Original Article
Barriers and Enablers to
From the *Emergency Department,
Hawke’s Bay District Health Board,
Hastings, New Zealand; †School of
Nursing, Eastern Institute of
Technology, Napier, New Zealand.
Address correspondence to Bob
Marshall, PhD, Eastern Institute of
Technology, PB 1201, Napier, New
Zealand. E-mail: bmarshall@eit.ac.nz
Received November 20, 2013;
Revised August 27, 2014;
Accepted August 29, 2014.
Agencies that supported this work:
College of Emergency Nurses New
Zealand (CENNZ).
1524-9042/$36.00
Ó 2014 by the American Society for
Pain Management Nursing
http://dx.doi.org/10.1016/
j.pmn.2014.08.015
Emergency Department
Nurses’ Management of
Patients’ Pain
--- Annatjie Pretorius, RN, MN,* Judy Searle, RN, MN,†
and Bob Marshall, PhD†
- ABSTRACT:
Pain is the most common reason for presentation to the emergency
department (ED). On presentation patients expect rapid pain relief,
yet this is often not met. Despite extensive improvements in analgesia
medication there are still barriers to nurses’ assessment, management,
documentation, and reassessment of pain. The aim of this study is to
identify barriers, enablers, and current nursing knowledge regarding
pain management. Using an anonymous quantitative web-based sur-
vey, members of the College of Emergency Nurses New Zealand were
invited to complete a questionnaire on pain assessment and manage-
ment. The questionnaires were analyzed using descriptive statistics.
Enablers to ED nurses’ improved management of pain were the pro-
vision of nurse-initiated analgesic protocols and pain management
champions. Common barriers perceived by the respondents were the
responsibility of caring for acutely ill patients as well as a patient with
pain. Similar barriers to previous research were identified and
included lack of time, workload, reluctance of clinicians to prescribe
analgesia, and the lack of nursing knowledge regarding opioid
administration. Raising awareness that oligoanalgesia exists in the ED
is essential. This research suggested that nurses would benefit from
ongoing education on the usage of opioids. Nurses’ attitude regarding
patients’ right to expect total pain relief as a consequence of treatment
was also an issue. ED nurses, by virtue of their role, are in a unique
position to be leaders in pain assessment and pain management.
Ó 2014 by the American Society for Pain Management Nursing
BACKGROUND
Pain is the most common reason for presentation to the emergency department
(ED), and it has been established that more than 70% of patients present with
pain as their main symptom (Ducharme et al., 2008; Lew
en, Gardulf, & Nilsson,
2010; Motov, 2012; Puntillo, Neighbor, O’Neil, & Nixon, 2003). Studies have
reported that 60%-80% of patients in pain are often undertreated (Curtis &
Morrell, 2006; Decosterd et al., 2007; Pines & Hollander, 2008; Stalnikowicz,
Mahamid, Kaspi, & Brezis, 2005). Pain is the third most common healthcare
Pain Management Nursing, Vol -, No - (--), 2014: pp 1-8
2 Pretorius, Searle, and Marshall
problem and has reported to be more debilitating than
both heart disease and cancer (Downey & Zun, 2010).
Pain assessment and the administration of analge-
sics and other pain relief methods are the professional
responsibility of the nurse. However, they are often not
able to independently prescribe analgesia, and their
concerns about a patient’s pain may be affected by
their relationship with doctors (Blondal &
Halldorsdottir, 2009). Failing to control a patient’s
pain can lead to deterioration in the patient’s physical,
mental, and social health (Modanloo et al., 2010).
Studies have reported that uncontrolled pain can lead
to increased analgesic drug requirements, as well as
disease and treatment complications. These problems
may result in decreased concentration, decreased
appetite, decreased physical activity, poor social
communication, sleep disorders, and a reduction in
quality of life (Modanloo et al., 2010).
Literature Review
Acute pain is one of the most common complaints in
the ED. Oligoanalgesia, the undertreatment of pain, is
a common phenomenon in the ED, resulting in a
serious clinical problem for ED patients (Decosterd
et al., 2007; Elcigil, Maltepe, Esrefgil, & Mutafoglu,
2011; Todd et al., 2007). Doctors and nurses are both
responsible for patients’ pain control, but nurses play
a critical role in the assessment and management of a
patient’s pain. Several types of barriers to pain
assessment and management have been reported and
have been grouped into patient-related barriers,
nurse-related barriers, physician-related barriers, and
system-related barriers. Previous studies have also re-
vealed that a lack of knowledge, inadequate pain
assessment, and reluctance to administer opioids
were important barriers for health care professionals
providing optimal pain management (Decosterd
et al., 2007; Elcigil et al., 2011; Modanloo et al.,
2010; Todd et al., 2007). Literature has indicated a
lack of knowledge regarding enablers and barriers to
pain management by ED nurses (Al-Shaer, Hill, &
Anderson, 2011; Tsai, Tsai, Chien, & Lin, 2007).
METHODS
Research Question
Despite the fact that ED nurses are in a frontline posi-
tion, there are limited data on ED nurses’ perceived
barriers and enablers to optimal patient pain manage-
ment both nationally and internationally (Elcigil
et al., 2011). Therefore the research question was
‘‘What are the barriers or enablers to the ED nurses’
ability to provide optimal pain management for their
patients?’’ A secondary aim was to identify existing
knowledge among ED nurses regarding pain manage-
ment principles. By identifying gaps in these areas it
will be possible to add to the existing nursing knowl-
edge related to enablers, barriers, and knowledge of
pain management in the emergency department.
Design
Members of the College of Emergency Nurses New
Zealand (CENNZ) were chosen as a purposive conve-
nience sample representing the ED nursing population
of New Zealand. To participate in this research, partic-
ipants had to be CENNZ members and currently work-
ing in an ED.
The tool used to collect data was a 43-item ques-
tionnaire. The barriers and nursing knowledge ques-
tions were developed from several previous studies
(Messeri, Scollo Abeti, Guidi, & Simonetti, 2008;
Tanabe & Buschmann, 2000; Visentin, Trentin, de
Marco, & Zanolin, 2001; Zanolin et al., 2007).
Because the researchers were unable to find
questions regarding possible enablers for pain
management in the ED, a sequence of questions was
developed. The questionnaire was piloted by six
ED nurses from the researcher’s hospital who
were asked to comment on item clarity and
comprehensiveness. This resulted in minor wording
changes in the enablers and demographics sections.
This questionnaire was made up of four sections.
The first two sections were related to enablers (nine
questions) and barriers (15 questions). The respon-
dents were asked to indicate (yes/no) if the proposed
questions were considered enablers/barriers to pain
management in their practice. There was opportunity
at the end of these sections for the participant to indi-
cate other possible enablers/barriers not mentioned in
the questionnaire. The third section of the question-
naire contained 13 questions about pain management
principles. The questions were subdivided into three
categories: general knowledge, opiates, and myths
and prejudices. These questions were from publically
available existing questionnaires by Messeri et al.
(2008) and Zanolin et al. (2007). A 5-point Likert scale
rating from ‘‘strongly disagree’’ to ‘‘strongly agree’’ was
used with these questions and subsequently reported
as percentages of correct and incorrect answers. The
fourth section requested demographic information
(gender, age range, ethnicity, education, years of expe-
rience nursing, years of experience in ED) from the
respondents.
Procedures
Approval for the project was obtained from
the New Zealand Multi-region Ethics Committee (CEN/
12/EXP/078), the tertiary institution’s Research Ethics
 Barriers and Enablers to Pain Management by ED Nurses 3

and Approvals Committee (#30/12), and the Maori Health years and older, had more than 15 years nursing expe-
Services of the regional District Health Board (DHB). rience (66%), and had postgraduate qualifications
The questionnaire was distributed via email to the (64%). The NCNZ identified that 41% of the work force
members of the CENNZ, inviting them to participate in of NZ nurses are aged 50 years and older (Nursing
a survey on pain assessment and management in the Council of New Zealand, 2011), compared with
ED. The email had a link to the Survey Monkey ques- 32.5% of respondents in this research. However,
tionnaire. Completion of the questionnaire indicated 82.5% of respondents in this research were older
provision of consent. A reminder email was sent out af- than age 36, compared with 74.4% of the national
ter 3 weeks. The six participants of the pilot study workforce (Nursing Council of New Zealand, 2011).
were asked not to complete the questionnaire. This International studies findings were similar, recording
choice of data collection approach ensured wide distri- the nurses’ average age as 42 years, with the majority
bution across New Zealand. of nurses aged 36-55 years (Al-Shaer et al., 2011;
Both descriptive quantitative and qualitative anal- Tanabe & Buschmann, 2000).
ysis approaches were used to analyze the data. A gen- The ethnicity of respondents (NZ European/
eral inductive approach (Thomas, 2006) established Other European 89%, Maori 5%) was similar to the
themes from the responses of the nurses regarding data collected in 2011 by the NCNZ (NZ European/
perceived enablers, protocols, and barriers regarding Other European 91%, Maori 7%), indicating an appro-
pain management in the ED. In general the qualitative priate sample of nurses’ ethnicity (Nursing Council
responses supported the quantitative results and have of New Zealand, 2011).
not been included here. There was a well-distributed range of ED experi-
ence among the respondents, ranging from 1 year to
more than 15 years. These findings are similar to the
RESULTS finding of Tanabe and Buschmann (2000), where the
The NZNO sent a total of 197 emails to their CENNZ nurses in their study had an average of 17 years nursing
members and a total of 172 surveys were returned experience and 11 years ED experience. The majority
and analyzed for a response rate of 87%. No Survey- of the respondents in this study (65.6%) had more
Monkey respondent IDs were duplicated, suggesting than 15 years nursing experience and 43.6% had 11
no one completed the survey more than once. or more years of ED experience.
Although not all respondents indicated whether
they had a nursing degree or diploma, 65% of the re-
Demographics
spondents indicated that they had postgraduate qualifi-
It was established (Table 1) that the majority of respon-
cations. This indicated that nearly 20% more of this
dents were women (92%), NZ European (80%), 36
sample had postgraduate qualifications than reported
by the NCNZ in 2011. The nurses whose knowledge
TABLE 1. was assessed by Tanabe and Buschmann (2000) also
Participant Demographics indicated that they had postgraduate qualifications or
additional education regarding pain management, and
Age
the nurses with a master’s degree demonstrated a
20-35 30 17.4%
36-50 86 50.0% higher level of knowledge.
51-65 53 30.8%
>66 years 3 1.7%
Qualifications Enablers
Registered nurse (diploma) 26 15.1%
From the nurse-empowering enablers (Table 2) it was
Registered nurse (degree) 49 28.5%
Postgraduate certificate/diploma 79 45.9% identified that the majority of respondents (97%)
Master’s degree or PhD 30 17.4% thought that having pain management protocols
Years nursing were important and that pain management courses
1-5 10 5.8% would be beneficial. Only a few EDs had a pain man-
6-10 24 14.0%
agement champion, and most of the respondents
11-15 25 14.5%
>15 113 65.7% (86%) thought that having a pain champion nurse in
Years ED nursing their department would be an enabler to patients’
1-5 50 29.1% pain management. Although most of the respondents
6-10 47 27.3% (95%) said education was an enabler, a small percent-
11-15 39 22.7%
age (10%) of the respondents in the 20-35 years age
>15 36 20.9%
group disagreed.
4 Pretorius, Searle, and Marshall
TABLE 2.
Responses to Enabler Questions
Possible Enablers for Nurses
Do nurse-initiated analgesia protocols improve pain
management for ED patients?
Do you have a pain management champion in your area?
Would pain management champions improve pain
assessments, pain management, and nursing knowledge
of pain?
Will attending pain management courses/in-service courses
improve nursing management principles?
Do you follow a protocol to assess a patient’s pain?
Would regular audits on pain management motivate nurses
to achieve the goal of optimum pain management?
Does treating pain as the fifth vital sign contribute to optimal
pain management care?
Would posters of pain assessment tools improve accuracy of
pain score assessment and documentation of pain score?
Does workload impact your ability to assess a patient’s pain?
Just more than a third of respondents (36%) aged
20-35 years with less than 5 years ED experience did
not follow protocols. Respondents aged 36-50 years,
regardless of ED years of experience, were less likely
to follow a protocol to assess a patient’s pain than
any other group. The concept of treating pain as the
fifth vital sign to improve pain management was not
accepted by 15% of the respondents. The respondents
less likely to accept pain as the fifth vital sign were
those aged 36-50 years of age with 6-10 years of ED
experience (26%). Although less than a quarter (24%)
of the respondents thought that visual pain scoring
tools were not an enabler to pain management in the
ED, one of the themes that emerged from the qualita-
tive section was that the use of pain scoring tools
would be an enabler. More than three quarters (79%)
of the respondents thought that their workload had
an impact on their assessment of a patient’s pain and
pain management. The respondents with less than
5 years ED experience (28%) disagreed with this.
Barriers
Two major barriers to pain management that were
identified were the responsibility for caring for other
acutely ill patients in addition to a patient with pain
and the lack of time to adequately assess and control
a patient’s pain (Table 3). This was especially evident
for respondents aged 20-35 years with less than 5 years
of ED experience, because all 22 of them agreed that
this was a major barrier, and a large percentage of those
aged 36-50 years with 6-10 years ED experience (88%)
also noted this.
A third of the respondents (33%) thought that
the inability to monitor analgesia side effects when
Yes No
97% 3%
19% 81%
86% 14%
95% 5%
70% 30%
51% 49%
86% 15%
76% 24%
79% 21%
patients leave the department for diagnostic proce-
dures was a barrier. The respondents more likely to
describe this as a barrier were the respondents aged
36-50 with more than 6 years ED experience (49%).
More than one third of the respondents (37%), regard-
less of age or years of ED experience, thought that the
need for frequent monitoring after administration of
intravenous opioids was a barrier.
The biggest patient-related barrier identified was
the reluctance of the patient to report pain, followed
by the patient’s use of alcohol or recreational drugs,
followed by the patients’ reluctance to take opioids.
About three quarters of respondents with 6-10 years
of ED experience (78%) and with less than 5 years
ED experience (74%), regardless of age, thought pa-
tients were reluctant to report pain. A third of all re-
spondents with less than 5 years of ED experience,
regardless of age (and 77% of those aged 20-35 years),
also perceived that the patients’ reluctance to take opi-
oids was a barrier.
Although lack of intravenous access and the
inability to determine adequate history of allergies
were not regarded as major barriers, 63% of respon-
dents with less than 5 years ED experience were
more likely to find this a barrier. A third of the respon-
dents aged 51-65 with more than 15 years ED experi-
ence also found lack of intravenous access to be a
barrier to pain management.
From the nurse-related barriers, a lack of knowl-
edge (67%) and inadequate initial pain assessment
(65%) were identified as the two main barriers to
pain management. The respondents with less than
5 years of ED experience (80%) thought their initial
pain assessment was adequate. More than half of
 Barriers and Enablers to Pain Management by ED Nurses 5

TABLE 3.
Responses to Barrier Questions
Possible Barriers Yes No

The responsibility of caring for other acutely ill patients in addition to a patient 83% 17%
with pain
Lack of time to adequately assess and control pain 81% 19%
Inability to monitor for side effects when patients leave the department for 33% 67%
diagnostic procedures
Time to find opioid keys 27% 73%
The need for frequent monitoring post–intravenous opioids 37% 63%
Patients’ reluctance to report pain 77% 23%
Patients’ reluctance to take opioids 62% 38%
The inability to determine adequate history/allergies 24% 32%
The patient’s use of alcohol or other recreational drugs 68% 32%
Lack of intravenous access 34% 66%
Nursing staff reluctance to give opioids 26% 74%
Inadequate initial assessment of pain and reassessment of pain relief 65% 35%
Inadequate staff knowledge of pain management principles 67% 33%

respondents (55%) aged 20-35 years with 1-5 years ED
experience did not think they lacked knowledge
regarding pain management principles.
The administration of opioids was not seen as a bar-
rier by most of the respondents. Although most of the
respondents (74%) were not reluctant to give opioids,
those aged 51-65 years with less than 10 years ED expe-
rience (58%) were most likely to be reluctant to use opi-
oids. Patients would more likely receive opioids from
nurses aged 20-35 years with 1-5 years’ experience.
Only a third of the respondents (35%) indicated
that they thought that the inability to medicate until
a diagnosis was made was a barrier. The largest group
(29%) was aged 36-50 years with more than 6 years of
ED experience.
Nursing Knowledge
Just less than three quarters of the respondents (74%)
had a good general knowledge of pain management
principles (Table 4). The majority of respondents
(85%) believed that pain should be treated as the fifth
vital sign. There were two areas where the respon-
dents lacked knowledge. More than half the respon-
dents (53%) did not believe that it was a patient’s
right to expect total pain relief from treatment and
just less than a third of respondents (31%) lacked cur-
rent knowledge regarding drug addiction habits.
Half of the respondents aged 36-50 years with
more than 6 years ED experience lacked current
knowledge regarding pain management principles;
these are the respondents who would most likely not
use alternative methods to distract patients from their
pain or expect that a patient would have total pain
relief from treatment.
The vast majority of respondents (85%), including
all those with less than 5 years ED experience, indi-
cated that it was necessary to continuously assess
pain as a vital sign. More than half of the total respon-
dents (53%) and nearly two thirds (64%) of those aged
20-35 years with less than 5 years ED experience were
less likely to believe it was a patient’s right to expect
total pain relief from treatment.
DISCUSSION
The findings of this research are a call to action for
nurses in the EDs of New Zealand to become proactive
in increasing their own knowledge regarding assess-
ment, principles, and management of pain. Nurses
play a vital role in the management of patients’ pain
and need to become active leaders of pain manage-
ment in the ED.
Respondents have voiced the need for nurse-
initiated analgesic protocols because they believe
these would enable nurses’ ability to improve patients’
pain management. This enabler would need the sup-
port of both ED medical staff and management and
also that of hospital administrators. It has already
been demonstrated that a structured standing orders
protocol for nurse-initiated intravenous opioids signifi-
cantly improves the frequency of delivering analgesics
with a consequent reduction in the patients’ waiting
time in the ED (Decosterd et al., 2007; Muntlin,
Carlsson, S€afwenberg, & Gunningberg, 2011;
Stalnikowicz et al., 2005). The biggest delay
identified in one study was the gap between the
prescribing of analgesic medication and its
administration (Grant, 2006). Having nurse-initiated
6 Pretorius, Searle, and Marshall

TABLE 4.
General Knowledge Regarding Pain Management
Correct Answer Indicated as Yes (Y)* or No (N) † Correct Incorrect

A patient should experience discomfort prior to giving the next dose of pain medications. (N) 85% 15%
Respiratory depression is the most common side effect of morphine. (N) 50% 50%
The preferred route of administration of opioid pain relievers to patients with cancer-related pain is 85% 15%
intramuscular. (N)
Twenty-five percent of patients receiving analgesics on a regular basis become drug addicted. (N) 69% 31%
Opioids should not be used in pediatric patients. (N) 85% 15%
It is necessary to continuously assess pain as a vital sign. (Y) 95% 5%
Distraction with nonpharmacologic techniques (music, imagery) decreases pain perception. (Y) 73% 27%
Giving opioids on a regular schedule is preferred over pro re nata (PRN)/as needed for continuous 48% 52%
pain. (Y)
It is a patient’s right to expect total pain relief as a consequence of treatment. (Y) 47% 53%
The most suitable dose of morphine for a patient in pain is a dose which best controls the 66% 34%
symptoms; there is no maximum dose (i.e., a level must not be exceeded) for morphine. (Y)
The most accurate judge of the intensity of the patient’s pain is the patient. (Y) 90% 10%
Patients with chronic pain need high dosages of analgesic compared with patients with 53% 47%
acute pain. (Y)
*Percentage of respondents who answered ‘‘strongly agree’’ or ‘‘agree’’ have been combined to produce the percent of correct responses and percentages
of ‘‘neutral,’’ ‘‘disagree,’’ or ‘‘strongly disagree’’ combined and reported as incorrect.
†
Percentage of respondents who answered ‘‘strongly disagree’’ or ‘‘disagree’’ have been combined to produce the percent of correct responses and per-
centages of ‘‘neutral,’’ ‘‘agree,’’ or ‘‘strongly agree’’ combined and reported as incorrect.

protocols would significantly reduce this gap. It has
also been identified that the majority of patients are
willing to accept analgesia from a nurse before being
assessed by a doctor/physician, and therefore the value
of nurse-initiated analgesics under the scope of stand-
ing orders and protocols is likely to benefit patients
(Grant, 2006; Stalnikowicz et al., 2005).
Although the respondents indicated an over-
whelming response to having nurse-initiated proto-
cols, they also demonstrated that they wanted
proactive physicians prescribing adequate analgesia
for patients. This would enable nurses to deliver
continuous analgesia without the necessity of finding
the physician and asking she or he to represcribe anal-
gesia. Nurses believed clinicians were still reluctant to
prescribe analgesia until they had assessed a patient
themselves and wanted this attitude to change.
Only a few respondents said their ED had a pain
management champion, and the need for pain manage-
ment champions was generally agreed. Most of the re-
spondents indicated that they needed and wanted
ongoing education regarding pain management.
The most common barriers were caring for
acutely ill patients in addition to a patient with pain
and lack of time because of workload. Although all
22 respondents aged 20-35 years with less than 5 years
of ED experience agreed that time to adequately assess
and control a patient’s pain was a barrier, a concern
was that this group of recent graduates also indicated
that they believed their initial pain assessment was
adequate and that they did not think they lacked
knowledge regarding pain.
One question identified that more than half of the
respondents did not believe that it was a patient’s right
to expect total pain relief from treatment. This was a
concerning finding, and further research is needed to
identify why these respondents did not believe it was
a patient’s right.
Limitations
Selecting to only collect data from the CENNZ mem-
bers excluded a large number of possible respondents.
This research concentrated only on pain management
in the ED and the ED nurses’ perceptions regarding en-
ablers and barriers to pain management, and there may
possibly be different enablers or barriers present in
other clinical areas. Although the enabler section of
the survey was derived from the literature, it consisted
of new questions, and their reliability and validity has
not been demonstrated.
Implications for Nursing Education, Practice,
and Research
Research indicates that the benefits of nurse autonomy
in the administration of pain medication in the ED
include reducing median pain scores and waiting times
(Fry & Holdgate, 2002). Pain assessment should be per-
formed by an ED nurse, and, when appropriate, pa-
tients should be treated for their pain before seeing a
clinician. Therefore there appears to be a need for
 Barriers and Enablers to Pain Management by ED Nurses
standardized nurse-initiated analgesia protocols, not
only for simple analgesia such as acetaminophen (para-
cetamol) and ibuprofen, but for schedule II analgesics
as well. Furthermore, the need for protocols with clear
guidelines on how to administer nonpharmacologic
pain relief (e.g., splinting a fractured limb, elevating a
painful limb, ice packs, heat packs) has the added
benefit that nurses can provide analgesia before
consulting a clinician regarding analgesics. Regular
evaluation of nursing competencies related to those
protocols would possibly improve compliance of pro-
tocol usage. Having the organizations, managers, and
all the stakeholders, such as the pain specialist team,
on board supporting the usage of the nurse-initiated
protocols would enhance pain management.
CONCLUSIONS
Our findings support those of other studies that sub-
stantial barriers are present for nurses regarding the
management of patients’ pain in the ED, including
workload and other factors limiting the ability to
assess, respond to, and monitor pain. The main en-
ablers to ED nurses’ improved management of pain
were seen to be nurse-initiated analgesic protocols
and pain management champions. Although nurse-
initiated protocols were identified as the perceived
REFERENCES
Al-Shaer, D., Hill, P. D., & Anderson, M. A. (2011). Nurses’
knowledge and attitudes regarding pain assessment and
intervention. Medsurg Nursing, 20(1), 7–11.
Blondal, K., & Halldorsdottir, S. (2009). The challenge of
caring for patients in pain: From the nurse’s perspective.
Journal of Clinical Nursing, 18(20), 2897–2906.
Curtis, L. A., & Morrell, T. D. (2006). Pain management in
the emergency department. Emergency Medicine Practice,
8(7), 1–28.
Decosterd, I., Hugli, O., Tamches, E., Blanc, C.,
Mouhsine, E., Givel, J.-C., Yersin, B., & Buclin, T. (2007).
Oligoanalgesia in the emergency department: Short-term
beneficial effects of an education program on acute pain.
Annals of Emergency Medicine, 50(4), 462–471.
Downey, L. A., & Zun, L. S. (2010). Pain management in the
emergency department and its relationship to patient satis-
faction. Journal of Emergencies, Trauma and Shock, 3(4),
326–330.
Ducharme, J., Tanabe, P., Homel, P., Miner, J. R.,
Chang, A. K., Lee, J., & Todd, K. H. (2008). The influence of
triage systems and triage scores on timeliness of ED analgesic
administration. The American Journal of Emergency Medi-
cine, 26, 867–873.
Elcigil, A., Maltepe, H., Esrefgil, G., & Mutafoglu, K. (2011).
Nurses’ perceived barriers to assessment and management of
pain in a university hospital. Journal of Pediatric Hematol-
ogy/Oncology, 33, S33–S38.
7
main enabler to improve patients’ pain management,
there is a concern regarding the nurses’ lack of knowl-
edge regarding opioids and how this might limit imple-
mentation of protocols. This research demonstrates
that adequate pain management remains an elusive
goal within the emergency nursing setting. By identi-
fying barriers and enablers to ED nurses’ management
of patients’ pain, it will be possible to narrow the gap
that exists between the ideal of universal effective pain
management and the reality of clinical practice.
Further research is needed to identify why half of
nurses do not believe that it is the patients’ right to
have total pain relief as a consequence of treatment.
More research is also needed regarding the waiting
room patients and the role of the triage nurse in pain
assessment and pain management while in the waiting
room. The increase in patients presenting to emer-
gency departments was not studied in this research,
but further research is needed in this area because
the respondents saw the workload as a barrier and so-
lutions need to be found to improve workload
pressures.
Acknowledgments
The authors would like to thank all those CENNZ nurses who
participated in the survey.
Fry, M., & Holdgate, A. (2002). Nurse-initiated intravenous
morphine in the emergency department: Efficacy, rate of
adverse events and impact on time to analgesia. Emergency
Medicine, 14(3), 249–254.
Grant, P. S. (2006). Analgesia delivery in the ED. The
American Journal of Emergency Medicine, 24(7), 806–809.
Lew
en, H., Gardulf, A., & Nilsson, J. (2010). Documented
assessments and treatments of patients seeking emergency
care because of pain. Scandinavian Journal of Caring Sci-
ences, 24(4), 764–771.
Messeri, A., Scollo Abeti, M., Guidi, G., & Simonetti, M.
(2008). Pain knowledge among doctors and nurses: A survey
of 4912 healthcare providers in Tuscany. Minerva Aneste-
siologica, 74(4), 113–118.
Modanloo, M., Seyyed Fatemi, N., Bastani, F., Peyravi, H.,
Behnampoor, N., Hesam, M., & Abdollahi, H. (2010). Com-
parison of pain assessment by patients and triage nurses.
Iranian Journal of Critical Care Nursing, 3(1), 9–10.
Motov, S. M. (2012). Acute pain management in the
emergency department: The evidence-based approach to
controversial issues. Retrieved June 16, 2012 from. http://
www.acep-emedhome.com/features_article.cfm.
Muntlin, A., Carlsson, M., S€afwenberg, U., &
Gunningberg, L. (2011). Outcomes of a nurse-initiated
intravenous analgesic protocol for abdominal pain in an
emergency department: A quasi-experimental study. Inter-
national Journal of Nursing Studies, 48(1), 13–23.
8 Pretorius, Searle, and Marshall
Nursing Council of New Zealand. (2011). The New Zealand
nursing workforce. Retrieved May 3, 2012, from. http://www.
nursingcouncil.org.nz/download/186/31march2011.pdf.
Pines, J. M., & Hollander, J. E. (2008). Emergency depart-
ment crowding is associated with poor care for patients with
severe pain. Annals of Emergency Medicine, 51(1), 1–5.
Puntillo, K., Neighbor, M., O’Neil, N., & Nixon, R. (2003).
Accuracy of emergency nurses in assessment of patients’
pain. Pain Management Nursing, 4(4), 171–175.
Stalnikowicz, R., Mahamid, R., Kaspi, S., & Brezis, M.
(2005). Undertreatment of acute pain in the emergency
department: A challenge. International Journal for Quality
in Health Care, 17(2), 173–176.
Tanabe, P., & Buschmann, M. B. (2000). Emergency nurses’
knowledge of pain management principles. Journal of
Emergency Nursing, 26(4), 299–305.
Thomas, D. R. (2006). A general inductive approach for
analyzing qualitative evaluation data. American Journal of
Evaluation, 27(2), 237–246.
Todd, K. H., Ducharme, J., Choiniere, M., Crandall, C. S.,
Fosnocht, D. E., Homel, P., & Tanabe, P. (2007). Pain in the
emergency department: Results of the pain and emergency
medicine initiative (PEMI) multicenter study. The Journal of
Pain, 8(6), 460–466.
Tsai, F. C., Tsai, Y. F., Chien, C. C., & Lin, C. C. (2007).
Emergency nurses’ knowledge of perceived barriers in pain
management in Taiwan. Journal of Clinical Nursing, 16(11),
2088–2095.
Visentin, M., Trentin, L., de Marco, R., & Zanolin, E.
(2001). Knowledge and attitudes of Italian medical staff
towards the approach and treatment of patients in pain.
Journal of Pain and Symptom Management, 22(5),
925–930.
Zanolin, M. E., Visentin, M., Trentin, L., Saiani, L.,
Brugnolli, A., & Grassi, M. (2007). A questionnaire to eval-
uate the knowledge and attitudes of health care providers on
pain. Journal of Pain and Symptom Management, 33(6),
727–736.