RESEARCH

NURSES KNOWLEDGE AND ATTITUDES TOWARD

PAIN IN THE EMERGENCY DEPARTMENT
Authors: Joane T. Moceri, PhD, RN, and Denise J. Drevdahl, PhD, RN, Tacoma, WA

Earn Up to 9.0 CE Hours. See page 108.

Introduction: The purpose of this study was to investigate
emergency nurses knowledge and attitudes about pain.
Methods: A descriptive design was used for this study. A
validated tool, the Knowledge and Attitudes Survey Regarding
Pain (KASRP), was administered to nurses working in 5 U.S.
emergency departments. Demographic data also were collected
from each participant.
Results: Ninety-one emergency nurses completed the survey.
The mean total KASRP score was 76%. No significant
differences were found in mean total scores by age, education
level, years of nursing experience, or years of ED experience.
Eight questions were answered incorrectly by more than 50% of
participants. Five of these questions were related to opioid

he adolescent with a broken leg from a skiing accident, the factory worker with a lacerated hand, the
woman in sickle cell crisisall are instances that
bring the patient to the emergency department for treatment of his or her pain. Pain is one of the most common
symptoms seen in the emergency department,1 with chest
pain and abdominal pain being the most prevalent types of
pain reported.2 The 2011 Pain in America report by the
Institute of Medicine3 was emphatic in its declaration that
pain, especially chronic pain, is an undertreated condition
in the United States across health care settings and providers. Although the medical literature is abundant with

Joane T. Moceri is Assistant Professor, University of Washington Tacoma,

Tacoma, WA.
Denise J. Drevdahl is Associate Professor, University of Washington Tacoma,
Tacoma, WA.
Supported by the Chancellors Fund for Research Scholarship Support, University of Washington Tacoma, Tacoma, WA.
For correspondence, write: Joane Moceri, PhD, RN, 1125 NW 12th Avenue,
#508, Portland, OR 97209; E-mail: joanemoceri@gmail.com.
J Emerg Nurs 2014;40:6-12.
Available online 26 July 2012.
0099-1767/$36.00
Copyright 2014 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2012.04.014

JOURNAL OF EMERGENCY NURSING

pharmacology and dosage, 2 concerned understanding of

addiction and dependence, and one was linked to nurse
assessment and patient report of pain level. Analysis of these 8
questions revealed that higher education levels had a weak
positive association with correct answers.
Discussion: Participants taking the survey scored comparably or
better than participants in other reported studies using the
KASRP. Years of nursing experience was not correlated with
correct responses. Findings from this study underscore the
Institute of Medicines Pain in America recommendation to
increase pain management education for all providers.
Key words: Pain; Pain management; Analgesics; Opioid; Nurse;
Emergency department

respect to patients experiences of pain and their preferences

for and dissatisfaction with pain management, less is known
about how providers, particularly registered nurses (RNs),
make pain management decisions. Because a nurses knowledge and attitude toward pain inform how she or he manages a patients pain, this article reports findings from a
study that explored emergency nurses understanding of
pain and the medications used to treat pain.
Differences in how providers perceive, assess, and treat
pain exist in all clinical settings.3,4 Research suggests that
physicians analgesic and opioid prescribing decisions are
influenced by a variety of factors, resulting in care disparities.
Some studies found that pain treatment decisions primarily
were influenced by the physicians gender, along with the
physicians training and experience.5,6 Organizational features of the health care system also may contribute to pain
management decision making; as a result, time spent in the
emergency department, the type of triage system used, and
ED crowding may lengthen the time that elapses before pain
assessment, medication prescription, and administration of
pain medication.7,8 Finally, patients personal characteristics
have an effect on providers clinical decision making, with
numerous studies documenting disparities in pain management based on the patients race, age, gender, and/or socioeconomic status.9-11
Although some studies have examined emergency nurses
decision making with respect to ED triage assessment,12,13

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TABLE 1

The 8 most difficult questions (correct answer and mean score in parentheses) from Ferrell and McCaffery's Knowledge and Attitudes Survey Regarding Pain (KASRP)
6. T/F: Respiratory depression rarely occurs in patients who have been receiving stable doses of opioids over a period of months. (T; 39.6%)
9. T/F: Research shows that promethazine (Phenergan) and hydroxyzine (Vistaril) are reliable potentiators of opioid analgesics. (F; 48.3%)
18. T/F: Vicodin (hydrocodone 5 mg + acetaminophen 500 mg) PO is approximately equal to 510 mg of morphine PO. (T; 34.4%)
26. Which of the following IV doses of morphine administered over a 4-hour period would be equivalent to 30 mg of oral morphine given q 4 hours? (b. Morphine 10 mg IV; 48.9%)
28. A patient with persistent cancer pain has been receiving daily opioid analgesics for 2 months. Yesterday the patient was receiving morphine 200 mg/hour intravenously. Today he has been receiving 250 mg/hour intravenously. The likelihood of the
patient developing clinically significant respiratory depression in the absence of new comorbidity is (a. less than 1%; 21.8%)
33. How likely is it that patients who develop pain already have an alcohol and/or drug abuse problem? (5%-15%; 24.4%)
36. Following abrupt discontinuation of an opioid, physical dependence is manifested by the following: (a. sweating, yawning,
diarrhea and agitation with patients when the opioid is abruptly discontinued; 34.4%)
37. B. Andrew is 25 years old and this is his first day following abdominal surgery. As you enter his room, he smiles at you and
continues talking and joking with his visitor. Your assessment reveals the following information: BP = 120/80; HR = 80; R =
18; on a scale of 0 to 10 (0 = no pain/discomfort, 10 = worst pain/discomfort) he rates his pain as 8.
Your assessment, above, is made 2 hours after he received morphine 2 mg IV. Half hourly pain ratings following the injection
ranged from 6 to 8 and he had no clinically significant respiratory depression, sedation, or other untoward side effects. He has
identified 2/10 as an acceptable level of pain relief. His physician's order for analgesia is morphine IV 13 mg q1h PRN pain
relief. Check the action you will take at this time. (4. Administer morphine 3 mg IV now; 48.2%.)
BP, Blood pressure; HR, heart rate; IV, intravenous; PO, by mouth; q, every; R, respirations.

little is known about emergency nurses understanding and

attitudes regarding pain, because the vast majority of studies have evaluated ED physician pain medication prescribing practices. Yet it is emergency nurses who assess patient
pain and administer pain medication. Emergency nurses
have identified several barriers to treating patients pain,
including inadequate pain management knowledge, inability to medicate until a diagnosis is made, lack of time to
assess and control pain, and patients use of alcohol or other
drugs.14,15 Other investigators also found that emergency
nurses often underestimated patients pain intensity.16
Because a review of the extant literature revealed no studies that examined U.S. emergency nurses understanding
of pain, the specific objective of the study was to measure
emergency nurses knowledge and attitudes about pain.
This line of inquiry is important because a wide cross section of U.S. society frequently uses the emergency department as a primary source of care.17 Findings from this study
add important information to the literature regarding what
nurses know about patients pain in the emergency department and can be used to inform future interventions that
improve pain assessment and treatment. Therefore this area
of study has the potential to change practice and thus
improve patient care and health outcomes for a broad spectrum of society.

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Methods

DATA COLLECTION

Data about emergency nurses knowledge and attitudes

toward pain were gathered using Ferrell and McCafferys
Knowledge and Attitudes Survey Regarding Pain (KASRP).18
The KASRP is a validated survey instrument (Cronbachs
>.70) that has been used in several studies19-22 and consists of 22 true and false questions, 13 multiple choice questions, and 2 case vignettes with 2 questions each (sample
questions are provided in Table 1). Emergency nurses completed the survey either electronically or in paper format
and were given the ability to remain anonymous if they
chose. Demographic data were collected about each participants race/ethnicity, age, gender, highest level of education,
years as a nurse, and years as an emergency nurse.
SETTING AND SAMPLE

This study was conducted in 5 hospital emergency departments located in the Pacific Northwest region of the United States. Institutional review and approval was obtained
from the University of Washington Humans Subjects Division, as well as from the institutional review boards of each
participating hospital. Approximately 365 nurses who
worked in the emergency departments of these 5 hospitals,

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RESEARCH/Moceri and Drevdahl

excluding administrators, were eligible and invited to participate in the study through letters and flyers posted in
emergency departments. Additionally, ED nurse managers
at each site informed staff nurses about the study and
encouraged them to participate.
DATA ANALYSIS

Data from the KASRP were analyzed using PASW version

18.0 software. Following the recommendation of Ferrell
and McCaffery,18 the data were analyzed using the percentages of total scores rather than attempting to separate the
questions into categories of knowledge or attitudes, because
some items measure both domains. Mean total survey
scores were calculated for each participant, survey questions
were analyzed for frequency of correct and incorrect
answers, and as suggested by Ferrell and McCaffrey,18
items with the least number of correct answers were
explored further. Descriptive statistics, including frequencies and means, as well as analysis of variance (ANOVA),
were used to compare differences in scores by demographic
characteristics of age, education level, years of nursing
experience, and years of ED nursing experience.
Results

Ninety-one RNs completed and returned the survey for a

response rate of 25%. The majority of respondents were
white (75.6%), with the next largest ethnic group being Latino/Hispanic (4.4%). The racial/ethnic representation was
typical for white nurses in the United States but was higher
than the national average for Latino nurses.23 The representation of Asian and African American nurses was less than
would be expected from national distributions.23 The largest
age group was between 20 and 30 years, which was nearly
double that of the next largest age group (31-49 years). This
sample of emergency nurses comprised a large group of
younger nurses, as well as nurses with 2 or fewer years of
emergency nursing experience. These characteristics may
be attributed to the fact that 85% of RNs younger than
age 30 years work in hospital settings, whereas fewer than
50% of RNs older age 55 years work in hospital settings.23
The mean number of years of nursing experience was 8.4,
with 31.1% having 2 years or less experience in nursing.
The mean number of years of ED experience was 5.9 years,
with 38.9% having 2 years or less ED experience. More than
half (51.1%) had associate degrees in nursing (ADN),
37.8% had a baccalaureate nursing degree (BSN), and
11% held a graduate degree in nursing (MN/MS). The distribution of education levels in the sample was similar to that
described by the National Sample Survey of Registered
Nurses23 for those employed in emergency departments,

JOURNAL OF EMERGENCY NURSING

with the exception of those with Masters degrees, who were

slightly higher in number than would be expected from
national statistics (11.1% compared with 7.3% nationally).
Table 2 summarizes the demographic information.
In this study, the mean total score for the KASRP was
76%. Scores ranged from 32.5% to 92.5%, with a standard
deviation of 9.26. A score of 80% or higher, representing
adequate knowledge about pain management, 18 was
achieved by 41% of participants, with 4.4% of all participants receiving a score of 90% or higher. ANOVA was
conducted to detect differences in mean total scores by
age, years of nursing experience, years of ED experience,
and/or level of education. Results showed no significant
differences in mean total scores by age or years of nursing
experience, including ED experience. Further, no significant difference in mean total scores was detected among
nurses with ADN, BSN, or MN/MS education levels.
Questions answered correctly by 90% or more participants tended to be more general questions about pain and
pain assessment rather than specific questions about medications, dosage, or treatments for pain. Based on procedures
used in earlier studies,24-26 we examined the 8 questions that
were answered incorrectly by more than 50% of participants,
because these questions represent limited pain management
knowledge. Five questions were related to opioid pharmacology and dosage, 2 concerned understanding of addiction and
dependence, and one was related to nurse assessment and
patient report of pain level. Table 1 shows these 8 questions
and the mean total scores for each.
ANOVA of the questions about opioid pharmacology and dosage demonstrated significant between group
differences for education level (df = 3, F = 4.528, P =
.005), with higher education levels weakly positively
associated with correct answers (r = .155). However,
no differences were detected between groups for years
of nursing experience or years of emergency nursing
experience. In a question about drug addiction/dependency, significant differences by education level, years
of nursing experience, and years of ED nursing experience were detected (df = 3, F = 8.836, P = .005).
Respondents with higher education levels, more years
of nursing experience, and greater time in the emergency
department selected the correct response more frequently. This question proved to be the only one where
significant differences were demonstrated between groups
in each of these categories. For the case vignette question
related to opioid dosage and pain scale, only 44% of
participants provided the correct answer, indicating that
these emergency nurses tended to believe their own
assessment over the patients self-reports of pain and thus
leaned toward undertreatment.

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TABLE 2

Demographic characteristics (n = 91)

Characteristic

Race/ethnicity
White
Latino
African American
Asian
Age (y)
20-30
31-40
41-50
51+
Education level
ADN
BSN
MN/MS
Missing
Years experience
1-5
6-10
11+
Years ED experience
1-5
6-10
11+

Participants (%)

National average (%)

75.6
4.4
1.1
2.2

83.2
3.8
5.4
5.8

42
22
19
8

46.2
24.2
20.9
8.8

44
34
10
3

48.9
37.8
11.1

59
18
13

65.6
20.0
14.4

51
16
23

56.7
17.7
25.6

ADN, Associate degree in nursing; BSN, Bachelor of Science in Nursing degree; MN/MS, Master's degree in nursing/Master of Science.

Discussion

With a mean total score of 76%, the participants in the

survey performed comparably or better than nurses in other
studies using the KASRP; a limited number of these studies
have been carried out in the United States, with the majority conducted internationally. The few studies conducted
in the United States revealed that perianesthesia nurses
earned a mean score of 72%,19 whereas nurses with oncology certification achieved a mean score of 77.5% compared
with 72.5% for those without certification.20 The average
score from a study of Turkish nurses was 35%,21 and it was
55% for a study conducted in Italy,24 whereas studies from
Ireland and Great Britain demonstrated scores in the mid
70s.22,25 These studies did not describe scores in terms of
education levels or years of experience.
Although a limited number of emergency nurses who
participated in the current study had more than 10 years

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of nursing experience (n = 23), similar research demonstrates mixed results for years of experience as an important factor in pain knowledge. For example, participants
in China received an average score of 47%, which was
significantly positively correlated with years of experience,27 and Tsai et al.28 reported a mean score of 49%
for Taiwanese nurses, which also was significantly positively correlated with years of experience. Yet a survey
by Wilson29 of nurses knowledge of pain revealed that
their knowledge scores were not associated with their
years of nursing experience, and Lewthwaite et al. 30
reported that 49% of Canadian nurses received a total
score of 80% or higher, with negative correlations among
age, experience, and score, but a positive correlation
between score and education level. Finally, in a large multi-state study examining the links among staffing, nursing
education, and patient mortality, Aiken et al.31 found that
nurses years of experience was not a critical factor in pre-

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dicting patient mortality, but education at the BSN level

or higher did make a positive difference in mortality for
surgical patients.
The finding in this study of no significant differences
between education levels and mean total scores is interesting in light of the work by Aiken and colleagues31 and may
indicate that continuing education related to pain management is more important than years of experience or education level. This finding also may suggest that it is not
education level that affects general knowledge and attitudes
about pain but rather that education level may affect specialized knowledge related to opioid use. Thus additional
offerings about pain and pain management at all education
levels and regardless of years of experience in nursing in
general, or even specifically in the emergency department,
seem warranted.
According to the literature, persons who take a pain
management course score higher on the KASRP than
those who do not take such a course. For example,
the study by LeMay et al. 32 demonstrated a 7%
improvement in scores for pediatric nurses who completed pain management workshops. Likewise, Bernardi
et al.24 reported a mean score of 51% for nurses who
had not previously taken a pain management course,
with scores of 59% associated with more education
about pain management. Thus nurses in the present
sample who complete a pain management course could
expect their KASRP scores to increase by 7% to 8%,
reaching an adequate score of greater than 80%. The
studies by LeMay et al.32 and Bernardi et al.24 provide
evidence that supports calls by the Institute of Medicine3
to increase pain management education at all provider
levels and for some providers to become experts in pain
management. Importantly, although several curricula are
available, little in the area of pain management education has been implemented.24
Although no differences were detected in mean scores
among age levels, years of experience, or education levels,
the findings demonstrate that nurses in the study were
most unfamiliar with topics related to opioids, including
pharmacology and dependency or abuse. This finding
concurs with the report by Tanabe and Buschmann14
that RNs had knowledge deficits in the area of pharmacologic analgesic principles and points to the conundrum of opioids 3 in which nurses continue to be
concerned with opioid use. This conundrum is demonstrated in the responses to the case vignette questions
in which emergency nurses, as a consequence of favoring
their own pain assessment over that of patients, undertreated patients pain. These responses imply that nurses
still may be unwilling to believe the patients reporting of

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pain levels, especially when the patients behavior does

not meet the nurses expectations of how a patient with
a pain number of 8, for example, should behave. However, even when the study participants agreed with the
patients assessment of their own pain, nurses still tended
to make decisions to undertreat. This finding highlights
both the complexity of pain assessment and the need
for a better understanding of pain and the attitudes surrounding pain that may maintain the status quo of wide
disparities in pain management. Further, these results are
congruent with similar research, which found that nurses
believed that patients exaggerate their pain and/or that
nurses underestimated patients pain, both of which
may contribute to inadequate pain treatment.33,34 It is
critical that nurses have a deep understanding of opioids,
given the widespread use of these forms of drugs across
the United States.3
LIMITATIONS

This study has several limitations. Because a convenience

sample was used, only the RNs interested in the study
took part, and they may not be representative of all ED
RNs. Although the racial/ethnic make-up of the sample
mirrored the racial/ethnic demographics of the Pacific
Northwest, it was not representative of RNs across the
United States, particularly for African Americans/blacks
and Asians, who were largely underrepresented. A third
limitation was the small number of participants with
more than 10 years of experience, although, as stated earlier, this factor may have less importance than is typically
assumed. Emergency nurses with a masters degree were
overrepresented compared with national statistics. Finally,
a lack of significant findings concerning differences in
scores by experience or education level may indicate that
this study was underpowered, although the study by
Coleman et al.20 with approximately the same sample size
was determined to be powerful enough to detect differences between nurses with oncology nursing certification
and those without it.
IMPLICATIONS FOR EMERGENCY NURSES

Findings from this study support prior research that points

to providers underprescribing pain medications to ED
patients16 and demonstrate the need for research and education on effective analgesic practice. 3 Although it is
unknown if the emergency nurses responses to the survey
are directly tied to the actual provision of their nursing
care, the results reported here indicate a need for targeted
education to ED nurses, especially with respect to opioid
pharmacology and dosing, regardless of the nurses years
of experience or education level. Because educational inter-

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ventions directed toward changing pain treatment in the

emergency department have demonstrated mixed results,35
this type of intervention should be conducted as part of a
formal research process to determine the best educational
delivery models.
Given that the Pain in America report3 recommends
that additional data on pain be collected, one mechanism to consider is for emergency departments to conduct
retrospective chart reviews of ED discharges.36 Analyzing
each discharge and the administration of pain medication
in terms of patient diagnosis, age, race/ethnicity, and
gender, for example, may reveal differential patterns of
pain prescriptions. Once identified, steps can be taken
to eliminate disparate care.
In conclusion, pain remains an important issue for persons visiting the emergency department. Decreasing pain
management disparities is important because the principle
of justice mandates that providers, including emergency
nurses, offer effective pain management to all patients.
Making informed decisions about pain management
requires expert knowledge of opioids and the ability to conduct a thorough pain assessment, which includes taking
into account both objective data and the patients subjective experiences of pain.
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