knowledge and attitudes of pain management by nurses in saudi arabian emergency departments

279 Pages·2015·3.09 MB·English

by  Nihad Mohammed

KNOWLEDGE AND ATTITUDES OF PAIN
MANAGEMENT BY NURSES IN SAUDI ARABIAN
EMERGENCY DEPARTMENTS:
A MIXED METHODS INVESTIGATION
NIHAD MOHAMMED
BSCN, MSCN
Supervisors:
Dr. Sandra Mackey
Associate Professor Amanda Johnson
Professor Elizabeth Halcomb

Submitted in fulfilment of the requirements for the degree of
Doctor of Philosophy

School of Nursing and Midwifery
University of Western Sydney, Australia
[March, 2015]
Dedication

In the name of Allah the merciful, and prayer and peace upon the best of his
creatures.
I dedicate this thesis to my mother whose continuous support has been my mainstay
throughout the entire process; and to my father, who passed away before I started my
study journey but who encouraged me to complete my postgraduate studies. I still
remember all his words of encouragement that have always helped me through any
difficulties.
I dedicate this work also to all my lovely family members, who have supported me
throughout my PhD studies, with all my love and appreciation.
Acknowledgments
I owe much gratitude to my mother and father whose unconditional love and
encouragement have sustained and supported me in every way throughout my life. I
am grateful to my sisters, brothers, nephews, and nieces who have all supported me
when I have been overseas studying. Special thanks to my cousin Mahmoud Qutub.
Thanks to Professor Y. Jamal and Dr. A. Al Youbi and to King Abdul Aziz
University Hospital who have given me the opportunity to pursue my graduate
studies, to Khalid Al Sweity at the Saudi Cultural Mission, and also Dr Lourance for
his help, useful advice and encouragement.
At the University of Western Sydney, I would like to thank the following people:
Associate Professor Terrence Sloan, Professor Esther Chang and Associate Professor
Yenna Salamonson. Thank you to Professor Maree Johnson, Associate Professor
Amanda Johnson and Professor Elizabeth Halcomb for their academinc support on
my thesis panel. I would like to offer particular and thanks to my principal supervisor
Dr. Sandra Mackay not only for her academic advice but also for her kind and steady
personal support through many difficult times.
I am grateful also to my GP, Dr. Ankita Roy and to my physiotherapists Cath
Emmerson and Nick Torrance. Thank you to Wendy Porter, my good friend and
mentor who helped me in so many ways and who advised and encouraged me in the
difficult task of academic writing in my second language.
Finally, thanks to God for having all these people around me to support me.
Statement of Authentication

The work presented in this thesis is, to the best of my knowledge and belief, original
except as acknowledged in the text. I hereby declare that I have not submitted this
material, either in full or in part, for a degree at this or any other institution.

Nihad Mohammed
Signature…………………………………….Date…………………………….
Table of Contents
List of Tables ............................................................................................................ v

List of Figures ......................................................................................................... vi

List of Abbreviations ............................................................................................. vii

Abstract ................................................................................................................. viii

Chapter One: Introduction ..................................................................................... 1

1.1
  Background: Saudi Arabian Healthcare ...................................................... 3

1.1.1
  Saudi Arabia: Country Profile ................................................................................ 3

1.1.2
  The Healthcare System ........................................................................................... 3

1.1.3
  Healthcare Service During The Hajj ....................................................................... 4

1.1.4
  Commitment to Healthcare ..................................................................................... 5

1.1.5
  Pain Management ................................................................................................... 5

1.1.6
  Emergency Department Guidelines ........................................................................ 6

1.1.7
  Pain Management Nursing Research ...................................................................... 6

1.1.8
  Certification of Registered Nurses .......................................................................... 7

1.1.9
  Scope of Practice for Registered Nurses ................................................................ 7

1.1.10 Registered Nurses’ Role in Saudi Arabian Emergency Departments ...................... 8

1.2
  Design ............................................................................................................... 8

1.3
  Aims ................................................................................................................. 9

1.4
  Significance .................................................................................................... 10

1.5
  Thesis Outline ................................................................................................ 10

1.6
  Conclusion ..................................................................................................... 12

Chapter Two: Literature Review ......................................................................... 13

2.1
  Pain Theory and the Physiology of Pain ..................................................... 13

2.1.1
  Pain Theory ........................................................................................................... 14

2.1.2
  Neuroevolutionary Functions of Pain ................................................................... 15

2.1.3.
  Pain Physiology ................................................................................................... 17

2.1.4
  Applying Pain Theory & Pain Physiology in the Clinical Setting ....................... 19

2.1.5
  The Detrimental Effects of Pain ........................................................................... 20

2.2
  Pain Management ......................................................................................... 22

2.2.1
  Pain Management as a Fundamental Aspect of Nursing Care ............................. 24

2.2.2
  Role of the Registered Nurse in Emergency Department Pain Management ....... 27

2.2.3
  Role of the Registered Nurse in Triage & Pain Assessment ................................ 30

2.2.4
  Prevalence of Pain in the Emergency Department ............................................... 34

2.3
  Knowledge and Attitudes Regarding Pain ................................................. 37

2.3.1
  Definitions of Nursing Knowledge ....................................................................... 38

2.3.2
  Definitions of Nursing Attitudes .......................................................................... 39

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2.4
  Nurses’ Knowledge and Attitudes Regarding Pain ................................... 40

2.4.1
  The Knowledge and Attitudes Survey Regarding Pain ........................................ 40

2.4.2
  Knowledge and Attitudes Regarding Pain: United States .................................... 42

2.4.3
  Knowledge and Attitudes Regarding Pain: Canada .............................................. 43

2.4.4
  Knowledge and Attitudes Regarding Pain: Europe .............................................. 44

2.4.5
  Knowledge and Attitudes Regarding Pain: Australia ........................................... 45

2.4.6
  Knowledge and Attitudes Regarding Pain: Asia .................................................. 46

2.4.7
  Knowledge and Attitudes Regarding Pain: Middle East ...................................... 47

2.4.8
  Knowledge and Attitudes Regarding Pain: The Emergency Department ............ 48

2.4.9
  Summary ............................................................................................................... 50

2.5
  Barriers to Optimal Pain Management ...................................................... 51

2.5.1
  Myths and Misconceptions about Pain ................................................................. 51

2.5.2
  The Use of Opioids and ‘Opiophobia’ .................................................................. 53

2.5.3
  Pseudoaddiction .................................................................................................... 55

2.5.4
  Socio-cultural Barriers .......................................................................................... 56

2.5.5
  Subjectivity ........................................................................................................... 57

2.5.6
  Culture and Communication ................................................................................. 59

2.5.7
  Other Barriers ....................................................................................................... 61

2.5.8
  Summary ............................................................................................................... 62

2.6
  Global Perspectives on Pain Management ................................................. 63

2.6.1
  The Global Burden of Unrelieved Pain ................................................................ 64

2.7
  Pain Management Nursing in Saudi Arabia .............................................. 68

2.8
  Conclusion ..................................................................................................... 70

Chapter Three: Methods ....................................................................................... 71

3.1
  Aims ............................................................................................................... 71

3.2
  Methodological Approach: Mixed Methods ............................................... 72

3.3
  Research Paradigm ....................................................................................... 74

3.3.1
  Pragmatism ........................................................................................................... 74

3.3.2
  Rationale for the Sequential Explanatory Mixed Methods Research Design ....... 76

3.4
  Overview of the Research Design ................................................................ 77

3.5
  Phase 1: The PAIN-MED Survey ................................................................ 78

3.5.1
  The Survey Method .............................................................................................. 79

3.5.2
  The Cross-Sectional Survey ................................................................................. 81

3.5.3
  Instrument Development ...................................................................................... 82

3.5.4
  Data Collection ..................................................................................................... 84

3.5.5
  Setting ................................................................................................................... 85

3.5.6
  Sample .................................................................................................................. 86

3.5.7
  Strategies for Managing Response Rate ............................................................... 87

3.5.8
  Data Management ................................................................................................. 90

3.5.9
  Data Analysis ........................................................................................................ 90

3.5.10
  Validity and Reliability ....................................................................................... 92

3.6
  Phase 2: Semi-Structured Interviews .......................................................... 94

3.6.1
  The Interview Method .......................................................................................... 94

3.6.2
  Semi-Structured Interview Guide ......................................................................... 95

3.6.3
  Sample and Setting ............................................................................................... 96

3.6.4
  Participant Recruitment ........................................................................................ 96

3.6.5
  Data Collection ..................................................................................................... 97

3.6.6
  Qualitative Data Management and Analysis ........................................................ 97

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3.6.7
  Interview Quality, Validity and Trustworthiness ................................................. 99

3.6.8
  Rigour ................................................................................................................. 100

3.7
  Triangulation ............................................................................................... 104

3.8
  Integrated Data Analysis ............................................................................ 104

3.9
  Ethical Considerations ............................................................................... 108

3.9.1
  Confidentiality and Anonymity .......................................................................... 109

3.9.2
  Data Storage ........................................................................................................ 110

3.9.3
  Secure Disposal of Data ...................................................................................... 110

3.10
  Conclusion ................................................................................................. 111

Chapter Four: Phase 1 Results ........................................................................... 112

4.1
  Survey Response Rate ................................................................................ 112

4.1.1
  Missing Data ....................................................................................................... 113

4.2
  Characteristics of Survey Participants ..................................................... 114

4.2.1
  Personal Demographics ...................................................................................... 114

4.2.2
  Professional Demographics ................................................................................ 114

4.3
  Knowledge and Attitudes Survey Regarding Pain .................................. 118

4.3.1
  Knowledge and Attitudes Survey Regarding Pain: Total Scores ....................... 119

4.3.2
  Factors Contributing to Total Scores in the Knowledge and Attitudes Survey
Regarding Pain ............................................................................................................... 119

4.3.3
  Confidence in Pain Management ........................................................................ 121

4.3.4
  Analysis of Items in the Knowledge and Attitudes Survey Regarding Pain ...... 121

4.4
  Factors Affecting Optimal Pain Management ......................................... 124

4.4.1
  Current Status of Pain Management ................................................................... 124

4.4.2
  Barriers to Optimal Pain Management ............................................................... 124

4.4.3
  Facilitators to Optimal Pain Management .......................................................... 126

4.4.4
  Write-in Responses to Open-ended Questions: Results ..................................... 127

4.5 Conclusion ...................................................................................................... 137

Chapter Five: Phase 2 Findings .......................................................................... 138

5.1
  Characteristics of Interview Participants ................................................. 138

5.2
  Major Themes and Theme Structure ....................................................... 139

5.3
  Theme One: Pain Management Practice Influenced by Nurses’
Knowledge ............................................................................................................ 139

5.3.1
  Interpreting Assessment Findings ....................................................................... 140

5.3.2
  Deciding How and When to Treat Patients’ Pain ............................................... 143

5.3.3
  Treatment with Opioids as a Cause for Concern ................................................ 144

5.4
  Theme Two: Pain Management Practice Influenced by Nurses’
Attitudes ................................................................................................................ 148

5.4.1
  Perception of Patients’ Expressions of Suffering ............................................... 149

5.4.2
  Perceptions of Patients’ Pain Tolerance ............................................................. 151

5.4.3
  Patient-Nurse Interactions .................................................................................. 153

5.5
  Theme Three: Influence of External Factors on Nurses’ Pain
Management Practice .......................................................................................... 156

5.5.1
  Continuing Education in Pain Management ....................................................... 157

5.5.2
  Emergency Department Workload ..................................................................... 158

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5.5.3
  Emergency Department Environment ................................................................ 159

5.6
  Summary ..................................................................................................... 161

Chapter Six: Discussion ...................................................................................... 162

6.1
  Discussion of Key Findings ........................................................................ 162

6.1.1
  Key Finding 1: ‘Reading’ the Way Patients Self-Report ................................... 163

6.1.2
  Key Finding 2: Differences in Pain Management .............................................. 170

6.1.3
  Key Finding 3: Nursing Unit Cultures ................................................................ 174

6.1.4
  Key Finding 4: Frustration & Compassion Fatigue ............................................ 177

6.1.5
  Key Finding 5: Use of Opioid Analgesia ........................................................... 178

6.1.6
  Summary ............................................................................................................. 180

6.2
  Implications and Recommendations ......................................................... 181

6.2.1
  Recommendations for Education and Clinical Practice ..................................... 181

6.2.2
  Implications for Policy ....................................................................................... 184

6.2.3
  Recommendations for Further Research ............................................................ 184

6.2.4
  Summary ............................................................................................................. 185

6.3
  Strengths of the Research Project ............................................................. 186

6.3.1
  The Quantitative Cross-Sectional Survey Method ............................................. 186

6.3.2
  The Qualitative Semi-Structured Interview Method .......................................... 186

6.3.3
  Mixing of Findings within the Mixed Methods Design ..................................... 187

6.3.4
  Survey Size and Response Rate .......................................................................... 188

6.3.5
  Summary ............................................................................................................. 189

6.4
  Limitations of the Study ............................................................................ 189

6.4.1
  Lack of Pre-Registration Education Data ........................................................... 189

6.4.2
  Lack of Data on Recentness of Pain Management Training .............................. 190

6.4.3
  Sampling of Interview Participants .................................................................... 190

6.4.4
  Missing Data ....................................................................................................... 191

6.4.5
  Sampling Strategies ............................................................................................ 191

6.4.6
  Summary ............................................................................................................. 191

6.5
  Conclusions .................................................................................................. 192

References ........................................................................................................... 194

Glossary ................................................................................................................ 227

List of Appendices ................................................................................................ 232

Appendix A: Pain Management in the Emergency Department (PAIN-MED) Survey . 233

Appendix B: Recruitment Poster .................................................................................... 241

Appendix C: Interview Schedule for Phase 2 Semi-structured Interviews ..................... 242

Appendix D: Human Ethics Approvals H9738 ............................................................... 244

Appendix E: Participant Information Sheet (Survey) ..................................................... 250

Appendix F: Participant Information Sheet (Interview) ................................................. 254

Appendix G: Participant Consent Form (Interview) ....................................................... 258

Appendix H: Results of Part II of the PAIN-MED Survey: Knowledge and Attitudes
Regarding Pain ................................................................................................................ 261

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List of Tables

Table 1: Response Rate per Participating Hospital .................................................. 113

Table 2: Personal Demographics ............................................................................. 114

Table 3: Employment Characteristics ...................................................................... 116

Table 4: Educational Characteristics ........................................................................ 118

Table 5: Mean KASRP Score & Participant Characteristics ................................... 120

Table 6: Perceived Confidence & Mean Total KASRP Score ................................. 121

Table 7: Lowest-Scoring KASRP Items .................................................................. 122

Table 8: Highest-Scoring KASRP Items .................................................................. 123

Table 9: Barriers to Optimal Pain Management ...................................................... 126

Table 10: Facilitators to Optimal Pain Management ............................................... 126

Table 11: Overall Results: Surveys with One or More Write-in Responses ............ 128

Table 12: Thematic Categories For Write-in Responses ......................................... 129

Table 13: Conditions in the Emergency Department ............................................... 129

Table 14: Perceived Issues Regarding Patients ........................................................ 131

Table 15: Healthcare Providers’ Knowledge of Pain ............................................... 132

Table 16: Adequacy of Care .................................................................................... 133

Table 17: Culture and Communication .................................................................... 134

Table 18: Healthcare Providers’ Attitudes Regarding Pain ..................................... 135

Table 19: Facilitators to Optimal Pain Management ............................................... 136

Table 20: Qualitative Data Analysis: Theme structure ............................................ 139

Table 21: Key Findings in Relation to Research Questions and Study Phases ....... 163

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List of Figures

Figure 1: Application of Sequential Explanatory Mixed Methods Design ................ 78

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