Patients' and nurses' perception of pain management in the emergency department

Background: Pain is one of the most common reasons for patients to seek care in the Emergency Department (ED) and pain management should have a primary focus since effective pain management is associated with patient satisfaction, earlier mobilization and shortened hospital stays. Despite earlier knowledge, there are still barriers to pain management at the ED which increase the risk of oligoanalgesia for the patients seeking care. Several previous studies have evaluated actions aimed at improving pain management, but, without additional knowledge of the patients’ and registered nurses (RNs’) perspective, it may not be possible to further improve pain management in the ED.

Aim: The overall aim of this thesis was to explore the patients’ and nurses’ perception of pain management in the ED.

Methods: A quantitative approach was used for Studies I, II and III and, in Study IV, both qualitative and quantitative analyses were used. All studies were conducted in Swedish EDs and the study participants consisted of patients and RNs.

Results: Study I, 77% of 647 patients seeking care stated that pain was present when they arrived at the ED and the odds of reporting pain was six times higher among patients <30 years old, compared to patients >60 years old. Thirty-three per cent had taken analgesic prior to admission. Study II, a total of 840 patients (medical records) with wrist/arm fractures or soft tissue injuries and who had received analgesics at the ED were analyzed. The results showed that mandatory pain assessment in the patient's computerized medical record was the only successful intervention to improve the frequency of documentation of pain assessment during care in the ED. However, no documentation of the reassessment of pain was found even though all patients received analgesics. Study III, a total of 160 patients answered a questionnaire and the results showed that more patients received analgesics and that there was a decrease in the intensity of pain in these patients at discharge after the implementation of mandatory documentary assessments of pain. No statistical differences were found regarding the satisfaction of the patients on pain management. Study IV, a total of 70 RNs answered a questionnairer and the results showed that RNs with >6 years of experience administered more analgesics according to the Nurse Initiated Pain Protocol (NIPP), compared to RNs with less experience. The findings also showed that the majority of the RNs thought that the NIPP provided adequate support to relieve the acute pain of patients in the ED.

Conclusion: There needs to be a primary focus on pain management in the ED since more than 75% of the patient stated that pain was present when they arrived at the ED. The findings show that mandatory documentation of the assessment of pain in the patient’s computerized medical record was a successful intervention to improve the frequency of the documentation of pain assessments in the ED. After the intervention, more patients received more analgesics and reported decreased intensities of pain at discharge from the ED. However, the patients’ own reported satisfaction regarding pain management during the ED visit was not significantly improved by implementing the mandatory documentary assessment of pain. The findings concerning the patient’s own reported satisfaction regarding pain management may be attributable to the RNs own working experience and their use of NIPP, but further research is needed to explore the factors that affect the patient’s own reported satisfaction regarding pain management during the ED visit.

List of scientific papers

I. Sturesson L, Ulfvarson J, Niemi-Murola L, Lindström V & Castrén M. Pain on arrival at the emergency department: A regional survey. Nordic Journal of Nursing Research. 2017, Vol.37(1): 7-11.
https://doi.org/10.1177/2057158516656998

II. Sturesson L, Lindström V, Castrén M, Niemi-Murola L & Falk A-C. Actions to improve documented pain assessment in adult patients with injury to the upper extremities at the Emergency Department – A cross-sectional study. International Emergency Nursing. 2016 Mar;25:3-6.
https://doi.org/10.1016/j.ienj.2015.06.006

III. Sturesson L, Falk A-C, Castrén M, Niemi-Murola L & Lindström V. Mandatory documentation of pain in the emergency department increases analgetic administration but does not improve patients’ satisfaction of pain management. Scandinavian Journal of Pain. 2016 (13) 32-35.
https://doi.org/10.1016/j.sjpain.2016.06.006

IV. Sturesson L, Falk A-C, Ulfvarson J & Lindström V. Registered nurses’ own experience of using a nurse-initiated pain protocol based on their working experience. [Submitted]