Background
In Australia, the number of critically ill patients managed in the emergency department (ED) is increasing [
1]. Between 2011 and 2016, the number of critically ill patients presenting to the ED increased by nearly 60% [
2‐
4], with over a third of patients (39%) needing intubation and mechanical ventilation [
5]. Although care of critically ill patients traditionally occurs in intensive care units, emergency staff are increasingly having to manage critically ill mechanically ventilated patients for extended periods of time [
6,
7]. Pain management is an essential component of quality care delivery for the critically ill patient. However, as many as 79% of patients experience moderate to severe pain, whilst intubated and mechanically ventilated from both their initial reason for presentation (e.g. trauma) and required treatments [
8]. Iatrogenic causes of pain include clinical procedures, physical examination, endotracheal intubation, mechanical ventilation, insertion of central venous catheters and chest drains; all of which commonly occur during resuscitation and stabilisation of a critically ill patient in the ED [
9,
10]. Intravenous analgesia is therefore commonly administered to alleviate pain, suffering, adverse physiological and psychological effects [
11], unplanned self-extubation, accidental removal of invasive monitoring devices, or injury to staff [
7,
10].
Pain is a subjective, complex and multidimensional concept that is broadly described as an unpleasant sensory experience associated with actual or potential tissue damage [
12], which can be influenced by psychological and environmental factors in every individual [
13]. Thus, the most reliable and valid indicator of pain is the patient’s self-report, yet for critically ill patients, communication of pain intensity is problematic; particularly for those with altered levels of consciousness, endotracheal intubation, requiring sedation, analgesia and potentially paralysing agents [
14]. These factors therefore place the critically ill patient at greater risk of inadequate pain detection, assessment and inappropriate management [
15]. In the absence of a patient’s ability to self-report pain, clinicians usually rely on observable pain indicators such as facial grimacing, crying and compliance with mechanical ventilation. These observations then form the basis for identification and evaluation of a patient’s pain intensity [
16].
International pain management guidelines recommend frequent assessment, monitoring and reassessment, and use of validated instruments [
11]. Historically, relief from pain through the provision of analgesia could only be initiated by a physician [
17]. The shifting stance from physician-only initiated pain management to nurse-initiated analgesic protocols has significantly improved the timely delivery of care and symptom management of pain for a broad range of conditions in ED [
18,
19]. A series of ED studies examining nurse-initiated analgesic protocols has demonstrated that emergency nurses can safely assess, initiate and administer analgesia to a range of patient groups and ambulatory conditions [
17,
20‐
39], including the titration of intravenous opioids [
35,
40].
In the resuscitation area of the ED, emergency nurses are increasingly responsible for the safety and wellbeing of critically ill patients, and are optimally placed to assess and initiate pain relief [
24,
41]. However, to date, how emergency nurses detect, assess, influence and manage acute pain for critically ill patients is unknown and has led to development of this research protocol. The objective of this mixed methods study is to examine emergency nurses’ perceptions and practices in assessing and managing acute pain in critically ill patients. Specifically, to:
1.
explore emergency nurses’ practices relating to the assessment, monitoring and administration of analgesia to critically ill patients in ED;
2.
examine care activities and behavioural patterns, actions, processes within the context of acute pain management;
3.
identify factors, perceived facilitators, barriers and workplace characteristics that influence emergency nurses’ practice in pain management of critically ill patients; and,
4.
explore how emergency nurses influence pain management decisions or act independently with regards to the critically ill patient in the ED.
Discussion
This will be the first comprehensive, integrated mixed-methods study to examine emergency nurses’ practices in assessing, monitoring and managing acute pain in critically ill patients. Emergency nurses undertake numerous clinical activities, often simultaneously or for multiple critically ill patients while working within the resuscitation area. The degree of knowledge and skills required to optimise and safely manage critically ill patients is highly complex, including acute pain management [
7]. Adequate pain management is paramount in optimising comfort, pain relief and wellbeing of critically ill or injured patients. International guidelines concerning effective acute pain management recommend adequate assessment in all patients, with practice systems in place to ensure appropriate and timely analgesia assessment, and frequent monitoring and reassessment [
11,
80,
81]. Emergency nurses are optimally placed to assess and initiate pain relief [
24,
41], however the complexity of emergency nursing practice, judgment and factors influencing the detection, assessment and management of pain for critically patients is unknown. This study will provide answers to addressing a critical knowledge/practice gap in the science of emergency nursing, practice and literature regarding the assessment and management of pain in critically ill adult patients in ED.
The incorporation of Donabedian’s expanded quality and safety model [
45] into the data collection and analysis, including the examination of factors influencing the clinical decisions and actions of emergency nurses, will develop a clearer understanding of what must be addressed to optimise acute pain management of critically ill patients in the ED. The systematic inquiry into the clinical environment (Antecedents) and model of care (Structure), the actions and interactions of emergency nurses in managing acute pain (Process), and, their influence in managing acute pain in critically ill or injured patients (Outcome), will assist this study to produce meaningful, practical and measurable recommendations concerning practice, education and policy.
Strengths and limitations
This study has several strengths, including its robust and straightforward design. Using a sequential explanatory mixed methods study design will enable rich exploration of the existing practice of emergency nurses in assessing, monitoring and managing acute pain in critically ill adult patients. The use of quantitative and qualitative methods and integration of data will provide the research team with multiple perspectives from which to understand the complex and multidimensional nature of nursing practice and pain management in the ED.
There are several potential limitations that need to be considered. Sequential mixed methods studies are time-consuming to undertake, but it is felt that the richness of data obtained makes this an appropriate approach. Recruiting eligible survey participants will be engaged through email, web-based and other indirect methods of information dissemination. Consequently, emergency nurses who did not have reliable access to the Internet or membership to the College of Emergency Nursing Australasia may be excluded from participation. Strategies have been proposed to limit the impact of this and to increase survey response rate [
51].
Observations and interviews will be undertaken in two trauma designated EDs, which may limit transferability of study findings. In undertaking observations and interviews in two large trauma designated ED facilities, it will increase the number and diversity in demographic characteristics of emergency nurses and critically ill patients; thereby developing a deeper understanding of how emergency nurses manage acute pain across a wide spectrum of critically ill patients, and increase transferability and generalisability of the study findings.
In observing emergency nurses within the clinical environment, nurses may demonstrate an increased awareness in assessing, monitoring and communicating with their patients about their comfort and therefore pain because of being observed. Strategies have been highlighted to address this issue. In additional, it has also been demonstrated previously that it is difficult for individuals to sustain behaviour that is dramatically different from normal for any length of time in a busy health care environment [
82].