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Write a report on knowledge and practice towards pain assessment in critically ill patient among Nurses in Emergency Room at Military Hospital Makkah.

Background of the Study

The International Association for the study of pain as defined pain as a hostile sensory and passionate experience that is related to potential tissue injury (Loeser and Treede, 2008). Pasero (2009) describes pain assessment as a necessary procedure which involves examining the location and intensity of pain. The role of providing the most appropriate ease for severely sick patients is an overall aim for doctors and nurses since pain is an experience that makes a patient uncomfortable. Pain can be caused by already existing illness, invasive procedures or distress (Arif-Rahu and Grap, 2010). Buttes et al. (2014) observe that pain assessment is the initial step towards pain management, and is very significant in patient care. The inadequate management of critical pain negatively affects the normal functioning of the organ system, in addition to physical and psychological outcomes (Bennett and Hurford, 2011). Studies indicate that critically ill adult patients (CIAP) experience pain while in a restful position and during usual care (Barr et al., 2013). The magnitude of CIAP is a drawback to the efforts being made in the improvement of knowledge and technology aimed at optimal pain assessment (Cogan, 2010). Based on the foregoing evidence, improved pain assessment for acute pain is an essential aspect in addressing the needs of patients and optimizing the possibility of recovery (Li et al., 2014). Therefore, evaluating Nurses knowledge and practice of guidelines associated with acute pain assessment and management is therefore fundamental to adequate pain relief.

Severely sick patients often undergo average to extreme pain, and in instances of deadly sickness, the alleviation of pain is overlooked, or at least not adequately esteemed by the health care providers (Barr et al., 2013). Studies have pointed out that 64% of patients remember having undergone pain and term it as the most stressful encounter during their critical stay (Puntillo et al., 2009). Even though pain is a crucial issue in critical care settings, the matter hasn’t sufficiently been researched by critical care nurses.

The hindrances faced by the nurses such as knowledge shortfalls about pain assessment, failure to evaluate and appreciate the presence of pain, individual and social preference have substantially contributed to inadequate pain evaluation among  severely sick patients (Pasero et al., 2009). Thomas (2008) found out that the incorrect pain assessment alongside the outcomes of inadequate pain alleviation in critically ill adults causes grievous physiological and psychological effect. However, there is limited literature on the nurses’ knowledge and practices on pain assessment notwithstanding the increased awareness on the same (Pasero et al., 2009). There exists no study focusing on the knowledge and practices of nurses in pain assessment among critically ill in the Emergency Room at Military Hospital Makkah.

To explore the knowledge and practices of nurses in pain assessment for critically ill patients in the Emergency Room at Military Hospital Makkah, Saudi Arabia.

  1. What are the pain assessment practices among nurses caring for critically ill patients in the Emergency Room at Military Hospital Makkah?
  2. What is the level of knowledge related to pain assessment among nurses caring for critically ill patients in the Emergency Room at Military Hospital Makkah?

The findings of this study will enable nurses to adequately assess the condition of the patients and provide patient-centered care and thus minimize discomfort and improve the quality of life.

Problem Statement

The study will enable the designing and implementation of strategies to enhance the knowledge and practices of pain assessment among nurses with an objective of reducing patient suffering.

The study is likely to influence the formulation of protocols and policy guidelines aimed at enhancing nursing practice.

Since the study will be based on nurses’ self-reports, this will not possibly allow the assessment of the actual practice with regard to pain assessment. Additionally, the allotted time for the study may not permit the use of important techniques of data collection such as observation of the routine practices. It is likely that some of the study participants may not return the questionnaires; an aspect that will lead to a low rate of non-response.

ANOVA – Analysis of Variance

CIAP- Critically ill adult patients

BLS- Basic life support

CPR- Pulmonary resuscitation

AED- Accident and Emergency department

ERC- Ethics and Research Committee

SPSS- Statistical Packages for Social Sciences

The researcher critically examined relevant articles and books to the research title. Search engines such as Google Scholar, PMC, and PubMed were used to conduct systematic research. Only articles published within the last eight years were included in the review.  40 studies were retrieved from the database after a quality check. 20 studies were included in the critical review. Ten of the studies were excluded due to duplication, and the other ten of them had restricted access. The specific key term used in the search are pain, pain assessment, nurse, critical care, nursing knowledge, and basic life support.

Basic life support (BLS) is an emergency procedure that comprises of ascertaining an arrest and initiating appropriate cardiac, pulmonary resuscitation (CPR) methods to sustain life until the recovery of the patient or access to the medical facility (Berg et al., 2010). Bajracharya and Nagarkoti (2016) resuscitation as the practice of restoring life or consciousness of one who is seemingly unconscious. Some of the vital elements of BLS include airways, circulation, and breathing. Inadequate circulation for approximately 200 seconds will result in permanent damage to the brain. The most prevalent type of emergencies include accidents and cardiac arrests with severe impacts. However, basic practices and skills can enhance the results, in addition to CPR which can increase survival chances (Berg et al., 2010). Ewy (2009) indicated that most of the patients that undergo pre-hospital cardiac arrest do not receive adequate and prompt resuscitation by healthcare experts. For each delay of resuscitation by a minute in case of cardiac arrest, the possibility of efficacious resuscitation is decreased by 10% (Rubertsson et al., 2014). Studies have also shown that there is over 49% survival rate when the timely administration of CPR with defibrillation is administered within five minutes of collapsing.

The first healthcare providers to witness a cardiac arrest in any medical facility and call for help are the nurses. Therefore, there is a need for the nurses to be in possession of current technological know-how and practical skills to help in effectively addressing matters of cardiac arrest among others (Ewy, 2009). Furthermore, studies have shown that knowledge of BLS is a significant factor in the ultimate result of critical emergencies. Devishree, Mahesh, and Jain (2018) carried out a cross-sectional descriptive study of 150 dental students on the knowledge regarding BLS in a pediatric patient. The authors evaluated the knowledge of the students on BLS in a pediatric patient using self-administered questionnaires and found out that all the participants did not possess adequate BLS knowledge. Awareness of the meaning of the BLS abbreviation among the respondents was 76%, whereas 62 percent of them were knowledgeable regarding the position of chest compressions in unresponsive adults. The outcomes of the study indicate that there was an inadequacy among the dental community students regarding the preparedness to handle such issues.

Objective of the Study

Similarly, Bajracharya and Nagarkoti (2016) undertook a descriptive cross-sectional study on the knowledge of BLS among 50 nurses engaged in different care units in the referral hospital of Nepal. The authors gathered data using self-semi structured questionnaires and found out that all of them were aware of BLS. However, 86 percent had no training in BLS. The authors concluded that there was an inadequacy in BLS knowledge in most of the nurses. Vasudevan et al. (2016) carried out a cross-sectional analytic study on the knowledge of simple BLS algorithm among nursing and medical students in teaching hospital and found out that the nursing students had a higher median knowledge score of 8.5 with the highest being reported amongst those that had experienced BLS before or attended a seminar on BLS. The nursing student had higher BLS knowledge when compared to medical students. Despite the existence of a knowledge gap in BLS, the nursing students have been found to outperform other students in healthcare regarding BLS or CPR knowledge (Josipovic, Webb, and McGrath, 2009).  Xanthos et al. (2009) also found out that nurses were more effective in teaching other nurses about BLS knowledge than doctors.

Salameh et al. (2018) carried out a cross-sectional descriptive study of 150 nursing students and 150 nursing professionals with the aim of comparing their knowledge on BLS. The outcomes indicated that the registered nurses had higher BLS knowledge (56.7%) compared to the nursing students. Xanthos et al. (2012) assessed the theoretical knowledge of nurses in BLS and found out that there was an alarmingly low level (10.3%) of BLS knowledge which was also not affected by the refresher BLS course and former experience.

The research will adopt a descriptive cross-sectional study approach. The researcher settled for a quantitative approach because it allows the collection of statistical data and carrying out quantitative assessment using statistical methods, so as to ascertain the knowledge level of nurses and explore the practices associated to pain evaluation for severely sick patients among the nurses in Emergency Room at Military Hospital Makkah. A cross-sectional design best fits the study because it will allow the investigator to analytically assess and record the knowledge level and practices in the actual manner among different nurses at the same time.

The study will be carried out at Military Hospital Makkah. Makkah armed forces hospital is located at Makkha centre opposite the King Abdullah Rd in Saud Arabia making it easily accessible to incidences of immediate emergency care. The hospital comprises of 200 beds for critical medical care providing healthcare services to military personnel and families. The hospital is one among the average military hospitals in the Kingdom and has approximately 564 healthcare providers with nurses being the majority (40%). The nurses have varying qualifications from masters, bachelors’ degree to diplomas. The researcher chose Military Hospital Makkah because it is one of the hospitals dealing with cardiac issues and burns unit. Based on its location it is believed that most of the nurses there deal with critically ill patients with different conditions.  

Research Questions

The study population comprises of nurses employed at Military Hospital Makkah. The facility has 226 nurses tasked with the role of attending critically ill patients. The nurses that make up the study population include those attached to the intensive care unit, neurological and emergency units.

The study will adopt purposive sampling approach in the selection of the facility and the respective units which the nurses are allocated. Purposive sampling will be used in the selection of the units to make sure that those involved in the study have expertise in handling critically ill patients and pain assessment. Each of the potential participants will individually be approached by the researcher and the objective of the study explained to them after which a request for their participation will be made. The willingness of the nurses to participate in the study will be expressed through reading and signing the consent form.

The Cronchran’s (1977) formula will be used to estimate the sample size as shown below:

Where; n = the estimated sample size

N = the study population and

e= approximate margin of error: 0.05 (95% C.I)

e2 = (0.05)2 = 0.0025

 (n) = 226/(1+0.3)   = 226/ (1.3)

n= 173

The independent variables include demographic profile namely age, job position, gender, education level, work experience, and training in pain assessment.

The dependent variables include practices associated to pain assessment and knowledge level associated to pain assessment.

A semi-structured questionnaire will be used to collect quantitative data. The researcher will individually design the semi-structured questionnaire and it will comprise of close and open-ended questions. The questions will be categorised into three areas namely knowledge, practices and demographic profile. The tool will be given to three professionals in critical care and entreated to assess the appropriateness and relevance of the specific items. The experts will be required to rate the items on a four-point Likert scale regarding their bearing to knowledge and practices of pain assessment.

Validity has been defined by Sayer (2010) as the precision and relevance of inferences arrived at on the basis of the study outcomes. This involves asking an appropriate question in the most understandable manner. The study will use content validity to measure the validity of the research tool to be used. Content validity will be determined on two stages. Each item was critically assessed for its appropriateness to measure the expected content. The questionnaire was then submitted to three experts for evaluation.

Orodho (2009) defines reliability as extent to which the tool yields similar outcomes on repeated trials. In order to achieve reliability, two professionals in critical care will be requested to carry out a pilot study to find out the completeness, uncertainty and determine the time taken for data collection using the proposed semi-structured questionnaire. Cronbach Alpha statistical tests will be used in testing the variables for reliability. Reliability coefficients of 0.90 will be regarded as exceptional, 0.80 as very good and those around 0.70 as satisfactory (Koul, 2009).

An approval to conduct the research will be obtained from the Ethics and Research Committee (ERC) of the institution. A pilot study will be carried out at Duqm Lint medical services centre. Seventeen questionnaires will be administered to nurses assigned to the Accident and Emergency department (AED) to ascertain the validity and reliability of the research tool. Duqm Lint medical services centre has been preferred because it is near Military Hospital Makkah and deals with critical ill patients. Pain casualties that seek for services in both facilities have relatively the same cause.

Significance of the Study

The questionnaire will be amended accordingly based on the outcomes of the pilot study. The researcher will individually drop the questionnaires at the offices of the various units where the potential nurses have been allocated and then picked at the end of the day. Each questionnaire will be attached to an introductory letter with details on the objective of the study

The completed questionnaires will be assessed and coded to find out the consistency then entered into Statistical Packages for Social Sciences (SPSS) for analysis. Descriptive statistics will be conducted for continuous variables and for categorical variables, frequency distribution and percentages will be utilised. The association between knowledge and the education level of the nurses will be determined using inferential statistics (ANOVA)

The ethical clearance of the proposal will be approved by the ERC of the institution. The ministry of health and the administration of Military Hospital Makkah will grant the permission to conduct the study. Informed consent in writing will be obtained from all the potential nurses and their identities withheld in the entire study.


Arif-Rahu, M. and Grap, M.J., 2010. Facial expression and pain in the critically ill non-communicative patient: state of science review. Intensive and critical care nursing, 26(6), pp.343-352.

Bajracharya, S. and Nagarkoti, L., 2016. Knowledge regarding basic life support among nurses of a tertiary level hospital of Nepal. Medical Journal of Shree Birendra Hospital, 15(1), pp.66-69.

Barr, J., Fraser, G.L., Puntillo, K., Ely, E.W., Gélinas, C., Dasta, J.F., Davidson, J.E., Devlin, J.W., Kress, J.P., Joffe, A.M. and Coursin, D.B., 2013. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit: executive summary. American Journal of Health-System Pharmacy, 70(1), pp.53-58.

Bennett, S. and Hurford, W.E., 2011. When should sedation or neuromuscular blockade be used during mechanical ventilation?. Respiratory Care, 56(2), pp.168-180.

Berg, R.A., Hemphill, R., Abella, B.S., Aufderheide, T.P., Cave, D.M., Hazinski, M.F., Lerner, E.B., Rea, T.D., Sayre, M.R. and Swor, R.A., 2010. Part 5: adult basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122(18 suppl 3), pp.S685-S705.

Buttes, P., Keal, G., Cronin, S.N., Stocks, L. and Stout, C., 2014. Validation of the critical-care pain observation tool in adult critically ill patients. Dimensions of Critical Care Nursing, 33(2), pp.78-81.

Cogan, J., 2010, September. Pain management after cardiac surgery. In Seminars in cardiothoracic and vascular anesthesia (Vol. 14, No. 3, pp. 201-204). Sage CA: Los Angeles, CA: SAGE Publications.

Devishree, R.A., Mahesh, R. and Jain, A.R., 2018. Knowledge about Basic Life Support (BLS) in Pediatric Patient among Dental Students. Journal of Pharmaceutical Sciences and Research, 10(2), pp.278-281.

Ewy, G.A., 2009. Do modifications of the American Heart Association guidelines improve survival of patients with out-of-hospital cardiac arrest? American Heart Association, pp.2542-2544. Available from: file:///C:/Users/Admin/Downloads/Documents/010a628d3ac752ee77df4fed2cb1c505c41d.pdf [Accessed November 12 2018].

Josipovic, P., Webb, M. and McGrath, I., 2009. Basic life support knowledge of undergraduate nursing and chiropractic students. Australian Journal of Advanced Nursing, 26(4), p.58.

Koul, L., 2009. Methodology Of Educational Research, 4Enew E. Vikas publishing house PVT Ltd.

Li, Q., Wan, X., Gu, C., Yu, Y., Huang, W., Li, S. and Zhang, Y., 2014. Pain assessment using the critical-care pain observation tool in Chinese critically ill ventilated adults. Journal of pain and symptom management, 48(5), pp.975-982.

Loeser, J.D. and Treede, R.D., 2008. The Kyoto protocol of IASP Basic Pain Terminology?. Pain, 137(3), pp.473-477.

Orodho, J.A., 2009. Elements of education and social science research methods. Nairobi/Maseno, pp.126-133.

Pasero, C., 2009. Challenges in pain assessment. Journal of PeriAnesthesia Nursing, 24(1), pp.50-54.

Pasero, C., Puntillo, K., Li, D., Mularski, R.A., Grap, M.J., Erstad, B.L., Varkey, B., Gilbert, H.C., Medina, J. and Sessler, C.N., 2009. Structured approaches to pain management in the ICU. Chest, 135(6), pp.1665-1672.

Puntillo, K., Pasero, C., Li, D., Mularski, R.A., Grap, M.J., Erstad, B.L., Varkey, B., Gilbert, H.C., Medina, J. and Sessler, C.N., 2009. Evaluation of pain in ICU patients. Chest, 135(4), pp.1069-1074.

Rubertsson, S., Lindgren, E., Smekal, D., Östlund, O., Silfverstolpe, J., Lichtveld, R.A., Boomars, R., Ahlstedt, B., Skoog, G., Kastberg, R. and Halliwell, D., 2014. Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. Jama, 311(1), pp.53-61.

Salameh, B., Batran, A., Ayed, A., Zapen, M., Ammash, A., Taqatqa, A., Nasar, M. and Naser, D., 2018. Comparative assessment of basic life support knowledge between professional nurses and nursing students. Archives of Medicine and Health Sciences, 6(1), p.54.

Sayer, A., 2010. Method in social science: revised 2nd edition. Routledge.

Thomas, J., 2008. Practical perioperative pain control in children and adults. Southern African Journal of Anaesthesia and Analgesia, 14(6), pp.11-17.

Vausedvan, B., Lucas, A., Bhaskar, A. and Areekal, B., 2016. Assessment of level of knowledge of basic life support algorithm among medical and nursing students in a tertiary care teaching hospital. International Journal Of Community Medicine And Public Health, 3(12), pp.3520-3525.

Xanthos, T., Akrivopoulou, A., Pantazopoulos, I., Aroni, F., Datsis, A. and Iacovidou, N., 2012. Evaluation of nurses’ theoretical knowledge in Basic Life Support: a study in a district Greek hospital. International emergency nursing, 20(1), pp.28-32.

Xanthos, T., Ekmektzoglou, K.A., Bassiakou, E., Koudouna, E., Barouxis, D., Stroumpoulis, K., Demestiha, T., Marathias, K., Iacovidou, N. and Papadimitriou, L., 2009. Nurses are more efficient than doctors in teaching basic life support and automated external defibrillator in nurses. Nurse education today, 29(2), pp.224-231.

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