillion, Puntillo, Viens, & Fortier, 2006). In a recent comparison within a mixed adult ICU, the CPOT showed greater discriminant validation than the BPS (Rijkenberg, Stilma, Endeman, Bosman, & Oudemans-van Straaten, 2015). However, Chanques and colleagues (2014) compared these scales with another behavioral scale named Non-Verbal Pain Scale (NVPS). Authors found similar psychometric properties between the BPS and CPOT. Authors rated the BPS as easiest to use and agreed that it is better than the NVPS.

Recent studies presented guidance on the use of the CPOT or BPS in ICU patients with delirium. Kanji and colleagues (2016) tested the psychometric properties of the CPOT on 40 delirious patients. Those patients had multiple types of diagnoses and were non-comatose and (90%) of them were mechanically ventilated. They were tested during both painful and non-painful procedures by CPOT that showed excellent validity and reliability. A modified version of the BPS was tested in 30 non-intubated, mostly delirious patients, who were unable to self-report their pain but could express sounds, during both painful and non-painful procedures (Chanques et al., 2009). A “vocalization” section was replacing the “ventilator” section of the original BPS. The BPS-Non-Intubated (BPS-NI) showed excellent psychometric properties as well. Thus, these two pain behavior scales are best choices for assessing pain in delirious patients (Chanques et al., 2009). Furthermore, recent studies presented guidance on the use of pain behavior scales for brain-injured ICU patients as well. Pain behaviors in traumatic brain-injured patients differ from other ICU patients, especially regarding facial expressions (Gélinas & Arbour, 2009) and consciousness level (Arbour et al., 2014).

The use of pain behavioral scales in ICU patients who are unable to self-report pain showed improvements in pain assessment and patient outcomes. However, some challenges remain to be addressed in order for patients to gain the benefits of pain assessment practices in ICUs. Rose and colleagues (2012) found, from 802 ICU nurse surveys, that only (33%) of the nurses used a pain assessment tool if patients were unable to communicate. In only (74%) of the surveys was the use of behavioral assessment tools noted to be moderately to extremely important. Having pain assessment tools available for clinicians and having a pain assessment protocol in place have been associated with greater odds of tools being used in practice (Rose et al., 2012).

For patients who are unable to do a self-report of pain or communicate well, nurses need to have observable behavioral and physiologic indicators, which are used as indicators for the assessment of pain. Furthermore; patients who are not able to provide their self-report of pain verbally or with other signs (e.g., head nodding, pointing to a scale), the use of a valid behavioral pain scale is strongly recommended (Gélinas & Johnston, 2007; K. A. Puntillo et al., 2008; Gélinas, Arbour, Michaud, Vaillant, & Desjardins, 2011).

Pain Management of Persistence of Undertreated Pain

Adequate pain management for ICU patients has a central role in preventing both short term and long-term morbidities result from physiological and psychological stress. Managing patients’ pain should cover both pharmacological and non-pharmacological intervention (Matthew JG Sigakis & Edward A Bittner, 2015).

Pharmacological Intervention of Persistence of Undertreated Pain

Currently, pain management in ICU supports two approaches for patients which are analgosedation and multimodal analgesia (Matthew JG Sigakis & Edward A Bittner, 2015). The first approach is analgosedation which focuses on relieving pain by using analgesics before sedatives. This method is recommended for patients who may experience agitation and restlessness, and for patients who have identifiable, potential causes of pain (Barr et al., 2013; Devabhakthuni, Armahizer, Dasta, & Kane-Gill, 2012). Using analgesics first required lighter sedation resulting in more awake, responsive patients, and better clinical outcomes such as shorter mechanical ventilation and ICU length of stay (Devabhakthuni et al., 2012). Devabhakthuni and colleagues (2012) present a critical evaluation of analgosedation studies. Authors concluded that analgosedation can focus on patient outcomes when providing pain relief. For example, use of an analgosedation protocol in a neuro-intensive care unit demonstrated the protocol to be feasible in this patient population with unique needs (Egerod, Jensen, Herling, & Welling, 2010).

The second recommended approach is the use of multimodal analgesia which includes the use of opioids. Recent guidelines support the use of intravenous (IV) opioids in ICU and ED as the first line approach to pain management (Barr et al., 2013). Morphine, Hydromorphone, Fentanyl, and Remifentanil are the most commonly used opioids. Spies and colleagues (2011), compared IV Remifentanil to Fentanyl and founded those drugs to be equianalgesic. Remifentanil has more advantages as a faster onset, shorter half-life, and not being metabolized by the liver or kidneys (Matthew JG Sigakis & Edward A Bittner, 2015). While Breen and colleagues (2005) compared IV Remifentanil to a Midazolam based intervention in a random sample of medical-surgical ICU patients on long-term mechanical ventilation (i.e. longer than 96 hours). Authors showed that the Remifentanil associated with better outcomes like shorter mechanical ventilation duration, shorter weaning to extubation time, and shorter offset of medication effect when discontinued.

A multimodal analgesia can also be used as a combination of opioids and non-opioid analgesics provides a balanced approach to analgesia (White & Kehlet, 2010; Erstad et al., 2009). This approach of pain management promotes the use of smaller doses of each drug being used. As well, balances drugs’ effects due to their different pharmacodynamics. Non-opioids such as Non-Steroidal Anti-inflammatory Drugs (NSAID), Acetaminophen, Gabapentin, Nefopam, Dexmedetomidine, and Paracetamol or Acetaminophen can be considered for multimodal analgesia (J.-F. Payen et al., 2013; Chanques et al., 2010). Finally, Ketamine has both anaesthetic and analgesic properties (Lindenbaum & Milia, 2012). Intravenous infusions of ketamine used for analgosedation may decrease opioid consumption, reduce airway resistance, spare bowel motility, lower opioid tolerance, and prevent opioid hyperalgesia (Patanwala, Martin, & Erstad, 2017; Joly et al., 2005; Lindenbaum & Milia, 2012; B. L. Erstad & Patanwala, 2016).

It is important to use opioids cautiously and consider their potential adverse effects (Erstad et al., 2009). In addition, consider the possible development of opioid tolerance (Dumas & Pollack, 2008). Also, to consider that use of opioids may induce hyperalgesia (Wachholtz, Foster, & Cheatle, 2015). Furthermore, opioid withdrawal symptoms may occur upon interruption of opioids (Liatsi et al., 2009; Korak- Leiter et al., 2005).

Non-Pharmacological Intervention of Persistence of Undertreated Pain

The combination of non-pharmacological to pharmacological interventions has shown better outcomes including pain control with less analgesics, decreased incidence of anxiety, depression, increased activity, and increased family involvement in care. The non-pharmacological approaches include distraction, relaxation, music, therapeutic touch, and massage (Suzanne, 2005).

Distraction is known as non-pharmacological intervention which helps patients drive their attention away from the source of pain towards a more pleasant source. Starting a conversation with the patient during a painful procedure, watching television, and family visits are all excellent sources of distraction (Suzanne, 2005).

Additionally, relaxation exercises involves rejecting any interfering thoughts by focusing on a word, phrase, prayer, or muscular activity. Most relaxation methods require a quiet environment, comfortable position and deep concentration. It requires only 6 seconds to be performed. The nurse encourages conscious patients to perform this technique frequently during the day to reduce their stress. It is helpful to calm the sympathetic nervous system, and it provides a sense of stress and anxiety control (Suzanne, 2005).

Therapeutic touch still has an important role despite highly technological ICU settings. Nurses may feel that touching is too simple to be effective. In fact, when nurses use touch, they are usually trying to convey understanding, support, warmth, concern, and closeness to patients. Touching not only affects the patient’s sense of well-being, but also promotes physical recovery from disease. It has a positive effect on perceptual and cognitive abilities, and can influence physiological parameters, such as respiration and blood flow. Nursing touch may be most helpful in situations in which people are experiencing fear, anxiety, depression, or isolation. It may also be beneficial for patients who have a need for encouragement or nurturing, who have difficulty verbalizing needs, or who are disoriented, unresponsive, or terminally ill. Patients often feel that the desire for touch increases with the seriousness of the illness (Suzanne, 2005).

It can be said that therapeutic touch is created on the supposition that physical body is surrounded by an invisible energy and kept alive by a prana which is a universal energy that flows throughout the body. It is transformed by non-physical vortices or chakras. An imbalance of energy seems to result in illness which can quite be intuitively assessed in physic diagnosis form and then directly treated (Fish, 1997). Martha Rogers’ nursing theory supports this view which is entirely based on a view of field world (Aghabati, Mohammadi, & Pour, 2010).

Rogers (1983) seems to postulate that environmental and human fields are determine patterns of wave and waves propagate that change. Nursing interventions like therapeutic touch are aimed to promote energy waves’ rhythmic flow that re-order and order the human field. Furthermore, symptoms are viewed as congestion, blockages, or imbalanced areas (Aghabati, Mohammadi, & Pour, 2010).

With the correction of dysrhythmias by therapeutic touch, balancing occurs in the whole field. Rogers (1970, 1990) explains that a human is a complex field of energy but to a trained sensing power, field of human energy can be assessed and perceived. A person is capable of developing this sensitivity through centering which is the achievement of a state of mind in which mind is quieted by the practitioner and focused all the intention and attention on patients’ assistance (Turner, Clark, Gauthier, & Williams, 1998).

Another non-pharmacological intervention is massage that initiates the relaxation response. Although the back is the most common location used for massage, backs are often difficult to access in ICU patients. Hands, feet, and shoulders are also good sites for massage. Massage is an excellent intervention for family members to use in their attempts to provide comfort to the critically ill (Suzanne, 2005).

Pain’s gate-control theory seems to postulate that a massage might be successful in closing of a gate that is hindering noxious stimuli’s transmission by the stimulation of big nerve fibers that have indicated to change the perception of pain (Ferrell-Torry, Glick, 1993). Healthcare experts in a setting of acute touch patients when carrying out procedures which can be painful and uncomfortable. According to White, “Touch is generally the most assaulted or neglected sense of a patient who is hospitalized” (White, 1988).

Nursing Role in Pain Management

The nurse plays an important role in providing pain management within critical care settings. The management of pain includes pharmacologic, non-pharmacologic, or a combination of both. Nurses are expected to develop the skill of balancing those treatment options (K. A. Puntillo, Smith, Arai, & Stotts, 2008). The nurse’s role involves measuring the patient’s response to those therapies. The adjustments of therapies are based on patients’ response to treatment (Suzanne, 2005). In addition to the drugs, administration and alternative therapies are also used to control pain (Ministry of Health of the Kingdom of Saudi Arabia, 2012).

Nurses Knowledge and Attitude Regarding Pain Management of Persistence of Undertreated

  In 2002 the research conducted by McCaffery and Robinson shown that the nurses have score higher marks who have advanced degrees and the experience of above 15 years regarding pain knowledge and attitudes surveys. The purpose behind the activity was to offer the individuals a tool for self-assessment of knowledge about pain management which will and provide teachers with the data which will help them setting education priorities. In January 2002 an online survey was published in under the name nursing 2002 in which nurses were invited for the participation in survey. 3282 individuals participated in the survey. The average age of the participants was female of 41 years old having a decade of experience of working as medical or surgical nurse in remote areas.to pass the survey the participants were required to correctly complete 80% of the survey. Only 3.9% of the participants passed the survey with 100% marks. The average score was 11 corrected answers out of 15 questions. More than half of the individuals were not able to score passing marks. Participants with masters degrees and have practiced in hospice and oncology settings were assessed to answer the questions with higher accuracy. On the basis of the survey conducted it is concluded that there is a biggest need of educational program for the nurses working in surgical and medical hospitals having less than five years. It is assessed that pain assessment and management are essential elements of nursing care. In 2011 a research was conducted by Al-Shaer et al using sample of 129 registered nurses from 10 different nursing units in hospital located in US. Modern version of Knowledge and Attitudes Survey Regarding Pain (KASRP) was used for the study. The nurses were concluded to have insufffient knowledge regarding the assessment and management of pain. Stats remained the same with respect to experience and other categories. In 2007 a study was conducted using two convenience samples to find out whether registered nurses working in orthopedic area, whose knowledge in pain management area is improved after the completion of knowledge and competency training and showed better results. The no of registered nurses participated in the survey was 113. 65 registered nurses from orthopedic area are included in group in I and 48 nurses from different clinical backgrounds were included in group II. The average score of accurate answers was 73.8%. Average score of group I was 75% and group II was 72.6%. Passing criteria set by McCAFFERY & Robinson was 80%. The results of the study were similar to results of the related studies regarding nurses

nowledge in clinical practice regarding pain management.

In 2011 Lewthwaite and colleagues conducted a research in urban tertiary care hospital on mid-western Canada. Modified version of Ferrell and McCaughey’s KASRP was used in the study. Out of 761 surveys the response rate was 43%. 93% of participants were female with average age of 42 years. 58% were diploma holders, 42% had bachelors or master’s degree. The majority was working in the area of surgery. Average score of the study was 79%. By using the Mann-Whitney U test it is assessed that the nurses with bachelors and master’s degree scored relatively higher marks as compared to diploma holder nurses. It was concluded that pain management is still a problem in health care system and nurses are needed to be educated on pain. The studies also reveal that nurses needs adequate knowledge in pharmacology but mere acceptance of problem will not solve the problem.

A descriptive research was conducted in paranesthesia areas for the assessment of knowledge and attitudes of healthcare service providers. In 2008 Knowledge and Attitudes Regarding Pain Management Survey made by McCaffery’s and Ferrell was handed over to a population of 138 in which 72 of them responded which makes the response rate 52%. The aggregate average score was 72.25% which was considerably low, identifying the need of research and development in pain management area.  And paranesthesia practices.

Another study conducted by McMillan, Tittle, Hagan, and small in 2005 for the purpose of determining the changes in attitudes and knowledge of pain resources nurses (PRNS) as a result of intensive pain management course. 18 nurses were examined before and after the participation in 32 hours intensive pain management and were selected from various units at a veterans administrations Hospitals in the southeast of United States. The test was conducted on pain management principles knowledge and the nurses attitude survey. The knowledge testing before the test was quite close to passing ratio but scores were improved drastically after going through the intense pain management course by elevating to 80%. In department of attitude toward pain the scores were low with the percentage of 66.6% and the slight improvement was seen in after test results with 69.3%. The improvement in results authenticated the effectiveness of the intense pain management course and the similar courses were recommended to be offered in other settings for the encouragement of practicing nurses for the provision of better health care facilities to the patients. It is proposed that nursing attitude and beliefs can impact the aggregated results of patient care in intensive care setups

 Another study conducted by Layman Young, Horton, and Davidhizar in 2006 to find out attitude of nurses towards pain assessment is implemented and the relation of the attitudes to experience and education. Young along with his partners established an open ended questionnaire which was based on expectancy-value model developed by Fishbein and Ajzan. A sample of 52 nurses from intense care unit ward was asked regarding their believe about pain assessment, use of pain assessment tools, usage of pain assessment tools for the improvement of patients condition. After that each of the participants graded their attitudes regarding their feeling about each belief. Their attitude regard to pain assessment ranged between very positive to negative however in general they were very positive about the use of pain management tools for the betterment of patient results. Using the Fishbein and Ajzen’s formula for the calculations of attitudes, the average score turned out to be 8.3 positive with scoring range between -6 to 28. Stats from study indicated that increase in years of experience was not the motive for positive outcome on the usage of pain assessment tool and their advantage for patients’ outcome. It was concluded that the Fishbein and Ajzen model turned out to be quite beneficial way of extracting information on the attitude of the nurses for the usage of pain assessment tools. For further improvement in the studies the research should be done with open ended questionnaire bigger amount of sample size under different settings. 

Barriers toward Proper Pain Management of Persistence of Undertreated Pain

There are varied circumstances present in critical care units which interfere with pain assessment, for example acuity of the patients’ conditions, altered level of consciousness, inability of patient to communicate pain (Morton & Fontaine, 2009), the use of sedation, and ventilation that is mechanical (Gélinas & Johnston, 2007).

The reasons that hinders the pain assessment are quite common in intense care unit and they restricts their abilities of proper decision making regarding pain assessment and pain management (K. A. Puntillo et al., 2008).

From 1980 it is assessed that that pain management is improved by pain assessment and ultimately the suffering will be reduced. Due to lack of practice and research there is a lack of pain assessment citation. (Kathleen Shannon & Tracey Bucknall, 2003).

Theoretical Framework of Persistence of Undertreated Pain

Paraphrase (ALL)

To guide this study, Patricia Benner’s conceptual framework, beginner to expert skills model was used. Benner’s model of work rightly fits in the study of knowledge in various situations faced in nursing. In the context of the Dreyfus Model Benner proclaims nursing process through five essential techniques. (Tomey & Alligood, 2006).

In the beginning nurses were missing the natural instinct coming from the background experience that is highly essential for decision making in different situations. This can be referred to the beginners phase. Amateur nurses are required to learn the common aspects of circumstances before jumping into the whole complex, and difficult clinical circumstances.  If you are able to distinguish the clinical situations it is the core of good clinical thinking. (Benner, Kyriakakis, & Stannard, 2011). During the second phase, the slightly experienced beginners will be able to perform in slightly acceptable and better manner in case they are in particular circumstances to enhance their knowledge. After that during third phase the competence level is raised due to which they are able to perform better and their efficiency in planning, management and knowledge of the situation. Benner (1984) narrates in these situations that the efficient nurse has a understanding that he knows what he is doing and has has the ability to overcome any kind of adversities in clinical nursing. In fourth phase the nurse are now quite capable. According to Benner these efficient and capable nurses are able to comprehend and understand situations as a whole rather than emphasizing on the smaller tasks. It is very important for a nurse to understand and comprehend the physiology and thinking in order to apply the gained knowledge. After fourth phase comes the fifth and final phase. At this stage the nurse is fully trained and is ready to show his expertise in their respective field of pain management. They have such natural instinct that they emphasize on the bigger aspect as compared to minor problems. They try to go after their natural instinct because when they are asked about the reasoning behind any decision they made they say that it felt right or it looked good. (Benner, 2001, p. 32). Benner explains the qualitative change in the competent nurse. The expert nurse is well aware of the needs of his patient. In fact he is aware of the response pattern and knows the patient in person. Benner was among the very first nurse theorists to focus on the importance of natural instinct to thinking skills and to associate types of knowledge, such as theoretical and practical to the course of professional nursing practice (Banning, 2008).

The Benners model is five staged procedure in which details about the knowledge and essential skills of nursing are discussed. The Benners model are further classified in accordance with the acquisition of assessment skills and development of confidence in practice (see Appendix I). This theoretical approach does not suggest that every nurse that is caring for the patient who is in pain, will be an expert, but besides the beginner to expert the nurses’ skills are upgraded from basic level knowledge of pain assessment into development of highly capable and strong assessment skills circumstantial knowledge in relation to the cause, recognition of pain, and available sources to control the pain. In the context of this study the staff nurse who are managing the care of severe case patients are not expected to raise to this level of Benner’s acquisition model as an expert but will try hard to acquire expertise in their ability to provide the patient pathophysiology, assessment, planning, and intervention for the achievement of pain control target and will continuously work towards the objective of being at ease if not free from pain during their stay in the Hospital. The most important part Benners work is sheer knowledge. The author desires to explain and discover the role of knowledge in the field of nursing. She calls her work enunciated research and decides differences theoretical and practical knowledge. (Tomey & Alligood, 2006, p. 142). Benner Oppose the nurse’s role to provide quality care is circumstantial. As explained by Benner (2001), there is a huge difference between knowing something against knowing how to do something. There is outside criteria of performance. For the moment the capable and expert nurses will assess a situation more effectively and efficiently than the level I beginner, level II advanced beginners or competent nurse. (Paley, 1996). The inside criteria can be assessed as the mental procedures qualities of each stage that are changeable. This is the situation in which the beginner should rely on the rules and regulations and their application whereas in case of experienced nurse the decisions are taken on the basis of experience and familiarity of the situation or how the circumstances will change (Paley, 1996). Nursing is a practical thing and restrictions of the real world are constantly there and real world resources are also available. There are certain things that may affect the person capability to respond efficiently. Measurement of performance can be useful and accurate at the capabilities selected to be gauged (Benner, 2001). Benner’s Model explains the knowledge that has basis from traditional background taking into concern that traditional experience is much more useful and valuable because it will come from cultural experiences. To apply Benner’s theory to the current research it becomes evident that attitudes and knowledge to occur in the same fashion as the Benner Proposes in the Beginner to expert model. The capabilities of fresh graduates of making highly complex decision making, patient care, the environment is not suitable. Benner, Tanner, and Chesla, (2009) have proposed that in this modern era it is very difficult to pass the license exam and be expert nurse who is well equipped with all the essential tools.

Chapter 3

Aim and Research Questions of Persistence of Undertreated Pain

Aim of Persistence of Undertreated Pain

The purpose of this study is to explore nurses’ knowledge and attitudes regarding pain management.

Study Questions

1.   What is the current knowledge of critical care nurses regarding pain management?

2.   What is critical care nurses’ attitude towards pain management?

Chapter 4

Methodology on Persistence of Undertreated Pain

Design of Pain Management

A descriptive cross-sectional study design was developed to examine nurses’ knowledge and attitudes towards pain management.

Setting of King Fahad Hospital of the University in Saudi Arabia.

The study was conducted in critical care units namely; Medical Intensive care unit (MICU), Surgical Intensive Care Unit (SICU), Coronary Care Unit (CCU) and Emergency Department (ED) at King Fahad Hospital of the University in Saudi Arabia.

Sample Persistence of Undertreated Pain

Using the software G* power version 3.1. (Faul et al., 2009) an effect size of 0.5 to achieve a power of 0.90 and statistical significance 0.05 a111, nurses were needed to participate in the study to reduce the probability of type I and type II error. All nurses who were eligible and agreed to voluntarily participate in the study were recruited.

Exclusion Criteria of Persistence of Undertreated Pain

1) Nurses who have less than six months experience. 2) Nurses who are on leave during study period such as career breaks, maternity leave, and long-term illness will be excluded from study.

Protection of Human Subjects of Persistence of Undertreated Pain

Prior to conducting the study, approval was obtained from the Institutional Review Board (IRB) committee at Imam Abdulrahman University. A research study was approved by ethical committee in the Standing Committee for Research Ethics on Living Creatures (SCRELC) and the hospital responsible authorities.

Participants were assured of anonymity in joining the study and were informed of its voluntary participation. Each participant was provided a written copy of the informed consent related to this study and completion of the questionnaire served as a consent to participate. All surveys were anonymous in nature, therefore, protected the identities of participants. All potential participants were informed that responses would be anonymous with data reported only in the aggregate. There were no risks involved with this survey.

Instrument of Persistence of Undertreated Pain

Nurses’ knowledge and attitude survey regarding pain which comprises two sections:

Section I: Socio-Demographic Data

The researcher developed this section to elicit information about the participants. It comprises ten questions on demographic information including age, nationality, education level, years of working experience, working place (ER/ICU), type of ICU, the current position in ICU, pain management – related workshops or lectures attended & availability of pain assessment tools in the hospital.

Section II: Knowledge regarding Pain

A modified nurses’ knowledge and attitude survey regarding pain (KASRP) will be adopted in this study. The survey was developed by McCaffery & Ferrell in 1987 and was modified with permission by Al-Shaer, Hill, & Anderson. The survey has been revised over the years to reflect changes in pain management practice. Content validity has been established by review of pain experts. Construct validity has been determined by comparing scores of nurses at various levels of expertise such as students, new graduates, oncology nurses, graduate students, and senior pain experts. Test-retest reliability was (r>.80). The modified KASRP is a closed-answer questionnaire composed of 21 true or false statements, seven multiple-choice items, 2 case studies with two multiple-choice items each, for a total of 32 questions. The researcher will do other modification after taking the permission of the author to match specific objectives. These modifications include: 1) Exclude 6 Cancer - related questions because cancer patients are treated in a specialized oncology unit not in ICUs. 2) Questions concerned with non – pharmacological pain management will be formulated by the researcher to include both pharmacological and non – pharmacological pain management measures.   

The newly modified KASRP is composed of 13 True or False Statements, and 16 Multiple Choice Questions where each question has only one correct response.

Study Procedure of Persistence of Undertreated Pain

a)   Consent was obtained from the nurses who agree to participate in the study. Nurses were informed that they have a right to withdraw from the study at any time; their responses and participation were anonymous, and no compensations or incentives were offered.

b)  The questionnaire was pre-tested for reliability by a group of critical care nurses (n=10) who were excluded from the study.

c) The questionnaire was distributed to all nursing staff by the researcher & head nurses.

d) The head nurses were assisting in scheduling appropriate time (60 minutes) for data collection.

d) Due to the risk of cross-contamination and threat to internal validity, the questionnaire was completed under the researcher's supervision.

Data collection

Surveys were distributed to nurses in critical care units mentioned prior in a university hospital in Saudi Arabia. Surveys were carried out with respect to confidentiality and anonymity along with ethical considerations. This method of distribution was needed by ethical approval committee and administration of the bed. Participants placed completed surveys in a specific file given to each department and kept in a secure locked drawer. The researcher collected all completed surveys in a period of two weeks starting from 24 February to 10 March 2019.

Tool Scoring System of Persistence of Undertreated Pain

The scoring system was used in both knowledge and attitude sections in which a score 1 was given to every correct question answered, zero marks deducted for wrong answers, and unanswered questions were not scored. Scores were calculated as follows: Overall score = (no. of correct answers earned / the total no. of correct answers given)*100; Categorical score = (no. of correct answers earned in each question / total no. of correct answers given in each category) *100 (Huang et al, 2013).

Pilot study of Persistence of Undertreated Pain

A random sample of 10 nurses was included in the pilot study, reliability and validity was performed.

Cronbach's Alpha  N of Items

.846           29

Reliability analysis of Persistence of Undertreated Pain

Reliability Statistics showed the value of Cronbach’s Alpha coefficient for the whole scale (both knowledge and attitude) as 0.846, which is an excellent internal consequence of the validity of this questionnaire.

Statistical Analysis of Persistence of Undertreated Pain

All categorical data were presented by frequency with percentage, and continuous data were presented by mean with standard deviation. Total knowledge and attitude score was tested for normality by Kolmogorov-Smirnov and found that total score was normally distributed.  Therefore, association between the total score and demographic variables was tested for significance by using ANOVA and independent t-test. All the analysis was done by using SPSS 21.0 version. P value less than 0.05 was considered as significant.

The total correct scores were computed by adding up the scores for each participant, then converting to percentages. Mean total scores were also calculated for the entire sample. Analysis was conducted to determine total percent KASRP scores for each participant, frequency of correct and incorrect answers for individual KASRP items and those questions participants found to be most difficult, and least difficult were individually analysed. Following the recommendations of Ferrell and McCaffery (2012), data from items 13-52 was analyzed using percentage of total scores. Their recommendation identifies that many of the items measure both attitudes and knowledge, so it is not possible, they suggest, to categories or groups the questions into knowledge or attitudes domains (Ferrell & McCaffery, 2012). The mean survey scores (total scores) for each participant were calculated. A threshold level of (80%) total KASRP score has been recommended for the KASRP as indicating knowledge and attitudes that support the delivery of adequate pain management and this threshold was employed in this study’s analysis (McCaffery & Robinson, 2002).

Chapter 5

Result of Persistence of Undertreated Pain

Results of Persistence of Undertreated Pain

Demographic Characteristics of Participants

The data was analyzed for the demographic characteristics of nurses (n=112), which illustrates that the majority of nurses (62.5%) were in between 25-35 years old, non-Saudi and bachelor degree holders (80.4%). Nurses’ working experience demonstrates that the majority (32.1%) of them were with 5 years to less than 10 years of experience, followed by (25%) of nurses with 10 years to less than 15 years of experience and the same percentage with 6 months to less than 5 years of experience. Only (17.9%) of them were with 15 years or more of working experience (table 1).

Among the study participants (51.8%) work in ICU and the remaining work in ED. The majority of participant work in medical ICU (37.9%). Around (74%) work as a staff nurse and the remaining as charge nurse (18.9%) and head nurse (6.9%). Further, the wide majority of the nurses (98.2%) reported the existence of pain assessment tools and pain management protocol in the hospital. Participation of nurses in the workshop to develop their professional knowledge and skills was also assessed. (50%) of nurses did not attend any workshops related to pain whereas (38.4%) of them attended less than three workshops and (11.6%) attended more than three (table 1).

Nurses Overall Knowledge and Attitude level of Persistence of Undertreated Pain

Figure 2 depicts the nurses’ overall level of knowledge, (7.1%) only were with good level of knowledge which indicates (80%) score. Meanwhile, (48.2%) of the nurses were with poor level of knowledge which indicates (50%) score. It is followed by (28.6%) of them with average level of knowledge which indicate (60%) score and (16.1%) with fair knowledge which indicates (70%) score.

Differences in Knowledge and Attitude Based on Nurses Demographic of Persistence of Undertreated Pain

The data was further analyzed to evaluate the association with demographic variables (table 2), there was no association between knowledge and the demographic variables, except for the current position in the ICU (p=0.043). The total knowledge and attitude score among the ICU nurses working under different titles were analyzed (figure 3) and the result shows that head nurses have a higher level of knowledge (64.6%) followed by charge nurses (53.2) and staff nurses (49.6).

The total knowledge and attitude score was analyzed for various ICU and ED which illustrates that the knowledge of nurses was more or less similar among the units. However, nurses working in MICU attain the maximum level (54.5), while lowest (47.5%) number of nurses works in CCU (table 2).

Number of Participants Who Answered Correctly to Each Item on the Nurse Knowledge and Attitude Survey Regarding Pain 

Table 3 shows the number of nurses who answered the questions correctly.  The majority of them (88.4%) answered correctly the question that “after an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with the individual patient’s response”.  This was followed by the question on the time to attain peak effect for morphine scored (80.4%) of correct answer. Almost the same number of nurses (79.5%) answered correctly for the question on the recommended route for administration of opioid analgesics for patients with brief, severe pain of sudden onset such as trauma or postoperative pain and four more questions ranked more than (70%). These questions were number 9, 12, 5, and 6 from part II. Additionally, among the 29 questions, majority of the questions scored more than (50%) of correct answers, but for 11 questions, correct answers sought was less than (50%). However, the lowest score (15.2%) was obtained for the question “Vital signs are always reliable indicators of the intensity of a patient’s pain”. Followed by (18.8%) for the question “If the source of the patient’s pain is unknown, opioids should not be used during the pain evaluation period, as this could mask the ability to correctly diagnose the cause of pain”. Followed by (21.4%) for the question “Patients might assist regardless of pain in its severe condition” respectively.

It is suggested by the outcomes of the result that there is quite a significant deficit of attitude and knowledge of nurses about the management of pain. The support concerns of study finding identified already in the study that some nurses have deficit of knowledge towards the management of pain.

Chapter 6

Discussion on Persistence of Under treated Pain

Discussion on Persistence of Under treated Pain

Pain is a common stressful symptom of different clinical conditions, experienced by the patients admitted under extreme circumstances in ICU and ED.  Persistence of undertreated pain has a negative impact on mortality and morbidity (Rose et al., 2012) and it has higher rate of complications, anxiety, and sleep disturbance (Coker et al., 2010). Proper assessment of pain is essential to understand the frequency and intensity of pain to diagnose the condition and to provide the required patient care without delay. In order to have an accurate assessment of pain, the healthcare providers should improve their attitude of understanding the assessment methods and should be knowledgeable enough to deal with the condition. Since nurses form the forefront workforce that is closely working with the patients to address their immediate need, their knowledge on pain management has supreme importance. The primary aim of this study was to explore critical care nurses’ knowledge and attitudes regarding pain management at a university hospital in Saudi Arabia.

Nurses Overall Knowledge and Attitude Level of Persistence of Undertreated Pain

This study explored knowledge and attitude regarding pain management of 112 nurses who are currently working in ICU and ED at King Fahad Hospital of University in Saudi Arabia. The results of this study demonstrated that the surveyed nurses had limited knowledge of pain management associated with poor attitude. Results showed that (7.1%) only were with good level of knowledge which indicate (80%) score while (48.2%) of the nurses were with poor level of knowledge which indicate (50%) score.

McCaffery and Pasero (1999) specified that the 80% marks specified that it is the minimum score on the KASPR survey. Ferrell and McCaffery (2008) proposed the avoidance of different items as measuring either knowledge or attitude. It is found that the most usefulness to be gained from assessment of data in terms of percentage of finished marks, as well as analysis of single items. For example they consider it useful to separate the items with the lowest number of accurate responses and those with highest marks. This is the reason why survey scores are reported in the form percentage instead of actual numbers. The deductions from the study are supported by the researches on nurses and attitude towards the management of pain. In the past the studies have been conducted on worldwide scale which highlighted that the modern day nurses don’t have enough knowledge and in acceptable attitude knowing the importance of attitude and knowledge towards the management of pain. (Shuaib, 2018; Wang & Tsai, 2010; Wilson. 2007; Al-Shaer, Hill, & Anderson, 2011; Lui, So, & Fong, 2008; Yildirim, Cicek, & Uyar, 2008; Teixeira & Durão, 2016; Mondol, Muhammad & Chowdhury, 2018; Mohamed, 2015; Rose et al., 2012).

Many other studies that are conducted in MIiddle Eastern countries aslo deduced that the nurses don’t have adequate knowledge on pain management. (Almalki, FitzGerald, & Clark, 2011; Al-Khawaldeh, Al-Hussami, & Darawad, 2013; Al Qadire & Al Khalaileh, 2014). In Saudi Arabia same type of studies are conducted and the same result was concluded that nurses lack positive attitude and knowledge of pain management (Eid, Manias, Bucknall, & Almazrooa, 2014; Mohammed, 2015; Fallatah, 2017; Rasmi Issa, Awaje H & Khraisat, 2017; Samarkandi, 2018).

Ineligible attitude and knowledge might be because of the lack of educational programs for the nurses and guidance malpractice or negligence. McCaffery et al. (2000) actually have suggested that nurses don’t follow the simple guideline of pain rating’s recording (p. 80). For this, reasons were suggested by authors as noted in studies include knowledge deficits and negative attitudes of nurses (Ferrell & McCaffery, 2012; McCaffery & Robinson, 2002; Pasero & McCaffery, 2011).  Compliance’s review with pain assessment seems to demonstrate a requirement for reinforcing the education of the staff for better communication with guidelines’ implementation and pain assessment (Melia, Morrell-Scott, & Maine, 2019). It can be said that another reason of ineligible knowledge might be because of nursing curriculum if not simply covering the pain management. Additionally, nurses in the KSA have a bound access to updated information and online resources from journals and books (Almalki, Fitzgerald, & Clark, 2011). That is why, it is not impossible that their responses may have been formulated on what they have learned during their nursing education before preregistration.

In addition, fifty percent of participants didn’t attend any type of workshop about pain. Shortage of programs on the pain management is explained by this. The results altogether accentuate the need for better and further education and train on the management of pain. Previous studies didn’t show any correlation between the courses of pain management and attendance of nurses in NKASP scores and recent two years. The context of courses of pain management might not have reflected the NKASP survey’s content or the approach of educational delivery might have been inefficiency in improving the understanding of pain of nurses (AlQadire & AlKhalaileh, 2012).

Differences in Knowledge and Attitude Based on Nurses Demographic of Persistence of Undertreated Pain

It is noticeable in the current study that nurses’ knowledge and attitude based on their demographic variables did not illustrate any positive correlation, except for their current position in the ICU (p=0.043). It also shows that nurses have a higher position which demonstrates an improved level of knowledge. This is further clarified through the level of knowledge of nurses based on their position. Among the nurses, head nurses who hold a higher position in the respective ICU illustrate a higher level of knowledge (64.6%).  This may be due to the fact that nurses with higher position may be in the supervisory level and hence, may be more responsible than others. Additionally, when looked into the total knowledge and attitude score of nurses from ED and ICU, it is observed that there is not much variation (figure 4).

Eid (2014), has examined the relation between NKASP scores of nurses and their specific demographic characteristics. A significant difference was shown by results in the clinical areas of nurses and NKASP scores (F3,588 ¼ 4.4, p < .01). Results show a significant and critical difference between nationalities of nurses with respect to the scores of NKASP (F5,566 ¼ 5.3, p < .001).

Almost all of nurses agreed about the existence of pain management tool and protocol, which is an indicator of the existence of a good practice. Studies illustrate that existence of such standardized tools leads to increased frequency of pain assessment, especially for the non-communicative patients (M. L. Phillips, Kuruvilla, & Bailey, 2018; S. Rijkenberg & van der Voort, 2016; Pudas-Tahka, Axelin, Aantaa, Lund, & Salantera, 2014). Validated pain assessment tools are suitable and reliable for the pain assessment. According to a study, the validated Care Pain Observation Tool can be used as a reliable and valid measure to assess pain in critically ill non-verbal patients in the ICU (Kwak & Oh, 2012).

Irrespective of the availability and awareness of pain assessment tool, the overall knowledge level of the study participants bring to the attention that almost half of them has a poor overall level of knowledge. This may be due to the lack of proper training among the nurses, which can be noticed from their exposure to such training workshops. This is evident from the fact that (50%) of them never got exposed to pain training programs and hence, the lack of skill development might be an interfering factor on the poor knowledge among half of the nursing team. Almost similar findings were reported by a study demonstrating poor overall knowledge and attitude regarding pediatric pain management (Alotaibi, Higgins, & Chan, 2018). A survey on the knowledge of oncology nurses on pain management clarifies the need for more effective evidence-based educational program in cancer pain management (Al-Atiyyat et al., 2018). However, proper training and education may help improve the level of knowledge. Yet another study on the barriers of pain management points out that nurse’s awareness of evidence-based practice increases with their education (Medrzycka-Dabrowska, Dabrowski, Gutysz-Wojnicka, Basinski, & Kwiecien-Jagus, 2018). In contrary to these findings, a research conducted in an Australian tertiary pediatric hospital states that although the nurses’ knowledge and attitude toward pain management were among the highest reported, areas for targeted education using in-service education and workshops were identified alongside a need for exploration of the impediments to providing best care. Nevertheless, a focused training program may be helpful in improving the knowledge level of nurses on pain assessment/management and thereby improving patient care. This is pointed out by a knowledge and attitude study, which found improvement in persistent pain management knowledge and attitudes among direct care nurses caring for hospitalized patients (Keen et al., 2017). Number of Participants Who Answered Correctly to Each Item on the Nurse Knowledge and Attitude Survey Regarding Pain The majority of nurses (78%) in this study were with poor and average level which indicated inadequate knowledge and poor attitude. The mean NKASP percentage score of (<50%) was similar to the results for nurses in Turkey (Yildirim et al., 2008; Ekim & Ocakci, 2012) and Jordan (AlQadire & AlKhalaileh, 2012). In contrast, nurses in the United States obtained higher scores (Lewthwaite et al., 2011; Moceri & Drevdahl, 2012; Duke, Haas, Yarbrough, & Northam, 2013). The results of data suggest that there is a significant deficit of critical care nurses’ knowledge and attitude regarding pain management. The study finding support concerns are already identified in the literature that some nurses have a knowledge deficit of knowledge and attitude towards pain management. This indicates that the nurses have required knowledge only on some aspects but not for all facets of pain management and assessment. A study on the nurses’ knowledge, attitude, and practice also concludes with almost the same findings stating that nurses have knowledge deficits about pediatric pain management and do not always use their knowledge in practice, particularly in relation to pain assessment (Peirce, Corkish, Lane, & Wilson, 2018).

Chapter 7

Conclusion and Recommendation of Persistence of Undertreated Pain

Conclusion on Persistence of Undertreated Pain

Overall, the objective of this study is to explore the attitude and knowledge of nurses in the critical care unit about the management of pain at the University Hospital in KSA. The overall knowledge in the study regarding pain management was insufficient for the management and assessment of pain of ill patients in the hospital’s critical units. Furthermore, there wasn’t a significant relation of pain assessment with demographic variables. Therefore, it is imperative that regardless of the knowledge level, nurses’ continuous education program might assist in proving the skills and knowledge of pain management and assessment. However, studies at a large scale were warranted at various hospitals with a very large size of sample for having a better understanding of reasons just why the level of knowledge is less than adequate and its implications on the outcome of patient care.

Information and knowledge of nurses are significant because nurses are in a very critical position for assessing managing the pain of patients in units of critical care.

Strength and Limitations of Persistence of Undertreated Pain

This study’s strengths involved the willingness of all nurses of critical care to have a part in responding to the questionnaire. In addition, size of sample was covered on the basis of calculation of G-Power that equaled 112 nurses. Meanwhile, limitations were least in studies in KSA on topic as well as the time consumed in the recollection of questionnaire papers which were missed. Busy duty and changing shifts are included in other limitations in addition to limited time loading the total work.

Recommendation of Persistence of Undertreated Pain

Actually, more research is required about the attitudes and knowledge of nurses towards the management of pain. Further studies for the identification of differences among specialty areas could assist in determining if various nursing area would be benefitted from more education on the management of pain. Studies in assessing the effect of educational interventions with the focus on nurses regarding their attitudes and knowledge towards management of pain would be required for measuring the effect of continuous programs of education. In several practice and geographical settings, additional study is required for determining if deficits in research are actually prevalent across the settings.

Educating all the new nurses is included in recommendations about the management and assessment of pain. Delivering them with a fine education including courses would improve the quality and knowledge of nursing care. In this area, further research is recommended and involving patients in studies would deliver a better outcome.

Chapter 8

Summary of Persistence of Undertreated Pain

Summary of Persistence of Undertreated Pain

Pain is a complex, subjective phenomenon; it means unpleasant feeling, which results from tissue injuries. Moreover, pain induces many harmful effects, which inhibit early recovery from critical illness (Morton & Fontaine, 2009).

Over the past 30 years, the attention devoted to pain experienced by critical care patients has devolved from pain as a co-existing symptom with illness to developing evidence-based guidelines to support assessment and management of pain (Barr et al., 2013; Celis- Rodriguez et al., 2013; DAS-Taskforce, 2015). Guidelines of difficult airway society (DAS-Taskforce, 2015) recommended that pain should be assessed routinely in all critical care patients. The assessment must done by using a valid tool either subjective (self-report) or objective (behavior observation). In addition, guidelines encourage the use of analgesic interventions depending on each individual patient need (DAS-Taskforce, 2015).

Persistence of pain can increase a patient’s length of stay in the hospital, leading to increased cost for the health care system. Prolonged and poorly managed pain can lead to decreased patient satisfaction (McCaffery & Pasero, 1999), while proper pain management reduces morbidity, and increases patient satisfaction and quality of life (The Joint Commission, 2001). Ineffective communication and collaboration between clinicians and patients is a barrier to effective pain management. An increase in nurses’ knowledge in the area of pain assessments, reassessments, pharmacological, and non-pharmacological management improves patient outcomes (Al Shaer et al., 2011). To promote quality care for patients, nurses must possess the skills needed to adequately address pain management issues (Stanley & Pollard, 2013).

Although pain is a significant challenge within the critical care environment, the problem has not been addressed quietly in Kingdom of Saudi Arabia (Issa, 2017; Thurayya et al., 2014; Summayah, 2017 & Nihad, 2015). This study aims to assess critical care nurses’ knowledge and attitude regarding pain management at a university hospital in Saudi Arabia. Design: A cross-sectional design. Settings: Data will be collected from 112 nurses of the critical care units including Surgical Intensive Care Unit (SICU), Medical Intensive Care Unit (MICU), Coronary Care Unit (CCU) and Emergency Room (ER) at a university hospital in Saudi Arabia. Tool: A modified nurses’ knowledge and attitude survey (NKAS) regarding pain will be adopted in this study. The survey was developed by McCaffery & Ferrell in 1987 and was modified with permission by Al-Shaer, Hill, & Anderson 2011 (Herr & McCaffery, 2011). Method: Ethical approval to conduct the study will be obtained. Data will be coded & analyzed using statistical package SPSS version 25.

الملخص باللغة العربية

ازداد الوعي مؤخرا عن مدى أهمية علاج الألم لتخفيف معاناة المرضى ولتحسين نتائج الرعاية المقدمة للمرضى وخاصة مرضى الحالات الحرجة والتي غالبا ما تستدعى خطورة حالاتهم لدخول وحدات الرعاية المركزة. وطبقا لنتائج الابحاث التى أجريت على مرضى الحالات الحرجة على مستوى العالم, تم الإبلاغ عن أن حوالي 5 ملايين مريض يحصلون على دخول وحدة الرعاية الحرجة كل عام حول العالم (Klein et al., 2010). وشكا حوالي 77 ٪ من هؤلاء المرضى من الألم أثناء إقامتهم في وحدات الرعاية الحرجة. و من بين هؤلاء المرضى، أبلغ 32٪ عن ألم شديد في حين أبلغ 60٪ عن ألم معتدل إلى شديد. ما يقرب من 80٪ من الألم المرتبط بإجراءات وحدات الرعاية الحرجة مثل إدخال الأنبوب الرغامي ، وفتح القصبة الهوائية (الفغر الرغامي)، والشق الجراحي، وصرف السوائل، وتبديل المواضع، والمصاص (تفريغ المعدة والأمعاء)، وإدخال القنية الوريدية وتضميد الجروح ، إلخ (Chanques et al., 2010; Klein et al., 2010 & Shuaib, 2018). الألم الغير معالج يؤدي إلى التغيرات النفسية، الحيوية، الأيضية والغدد الصماء العصبية التي تزيد من الفترة المرضية ومدة البقاء في وحدات الرعاية الحرجة (Muhammad, 2018). ويزيد الألم الغير معالج من تفاقم القلق والحرمان من النوم والهيجان والهذيان والاكتئاب الذي غالباً ما يؤدي إلى حالة مزمن (Carrillo-Torres et al., 2016 & Mindy, 2013). هناك العديد من العوائق التي تحول دون التعرف على الألم وإدارته بشكل صحيح مثل التخدير ، ووجود الأنبوب الرغامي ، وما إلى ذلك (Herr et al., 2011& Pasero et al., 2009). لذلك أصبح من الضروري أن يحصل كادر التمريض على المعرفة المطلوبة المتعلقة بأنواع الألم في وحدات الرعاية الحرجة، وأدوات تقييم الألم الصحيحة، وإدارة الألم المناسبة. يعد التقييم الدقيق للألم و بشكل موثوق، المفتاح المؤدي لتقليل المعاناة وإدارة الألم بنجاح (Kozier, 2008 & Al-Shaer et al., 2011). على الرغم من أن الألم يمثل تحديًا كبيرًا في بيئة الرعاية الحرجة ، إلا أن المشكلة لم يتم طرحها بكثرة في المملكة العربية السعودية (Issa, 2017; Thurayya et al., 2014;  Summayah, 2017 & Nihad, 2015).

الهدف: تهدف هذه الدراسة الى تقييم معارف وسلوك الممرضين والممرضات العاملين بوحدات الحالات الحرجة نحو علاج الالم في مستشفى جامعي بالمملكة العربية السعودية. التصميم: سوف يستخدم التصميم الوصفي لإجراء هذه الدراسة. أدوات البحث: سوف يتم استخدام أداة واحدة لجمع البيانات الخاصة بهذا البحث. تنقسم هذه الاداة الى محورين: المحور الاول: تتعلق بجمع البيانات الخاصة بكوادر التمريض المشاركين بالبحث. المحور الثاني: اختبار مكون من مجموعة من الاسئلة التي تتعلق بالجوانب المعرفية والسلوكية لدى العينة المشاركة في البحث عن الالم من حيث طرق العلاج. العينة: سوف يتم تطبيق الدراسة على 112 من كوادر التمريض ممن مر عليهم 6 أشهر فأكثر بالعمل في وحدات الحالات الحرجة، بما في ذلك: (العناية المركزة الباطنية، العناية المركزة الجراحية، العناية المركزة القلبية والطوارئ) في مستشفى جامعى بالمملكة العربية السعودية ووافقوا تطوعا للمشاركة في البحث. الطريقة: سيتم الحصول على الموافقة الأخلاقية لإجراء الدراسة. سيتم جمع البيانات وترميزها وتحليلها للحصول على النتائج والاستنتاجات والتوصيات. الاجراءات: تقديم البحث للجنة أخلاقيات البحث بالجامعة للحصول على الموافقة لإجراء البحث. الحصول على موافقة المسئولين بالمستشفى وذلك بعد شرح مفصل لهدف وطريقة إجراء البحث. الحصول على الموافقة النصية من الممرضين والممرضات العاملين بالعناية المركزة للمشاركة بالبحث وذلك بعد اعطاء معلومات وافية عن حقوقهم والهدف من البحث والمشاركة المتوقعة منهم من خلال عمل مقابلة معهم. تجربة الادة المستخدمة في جمع البيانات وذلك عن طريق عرضها على 10 ممرضات مع الاحتفاظ بسرية الاختبار. الترتيب المسبق مع المشاركين في البحث على الوقت والمكان المناسب لإجراء الاختبار. سوف يتم توزيع نسخ ورقية على الممرضين والممرضات مرفق بها خطاب الحصول على الموافقة النصية للمشاركة في البحث. تجميع الاداة بعد استكمالها بواسطة المشاركين سوف يكون يد بيد من المشاركين. بعد تجميع الأداة سوف يتم افراغ البيانات وتحليلها إحصائيا لاستخلاص النتائج والاستنتاجات والتوصيات.