Running Head: INTEGRATIVE REVIEW 1

Integrative Review

Alexis Reyes

Karen Mellott, PhD, MSN, RN

NUR 4122 - Nursing Research

Bon Secours Memorial College of Nursing

April 2, 2019

“I Pledge…”
INTEGRATIVE REVIEW 2

Abstract

Purpose: The purpose of this integrative review is to evaluate emergency department

patients with pain and asses if effective interventions for pain relief occur

Background: Pain is a common issue found in patients coming into the emergency

department, but reports show pain is not effectively treated during hospitalization.

Evaluation of the many forms of and protocols for pain management are necessary in

order to test if pain interventions are effective or ineffective.

Method: This is an integrative review in which research was collected from online

databases. The articles discussed are quantitative studies that were chosen based on

specific criteria. This research was then used to evaluate the effectiveness of pain

management in the acute pain patient.

Results and Findings: Findings show that there is an inadequacy in resolving patient’s

pain. Patients state that pain is not effectively treated.

Limitations: Limitations in this review include small sample sizes, lack of diversity and

strictly subjective results. Each research article was done in one location causing bias to

results of the one hospital.

Implications for practice: Pain management is not effectively being treated and with all

the different forms of treatment available this should not be an issue. Pain will continue

to be an issue unless better interventions are taken.

Recommendations: Pain assessment protocols and more effective education need to be

given to health care providers in order to better implement pain interventions.

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Integrative Literature Review

The purpose of this integrative review is to evaluate emergency department

patients with pain and asses if effective interventions for pain relief occur. Pain is one of

the main reasons for emergency department visits, statistically at 78% of patients

complaining of pain (Masoudi, Aboutalebi & Sadat, 2017). As common as pain is,

patients in the Emergency Department are commonly known to have poor pain

management or report no relief of pain (Masoudi et al., 2017). Research on this

phenomenon evaluates patient’s satisfaction or dissatisfaction with their pain

management.

Pain is subjective to the patient making treatment both physiological and

psychological. Several forms of pain relief are available other than just the traditional

analgesic including non-pharmacological options (Dale & Bjornsen, 2015). With all these

forms of treatment, evaluation is important to understand if pain management

interventions are effective from the patient’s perspective. Nurses act as the forefront

advocate for patient’s receiving pain relief. It is of great importance for nurses to have the

proper knowledge and to effectively document in order to help the patients get the most

beneficial treatment. The aim of this review is to inspect information that has been

gathered on the topic and asses if it answers the PICOT question: How do acute pain

patients dealing with pain perceive their pain relief/treatment during their time in the

Emergency Department?

Design and Methods

This review is based off of 5 specifically chosen research articles. The method of

choosing scholastic research articles was through databases including EBSCO, PubMed
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and Google Scholar. Search words used included acute pain, emergency department or

emergency room, and pain interventions or pain management. This search found over

1,100 articles. These where narrowed down with filters such as year between 2013-

present, prevalence and peer-reviewed leading to 79 results.

A limiting factor of “full-text” made the search too narrow. Full-text was

disregarded when searching for articles. Also having any “and” vs “or” made the search

very narrow. All searches had to be done in “or” when it came to searching words in

similar categories. Exclusion criteria in this review included patients with chronic pain

compared to acute and children. Several of the articles in the databases involved these

factors, but do not relate to the specific PICOT question.

Findings and Results

Findings and results from the research articles identify these common

themes as factors effecting acute pain patients in the emergency departments: ineffective

pain assessments, lack of pharmacologic intervention for patients due to fear or distrust

and failure to follow pain management protocols (Dale & Bjørnsen, 2015; Madsen, Ovist,

Möller, & Schultz, 2018; Masoud et al., 2017; Scholten et al., 2015; Ucuzal & Doğan,

2015). These three themes were seen throughout all articles and directly support research

for the PICOT question. The five articles covered in this integrative review are

summarized below in the appendix.

Poor Pain Assessment

The five articles show that nursing pain assessments are not always accurate and

show a lack of re-assessment (Dale & Bjørnsen, 2015; Madsen et al., 2018; Masoudi et

al., 2017; Scholten et al., 2015; Ucuzal & Doğan, 2015). In the study conducted by
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Masoudi et al. (2017) 450 patients participated in a observational prospective study.

Patients were assessed based on criteria including demographics, type of trauma and the

patients Verbal Rating Scale (VRS) of 0-7. Zero represented no pain and 7 represented

severe pain. These factors were assessed at arrival and then the pain VRS once more 4

hours later. The method for collecting data was specifically based off each patient’s

verbal response and how the nurse documented the information. Statistical analysis was

done using the Mann-Whitney and Kruskal-Wallis tests. Based off these tests, the results

from the study show a significance level of 0.05, which indicates significance. The results

showed that only 66% of patients were assessed for pain in the first hour and re-

assessment had very little change in pain rating. Results also showed that assessment was

more often to be done on patients with higher rated pain in comparison to patients with

lower pain ratings.

In the research conducted by Dale & Bjørnsen (2015), pain assessment was

heavily assessed in patients coming into the emergency department. In a prospective

study, 764 patients were used to look at how nurses in a Norwegian Emergency

Department went about handling patients arriving in acute pain. Data was collected over

twenty days by examining files documented by nurses and physicians who assessed

patients with acute pain that met specific criteria. Data collected looked at the patients

subjective Numeric Rating Scale (NRS) for pain. The scale went from one to three which

represented mild pain, four to six moderate pain and 7-10 marked as severe pain. Data

analysis was conducted with the SPSS version 22.0. The statistics showed significance at

0.05. Results showed that 23% of patients were not assessed for pain due to other health

findings taking priority. Other findings included more women not receiving pain
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assessments in comparison to men. Re-assessment in patients showed little to no change

in original pain NRS.

In a quantitative before and after intervention study conducted by Madsen et al.

(2017), nurse controlled pain management vs patient controlled oral analgesia was

assessed. 170 patients with acute abdominal pain were chosen. Patient’s medical charts

were assessed for pain NRS. The data collected over the patients stay in the emergency

department. Data was analyzed using a power calculation that assessed patient

satisfaction with pain management. Statistical significant data included patients reporting

better pain management when they had control of their pain vs the nurses. Poor nurse

pain assessment lead to inefficient or non-existent treatment.

Scholten et al. (2014) conducted a study that similarly looked at pain management

of patients in emergency care. This research was done on a random sample of 1066

patient medical files. These patients included assessment of not only the emergency

department in three regions of the Netherlands, but also looked at General Practitioner

Co-operations (GPC), an emergency medical service (EMS) and two helicopter

emergency medical services (HEMS). The data collected information based off a

standardized tool that assessed patient pain levels in each group. Data analysis was done

using the SPSS 21 tool. Findings from the study found that in the Emergency

Department, only 25% of patients had a recorded pain assessment and if patients were

assessed they were not re-assessed.

The purpose of Ucuzal & Doğan’s research was to asses emergency nurses

knowledge, attitudes and clinical judgment on patients pain (2015). This descriptive

study was conducted on 98 Turkish nurses in Malatya State Hospital. Of the 98 nurses,
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57 answered the questionnaire created to collect data on nurses’ perceptions of pain in the

three categories discussed above. Nurses were granted confidentiality and were asked 15

“true” or “false” questions. After they were asked to rate their confidence one to five on

the accuracy of their questions. Data analysis was conducted using the SPSS 15.0

software. Results from the research showed that 80.7% of nurses did not use a pain scale

for assessment, 64.9% did not document the stated pain and 70.1% admitted to needing

help with pain assessments.

Lack of Pharmacological Intervention

A theme the five articles include is the minimal to no use of pharmacological

interventions to treat acute pain patients (Dale & Bjørnsen, 2015; Madsen et al., 2018;

Masoudi et al., 2017; Scholten et al., 2015; Ucuzal & Doğan, 2015). The Masoudi et al.

(2017) article found a lack of pharmacologic intervention in 60.8% of the patients. Over

half the acute pain patients were given nothing for pain, while only 13.3% of patients

received analgesics at an average of 41 minutes after assessment. The researchers Dale &

Bjørnsen (2015) also had similar statistics of only 14.2% of acute pain patients treated

with analgesics. In contrast to these studies, the research findings by Madsen et al. (2018)

had all patients in acute abdominal pain receiving analgesics. Although patients received

treatment by nurses, pharmacologic intervention had not occurred until 2.3 hours after

arrival to the emergency department. Scholten et al. (2015) found that out of patients with

severe or unbearable acute pain only 50% received pain medication. Medication

administered was paracetamol, which only treats mild to moderate pain. No use of

opioids was found for patients in severe pain in the emergency department.
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From the nurse’s perspective, researchers Ucuzal & Doğan (2015) found lack of

pharmacological intervention because nurses feared overdosing the patient. In the

findings, 26.3% reported fear of overdose was strong enough to have them not treat the

patient. Another finding on lack of pharmacological intervention was the assumption that

acute pain patients only need pain medication once there pain became severe or

unbearable. This category also included the concept that sleeping patients where not in

need of pain relief.

Failure to Follow Pain Management Protocol

Another theme seen throughout the five articles is the failure to accurately

complete or follow protocols designed in order to effectively treat acute pain (Dale &

Bjørnsen, 2015; Madsen et al., 2018; Masoudi et al., 2017; Scholten et al., 2015; Ucuzal

& Doğan, 2015). Protocols are necessary in order to accurately and efficiently treat pain.

Masoudi et al. (2017) in their study found that following protocol of patient check in,

assessment and intervention led to a 32% reduction in pain for the patient. Emergency

room protocol for the research done by Dale & Bjørnsen (2015) stated that all patietns in

moderate to severe pain should receive intervention. Researchers Dale & Bjørnsen (2015)

found that of the 23% who reported moderate to severe pain only 14.3% actually received

pain relief. Protocols for the nurses are surrounded by patient centered care; therefore

patients should have high influence on their care. Madsen et al. (2018) briefly discussed

that nurses felt the need to restrict patients from being the in control of their pain due to

distrust of the patients knowledge on medication.

One of the most important forms of protocol is effective documentation of

patient’s pain assessment, intervention and current status. Researchers Scholten et al.
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(2015) found in their study numerous flaws in pain management protocol when it came to

documentation. Less than 50% of the patient files stated non-pharmacologic

interventions, pharmacologic pain treatment was 73%-99% inaccurate to pain treatment

protocol and failure to document time of administration occurred 73%-100% of the time.

Similarly to the Scholten et al. (2015) findings, Ucuzal & Doğan (2015) found that only

35.1% of nurses documented accurate records of patient’s pain during assessment.

Discussion and Implications

All five of the articles discussed help to answer the PICOT question of pain

management in emergency room acute pain patients and if they are receiving the

interventions necessary. Each article reviewed a concept pertaining to pain management

in the emergency rooms and how effective or how often interventions were. Research

from Masoudi et al. (2017) and Dale & Bjørnsen (2015) both directly answer the question

if pain is being effectively treated. Unfortunately in both studies acute pain in the

emergency department is not adequately treated. Patients continued to leave emergency

department care with minimal to no pain relief. Madsen et al. (2018) and Ucuzal &

Doğan (2015) both directly addressed the importance of patient centered pain

management. The patient’s report is the most accurate source of patient’s pain. Lack of

patient participation in treatment would lead to ineffective pain management. Lastly, the

random sample chart reviews done by Scholten et al. (2015) showed how ineffective

emergency care was in treating pain. This was due to lack of documentation and

deviations form pain management protocol.

The articles state implications and recommendations to further research. The

common implication in all the articles is that pain is clearly not being effectively
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managed in emergency room acute pain patients. The continuation of inadequate pain

treatment can lead to chronic pain, physiological and psychosocial disorders (masoudi et

al. (2017). Specifically Madsen et al. (2018) stated that attitudes and knowledge on pain

management be examined. The perspective of both the nurse and patient will allow for

better understanding of what causes inadequate intervention. Scholten et al. (2015)

believed that protocols needed to be further reviewed, while Ucuzal & Doğan (2015) saw

from their research an urgent need to create education programs for nurses on pain

management.

Recommendations overall had common factors including: better education for

emergency department nurses on how to effectively assess and treat acute pain patients,

stricter more universal protocols on managing emergency department pain patients and

finding new methods to improve pain treatment altogether. The recommendations

directly address the answer of the PICOT question, which is ineffective pain

management. Future research looks into steps to help emergency departments better treat

acute pain patients.

Limitations

The researcher noted many limitations when conducting the integrative review.

The researcher had no prior experience in conducting the review and lacks the proper

knowledge of how to effectively complete one. Pertaining specifically to the PICOT

topic, the researcher has little to moderate knowledge on the process of pain management

as a registered nurse in the hospital setting. Experience in the Emergency Department is

limited, but the researcher has had some exposure. This review is not an exhaustive so

information is limited. Although information directly from the researcher is sparce, the
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five research articles used in the review are effective in providing information needed for

the PICOT.

Information for the integrative review was heavily influenced by the research

completed in the five research articles covered throughout the study. Throughout the

research articles several common limitations were noted in each of the articles. The most

commonly seen limitation includes the small sample size in each of the articles. The

sample sizes were enough to be statistically significant, but the samples would show

more accuracy with a larger sample. Another commonly seen limitation in these articles

involves documentation errors or inaccuracy. Failure to document pain management,

treatment or interventions was commonly seen as a limitation due to ineffective charting

or lack there of. Lastly, the final common limitation was the subjective perception of pain

in each individual patient. There is no specific baseline for pain since individuals

perceive pain differently making it highly variable. These factors should all be considered

in order for future research and in order to better support reliability.

Conclusions

The information from the articles shows significant evidence to confirm that

registered nurses are not effectively treating acute pain patients coming into emergency

department. This is due to ineffective pain assessments, lack of pharmacologic

intervention for patients due to fear or distrust and failure to follow pain management

protocols. In order to more effectively handle pain management in the future, nurses

need to have better education on proper pain assessment and re-assessment. Also further

education on pharmacologic treatments such as analgesics and opioids would only better

support pain management as nurses continue to hesitate to administer these drugs right
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away. The PICOT question asked if pain management for acute pain patients in the

emergency department is effectively treated. Unfortunately, research shows that pain

management continually remains a problem within the emergency departments and better

interventions are needed.

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References

Dale, J., & Bjørnsen, L. P. (2015). Assessment of pain in a Norwegian Emergency

Department. Scandinavian Journal of Trauma, Resuscitation and Emergency

Medicine, 23(1). https://doi.org/10.1186/s13049-015-0166-3

Madsen, S. B., Qvist, N., Möller, S., & Schultz, H. (2018). Patient-controlled oral

analgesia for acute abdominal pain: A before-and-after intervention study on pain

intensity and use of analgesics. Applied Nursing Research, 40, 110–115.

https://doi.org/10.1016/j.apnr.2018.01.007

Masoudi Alavi, N., Aboutalebi, M. S., & Sadat, Z. (2017). Pain management of trauma

patients in the emergency department: a study in a public hospital in Iran.

International Emergency Nursing, 33, 53–58.

https://doi.org/10.1016/j.ienj.2016.10.005

Scholten, A. C., Berben, S. A. A., Westmaas, A. H., van Grunsven, P. M., de Vaal, E. T.,

Rood, P. P. M., … Schoonhoven, L. (2015). Pain management in trauma patients

in (pre)hospital based emergency care: Current practice versus new guideline.

Injury, 46(5), 798–806. https://doi.org/10.1016/j.injury.2014.10.045

Ucuzal, M., & Doğan, R. (2015). Emergency nurses’ knowledge, attitude and clinical

decision making skills about pain. International Emergency Nursing, 23(2), 75–

80. https://doi.org/10.1016/j.ienj.2014.11.006
INTEGRATIVE REVIEW 14

Appendix

Table 1 Masoudi Alavi, N., Aboutalebi, M. S., & Sadat, Z. (2017). Pain
Article Reference management of trauma patients in the emergency department: a study
in a public hospital in Iran. International Emergency Nursing, 33, 53–
58. https://doi.org/10.1016/j.ienj.2016.10.005

Problem Statement /  Pain is not effectively managed in Emergency Department

Background patients.
Research / Research  Pain is a common issue within EDs and studies will help to
Question- Specific
further understand the problem.
Aim or Purpose /
Significance  The article’s purpose is to examine patients within the
statement emergency department in a hospital located in Iran and see if
pain is being handled effectively or not.
 If pain is an issue in EDs there needs to be interventions to
improve pain management.

Conceptual /  No theoretical framework identified within the article.

Theoretical
Framework

Method Design /  Quantitative Observational prospective study

/ Philosophical  Patients arriving to the ED in pain that met specific inclusion
Underpinnings criteria were assessed by demographic, a verbal rating scale (0-
10) and interventions. They were then re-evaluated every 30
min for 3 hours to see if pain had altered.

Sample / Setting /  Sample size consisted of 450 patients

Ethical  Public Iranian hospital in Kashan city.
Considerations
 - Ethical considerations include approval by the hospital
administration and informed consent given to participants with
the ability to opt out or research.

Major Variables  Pain management

Studied (and their  Interventions (pharmacological/ non-pharmacological)
definition)

Measurement Tool /  Patients arriving into ED were asked a verbal rating scale on
Data Collection pain. These statistics were put into statistical pain scales and
Method showed significance.
INTEGRATIVE REVIEW 15

Data Analysis  SPSS16

 Kolmogorov- Smirniov tests
 Mann-Whitney test
 Kruskal-Willis test
 Wilcoxon statistics
 All appropriate for design
Findings /  Researchers found that Pain was not being effectively handled
Discussion in the particular ED.
 The significance level was 0.05; therefore the test is
statistically significant.
 The study findings correlate with knowledge known about pain
management in the ED and confirms that pain management
needs to be re-evaluated on how it can be better treated.
Appraisal/Worth to  Further research is needed to investigate other ways to better
practice understand why pain is so poorly managed.
 Limitations included only 1 hospital being assessed, RNs being
more at tentative to pain management since they were being
observed, and the sample size being majority men.
 This study can be used to help further support the need to better
pain management in the ED since it proves that there are still
errors in the pain management interventions.
INTEGRATIVE REVIEW 16

Table 2 Dale, J., & Bjørnsen, L. P. (2015). Assessment of pain in a Norwegian

Article Reference Emergency Department. Scandinavian journal of trauma, resuscitation
and emergency medicine, 23, 86. doi:10.1186/s13049-015-0166-3

Problem  Poor pain management occurs within the emergency departments.

Statement /  Pain management is a common problem in emergency departments all
around the world. Pain assessment strategies need to be assessed in order
Background / to see where problems are occurring.
 Purpose is to compare pain assessments in the ED with appropriate
Research protocols instilled.
Question-  To be able to see if ED’s follow appropriate protocol in pain assessment
Specific Aim or and to better understand how to treat pain.
Purpose /

Significance
statement
Conceptual or  No theoretical framework is directly stated.
Theoretical
Framework
Method Design /  This is a quantitative prospective data study.
Philosophical  No philosophical underpinnings stated.
Underpinnings

Sample /  The sample size includes 764 patients that came into the ED with issues
involving pain.
Setting /  Setting was within the ED of a Norwegian Hospital
Ethical  Two groups, the Regional Committee for Medical and Health Research
Considerations Ethics and Data Protection Officers approved the study.

Major Variables  Independent variable is the patients coming into the ED while the
Studied (and dependent variable is the pain they rate and subjectively experience.
their definition)  They are not clearly stated in the article, but can be understood if read
throughout the article.

Measurement  A 20 day study was done at the ED in St. Olav’s Hospital in Norway.
Tool / Information was collected during prime ED times. Certain criteria where
Data Collection noted for each patient’s pain on a 11 point scale 0-10.
Method
Data Analysis  Fisher’s exact test, SPSS version 22.0. These were appropriate designs
used.

Findings /  Research found that most patients were not adequately assessed for pain
and pain was not given sufficient interventions.
Discussion
INTEGRATIVE REVIEW 17

 p<0.05 which shows statistical significance.

 Findings correlate with other studies done within EDs showing poor pain
intervention and assessment.

Appraisal/Worth  Further research is needed in order to effectively handle patient’s pain in

to practice the ED. Limitations are not clearly listed, but poor pain management
documentation and follow up are included. Implications include making
sure each patient no matter what demographic is being assessed for pain
and focusing on changing the attitude of health care providers on pain.
This is a trust worthy study that can be used in order to further
information on ED pain management.
INTEGRATIVE REVIEW 18

Table 3 Madsen, S. B., Qvist, N., Möller, S., & Schultz, H. (2018). Patient-controlled oral
Article Reference analgesia for acute abdominal pain: A before-and-after intervention
study on pain intensity and use of analgesics. Applied Nursing
Research, 40, 110–115. https://doi.org/10.1016/j.apnr.2018.01.007

Problem  Insufficient pain management can lead toward continuous pain, which can
Statement / lead toward cardiovascular effects.
 Patients with acute pain are not effectively being treated for their pain.
Background / The study involves patient assessment for pain management vs nurse
Research management of the patient’s pain.
Question-  Assessing effectiveness of pain management by the patient vs nurse
Specific Aim or controlled analgesics.
Purpose /  The significance of the study is to identify if patients have better pain
management vs the nurses judgement of how to manage the patients pain.
Significance
statement
Conceptual or  No framework stated within the study.
Theoretical
Framework
Method Design /  Quantitative intervention study
Philosophical  No phiisophical underpinnings stated
Underpinnings

Sample /  Sample size of 170 patients.

 Adequacy of the sample size is acceptable, but on the smaller size with a
moderate attrition rate originating with 234 patients approached. Some
bias is included since the patient pain management group only had 39
Setting /
patients, while the nurse pain management group had 131 patients.
Ethical  Setting takes place in the emergency and surgical department of the
Considerations University Hospital in Southern Denmark.
 Permission for the study was granted by the Regional Scientific ethical
Committees for Southern Denmark and all participants gave consent to
the study.

Major Variables  Independent variable: Administration of pain medication

Studied (and  Dependent variable: Numerical rating of pain level
their definition)
 Variables are stated from the start of the article.

Measurement  Numerical Rating Scale was used to asses pain level

Tool /  Validity was not explicitly stated, but tests are appropriate for the study
 Data was gathered by choosing adult patients who came into the ED with
Data Collection
Method acute abdominal pain. Patients needed to have an 18+ hour stay with
agreement to allow for intervention with this study. Data was then taken
INTEGRATIVE REVIEW 19

from those patient’s medical files.

Data Analysis  Medical charts were assessed using chi-squared Kruskal-Wallis tests.
 Appropriate for the study

Findings /  Research found that NRS pain scores were lower for patients who had the
PCOA control of their pain in comparison to the nurse-controlled pain.
Discussion  Results are statistically significant
 Other studies show proof of poor patient satisfaction in the pain
management area. Different results from this compared to other studies
includes use of a PCOA.

Appraisal/Worth  Further research needs to be implemented in order to better understand

to practice the effects of PCOA on pain management in comparison to nurse-
controlled analgesics.
 Limitations of the study include small sample size of people on the
PCOA. Other limitations include exclusivity of only one hospital.
 Implications for the study include the need for more patient control in
monitoring their pain. Also more education for the healthcare providers
on analgesic control in order to better handle patient pain.
INTEGRATIVE REVIEW 20

Table 4 Ucuzal, M., & Doğan, R. (2015). Emergency nurses’ knowledge, attitude and
Article Reference clinical decision making skills about pain. International Emergency
Nursing, 23(2), 75–80. https://doi.org/10.1016/j.ienj.2014.11.006

Problem  Effective pain management is implemented based on the nurse’s

Statement / knowledge, attitude and clinical choices, yet pain interventions are little
to not affective.
Background /  Nurses are the top way patients in the emergency department can receive
pain relief, but patients still complain of inaccurate pain relief. Finding
out the nurses perspectives on how pain is treated can give resolution to
Research this phenomenon.
Question-
Specific Aim or  The aim is to asses emergency department nurses’ knowledge, demeanor
Purpose / and clinical judgment skills on pain.
 The research allows emergency departments to see how nurses can better
Significance treat pain management in patients.
statement
Conceptual or  No theoretical framework is listed in the study
Theoretical
Framework
Method Design /  This is a descriptive study, which incorporates quantitative and qualitative
study.
Philosophical  No philosophical underpinnings are specifically listed.
Underpinnings
Sample /  Only 57 out of 98 nurses decided to participate in the research. The
sample size was on the smaller size making information not as adequate.
The sample consisted of majority female nurses with at least a bachelor’s
degree between the ages of 18 to 37 years that worked for about 3 years
Setting /
as a nurse in the Emergency department.
Ethical  The setting takes place at the Malatya State Hospital and Turgut Ozal
Considerations Medical Center of Inonu in Turkey.
 Approval was granted by the ethical committees and head physicians of
the hospitals.

Major Variables  The independent variable are the nurses chosen for the questionnaire and
Studied (and the dependent variables are the responses they gave.
their definition)  The variables are not directly listed within the article, but after assessment
they can be deduced.

Measurement  Demographic Information Questionnaire, Knowledge and Attitude

Tool / Questionnaire about Pain and Clinical Decision Making Survey were
used in the research study.
 Validity was not clearly identified in the article.
INTEGRATIVE REVIEW 21

 The data was collected during the end of the nurses shifts who chose to
Data Collection participate in the study. Confidentiality was promised to each nurse and
Method the study and procedure where fully explained.

Data Analysis  Statistical tests used include the Statistical Package of Social Science
(SPSS) 15.0 software.
 They are appropriate for the study.

Findings /  Research found that nurses in the emergency department were not
Discussion adequately handling pain. Majority knew that patients were the best
source of pain assessment, but still failed to provide the treatment they
needed.
 Findings are statistically significant
 Research shows several similarities including the knowledge that nurses
tend to wait to provide analgesics until pain becomes unbearable.
Similarities also include the knowledge that most nurses would say
patients are the best source for their pain rating. Some differences noted
in other studies include oncology nurses treating pain early before it
becomes unbearable.

Appraisal/Worth  More research is needed in order to asses the validity of this study since
to practice the sample size was small.
 Limitations include the small sample size, majority women, emergency
nurses exclusive to the two locations in Turkey and questionnaire biases
such as nurses being overly confident in the practice they know about
pain management.
 Implications for emergency nurses include more education programs on
pain assessment and continuous intervention for the nurses. Treatment
starts from when the patient comes in and after they leave (providing
them with proper medications of non-pharmacological interventions to
have for home).
INTEGRATIVE REVIEW 22

Table 5 Scholten, A. C., Berben, S. A. A., Westmaas, A. H., van Grunsven, P. M., de Vaal, E. T.,
Article Reference Rood, P. P. M., … Schoonhoven, L. (2015). Pain management in trauma patients
in (pre)hospital based emergency care: Current practice versus new guideline.
Injury, 46(5), 798–806. https://doi.org/10.1016/j.injury.2014.10.045

Problem  Acute pain is undertreated in patients particularly in emergency

Statement / situations. One of the best preventative measures is early detection and
treatment. Evidence based guidelines allow for effective pain
Background / management treatment. Assessing the emergency department is
important, but if early treatment is key to pain improvements than looking
at other emergency care such as Emergency medical services, helicopter
Research emergency services and General Practitioner Co-operations.
Question-
 Information is needed on how well emergency care follows pain
Specific Aim or
Purpose / management protocols and how effective they are in treating pain.
Information on effectiveness of correct use of the evidence based
Significance guidelines is needed. Assessing the emergency department is important,
statement but if early treatment is key to pain improvements than looking at other
emergency care such as Emergency medical services, helicopter
emergency services and General Practitioner Co-operations.
 The aim of the study is to look at how accurately emergency care
personnel follow the evidence based protocol on dealing with pain
treatment.
 The significance of the study is to make sure healthcare personnel are
being effective in treating acute pain patients. This knowledge allows for
better pain management in the future.

Conceptual or  No theoretical framework was listed in the article.

Theoretical
Framework
Method Design /  Quantitative random sample
 No philosophical underpinnings
Philosophical
Underpinnings
Sample /  1066 electronic patient files were randomly sampled. The sample size
once inclusion and exclusion criteria were assessed left with 150 cases to
assses. The sample size is adequate and meets the criteria of acute pain
patient needed for the study.
Setting /
 The study took place in three regions of the Netherlands with emergency
Ethical care personnel.
Considerations  The study was approved and funded by the Netherlands Organization for
Health Research and Development. Patient information was completely
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randomized, put into numerical statistics and did not break HIPPA laws.

Major Variables  Independent variable are the patients complaining of acute pain that
Studied (and match appropriate criteria. The dependent variables are the forms of pain
their definition) management protocol being followed and how effectively they are
followed.
 They are clearly stated within the beginning abstract of the study. They
are appropriate for the study.

Measurement  Numerical rating scale in order to rate patient pain and guidelines ‘Pain
Tool / management for trauma patients in the chain of emergency care’.
 Validity of the tools was not clearly stated, but are appropriate for this
study.
 Information was taken from random patient files and applied to specific
inclusion criteria ( over 18 years, arrived in emergency department in
pain, stabile, and verbally responsive) and exclusion criteria ( drowning,
suicidal, those subjected to domestic violence, and wound inspection and
stich removals). The information was then made into quality indicators by
Data Collection
a statistical algorithm to place them into numbers.
Method
Data Analysis  Descriptive statistics were used and put into means and standard
deviations to asses information. An SPSS 21 statistic was used.
 The test is appropriate for this kind of study.

Findings /  The research found that documentations show poor results on pain
Discussion management for patients. This includes areas involving re-assessment of
pain, treatment measures of pain, any non-pharmacologic interventions
and accurate time of treatment.
 Findings show statistic significance
 Findings from this research study directly relate to results found in other
studies including other retrospective and prospective cohort studies on
emergency care pain. Differences involved in this study compared to
others are this study not only looked at the emergency department, but
also assessed the pain management done in other chains of emergency
care.

Appraisal/Worth  Future research is needed in order to implement standardized protocols to

to practice treating acute pain patients.
 The biggest limitation to this research is the fact that this information is
strictly based on accuracy of documentation. If certain information was
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not documented it was not included toward the treatment of pain. Poor
documentation could decrease the pain management the patients may or
may not have had.
 Implications include focusing on more accurate documentation of the pain
management that patients receive. Another factor is the need for more
standardized protocols in pain intervention. This information can be used
to support assessment of pain management in the emergency department
acute pain patient.