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Publicly Available Published by De Gruyter July 1, 2015

Prehospital personnel’s attitudes to pain management

  • Maaret Castrèn , Veronica Lindström EMAIL logo , Jenny Hagman Branzell and Leila Niemi-Murola

Abstract

Objectives

Pain is one of the most common reasons for patients to seek acute medical care. The management of pain is often inadequate both in the prehospital setting and in the emergency department. Our aim was to evaluate the attitudes towards pain management among prehospital personnel in two Scandinavian metropolitan areas.

Methods

A questionnaire with 36 items was distributed to prehospital personnel working in Helsinki, Finland (n=70) and to prehospital personnel working in Stockholm, Sweden (n=634). Each item was weighted on a five-level Likert scale. Factor loading of the questionnaire was made using maximum likelihood analysis and varimax rotation. Six scales were constructed (Hesitation, Encouragement, Side effects, Evaluation, Perceptions, Pain metre). A Student’s t-test, ANOVA, and Pearson Correlation were used for analysis of significance.

Results

: The response rate among the Finnish prehospital personnel was 66/70 (94.2%) while among the Swedish personnel it was 127/634 (20.0%). The prehospital personnel from Sweden showed significantly more Hesitation to administer pain relief compared to the Finnish personnel (mean 2.01 SD 0.539 vs. 1.67 SD 0.530, p < 0.001). Those who had received pain education at their workplace showed significantly less Hesitation than those who had not participated in education. There was a significant negative correlation (p < 0.01) between Hesitation and Side effects. There was also astatistically significant(p < 0.01) correlation between Perceptions and Hesitation, indicating that a stoic attitude towards pain was associated with indifference to possible Side effects of pain medication (p < 0.05).

Conclusions

The results show that there was a significant correlation between the extent of education and the prehospital personnel’s attitudes to pain management. Gender and age among the prehospital personnel also affected the attitudes to pain management. The main discrepancy between the Swedish and Finnish personnel was that the participants from Stockholm showed statistically significantly more hesitation about administering pain medication compared to the participants from Helsinki.

Implications

The results of the study highlight the need for continuous medical education (CME) for prehospital personnel. CME and discussions among prehospital personnel may help to make a change in the personnel’s attitudes towards pain and pain management in the prehospital context.

1 Introduction

The journey of the patient in Emergency medical services (EMS) usually starts with care provided by the prehospital personnel and personnel in the emergency department (ED). Pain is one of the most common symptoms in an emergency setting, causing over half of the visits to the ED [1,2]. The prevalence of pain in the prehospital setting is not well studied, but Galinsk et al. [3] report that approximately 42percentofpatientsinthe prehospital setting suffer from pain. It is well known that the response by professional personnel to the management of acute pain in the ED is not optimal, meaning that many patients remain in a distressed condition and are dissatisfied with the care they receive in the ED [1,4]. There are several reasons for sub-optimal pain relief in the ED: not acknowledging the pain [5], inability to assess pain [6], lack of pain management guidelines in the ED [7], and failure to meet the patient’s expectations of pain relief [8]. Pain management in the prehospital setting is also described as sub-optimal [3,9,10,11]. The reasons for inadequate pain relief in the prehospital setting are not as well studied as in the ED, but some reported hindrances to administering pain relief include: lack of knowledge [12,13,14], attitudesamong the personnel [12], an inadequate analgesia protocol [12,14]and inabilitytoassess pain [12,14,15].Asshown above, the hindrances in the prehospital setting to achieving optimal pain relief are similar to the hindrances identified in the ED[12]. However, since pain is associated with increased risk of complications suchasdelirium, depression, sleep disturbanceand decreased response to interventions for other illnesses, especially among the elderly [9], pain should be considered as the fifth vital sign [16]. Acknowledging the importance of good pain management, some EMS systems use pain management asa key performance indicator [17], and appropriate analgesia can be seen as one of the justifications for advanced prehospital care [13]. There have been attempts to improve pain management in the prehospital setting [7,18,19]. Nevertheless, there is still a need to further investigate the reasons for sub-optimal pain relief in the prehospital setting in order to create a basis for further improvement work on pain management. At present there are no known studies investigating whether there is a difference between prehospital personnel’s attitudes to pain management in various EMS systems. Therefore, the aim of this studywastosurveytheattitudestowardspainmanagementamong the prehospital personnel in the metropolitan areas of Helsinki, Finland, and Stockholm, Sweden.

2 Material and methods

An observational questionnaire study was conducted. A survey was administered to prehospital personnel in the EMS in a metropolitan area of Helsinki, Finland, and Stockholm, Sweden during 2012.

2.1 Study setting, Helsinki

In Helsinki, the EMS serves a population of approximately 621,000 people. The Rescue Department is responsible for EMS along with the University Hospital-based prehospital physicians The EMS is three-tiered; the first tier consists of personnel with basic life support (BLS) knowledge. The BLS personnel competencies include: ability to use semi-automated defibrillators, tracheal intubation of a lifeless person, and vascular access. No intravenous pain medicine is used on the BLS level. The second tier consists of personnel with advanced life support (ALS) competencies, and one medical supervisor unit. The ALS personnel are Registered Nurses (RNs) or RNs with additional training in prehospital care. A physician-manned unit is the third tier. The Finnish EMS has 24/7 involvement of experienced prehospital physician’s and the personnel can always consult a prehospital physician and request assistance at an emergency scene or by phone.

2.2 Study setting, Stockholm

There are similarities and differences in the investigated settings, and in Stockholm, Sweden health care is provided to a population of 2.2 million people. The County Council is responsible for the EMS in Stockholm and the service is provided by the organisations within the county and private companies contracted by the County Council. During the study period, three companies were contracted to provide EMS; one company owned by the County Council and two private companies. In Stockholm, the EMS is two-tiered during the day time. The first tier consists of ALS personnel with the same competence as the Finnish ALS personnel. The second tier is a physician-manned unit (7–21), but the physician has not been explicitly appointed as the person responsible for the EMS. During the night shift (22–07), when no physician-manned unit is available, the personnel can contact a physician by phone if advice is needed. This physician is located at the Emergency Medical Communication Centre and does not work as a physician in the prehospital field.

2.3 Data collection and participants

A paper questionnaire was distributed to the Helsinki participants before a lecture. The lecture was part of an internal educational seminar for the prehospital personnel. Participation in the seminar was mandatory but answering the questionnaire was of course voluntary. Half of the prehospital personnel attended the seminar on one day and the other half had an identical seminar two weeks later. The participants (n=70) were emergency medical technicians (EMTs) and RNs. In Stockholm, the questionnaire was sent as a link by e-mail to an administrator at each of the three included EMS providers. The administrators forwarded the link to their employees, both EMTs and RNs (n=634). The electronic questionnaire was available for the Swedish participants for 21 days. A reminder was sent via the administrators to the participants on daysevenand dayfourteen.Intheelectronic questionnaire answering the questions was mandatory, meaning that submission of the questionnaire was only possibleif all the questions were answered.

2.4 Questionnaire

The questionnaire consisted of four demographic questions (age, gender, education level and years in profession), 32 pain-related items and two open questions about assessment strategies and pain management. Out of the 32 pain-related items, 22 items had been used in a previous study by Niemi-Murola et al. [20] and five in a study by Stalnikowicz et al. [21]. Five new questions were added. Each item was weighted on a five-level Likert scale from one (1) to five (5), where one indicated strong disagreement and 5 indicated strongly agreement. A Cross-cultural adaptation process was conducted since the original questionnaire was in Finnish. The first part of the adaptation process was to translate the original Finnish version into Swedish. This was done by two independent bilingual translators with Finnish as their mother tongue but who were also fluent in Swedish. The two translators were not aware of the purpose of the translation or the use of the questionnaire. The translated versions were compared and differences were adjusted in order to create one single version. This version was given to a third person for back translation into Finnish. Comparison with the original Finnish version was finally made as a linguistic validation in order to establish conceptual equivalence.

2.5 Ethical considerations

This study was designed to meet the ethical principles for research described bythe International Council of Nurses, ensuring anonymity, integrity and confidentiality for the participants [22]. By doing so, according to Swedish [23] and Finnish regulations on questionnaire studies, ethical committee approval is not needed.

2.6 Analysis

After maximum likelihood factor analyses with varimax rotation, six scales were created (Hesitation, Encouragement, Side effects, Assessment, Perceptions, Pain metre). Ten of the original items had weak loadings or loaded on several factors and were not included in the final factor analysis. As six factors had eigenvalues over one, a seven-factor solution was accepted. The reliabilities of the scales comprising the inventory were calculated using Cronbach’s alpha.EigenvaluesandCronbach’salphasforscalesare presentedin Table 1. Values less than 0.3 were omitted from the table (Table 1). Correlations among scales and demographic data were computed as PearsonCorrelation coefficients. Differences between age groups and participation in educational sessions were calculated using ANOVA. Differences between genders and prehospital health care personnel working in the two different metropolitan areas were analysed with a two-tailed Student’s t-test for independent samples.

Table 1

Factor loading of the questionnaire consisting of 36 items using maximum likelihood analysis and varimax rotation.

1 2 3 4 5 6
Scale 1. Hesitation
27. I hesitate to administer analgesics because of their hypotensive effect .819
26. I hesitate to administer opioids due to their nauseating effect .695
6. I hesitate to administer analgesics because doing so might decrease the patient’s blood pressure .616
8. I hesitate to administer analgesics because doing so might affect the patient’s breathing .581
3. I hesitate to administer analgesics because doing so might hinder diagnostics (in the hospital) .440
Scale 2. Encouragement
2. Patients need encouragement to talk about their pain’ .845
11. Patients does not need encouragement to talk about their pain’ –.717
21. It may be difficult for the patient to talk about their pain .467
Scale 3. Side effects
16. Opioids seldom cause significant nausea or vomiting .860
17. Hypotension caused by administration of analgesics is seldom significant .534
5. Opioids often cause significant nausea and vomiting .334 –.414
20. Opioids seldom cause respiratory depression .414
22. Administration of analgesics seldom hinders diagnostics .335
Scale 3. Evaluation
25. It is difficult to estimate pain in demented patients –.656
23. You can estimate the intensity of pain of an unconscious patient by looking at him/her .578
14. You can estimate the intensity of pain of a demented patient by looking at him/her .556
19. It is difficult to estimate pain in unconscious patients –.404
4. It is easy to estimate pain in demented patients .386
Scale 4. Perceptions of pain
34. A pain complaint might distract the doctor from my real problem .513
33. It is easier to suffer from pain than from the side-effects of analgesics (e.g. nausea, vomiting) .505
24. The patient is the expert as regards his/her pain –.449
32. ‘Good patients’ do not talk about their pain .438
35. Analgesics should be given only when pain is unbearable .431
12. I rely on the patient’s own estimation of his/her pain –.383
Scale 6. Pain metre
1. Use of a pain metre facilitates monitoring of the efficacy of pain medication .839
10. Use of a pain metre facilitates estimation of pain .742
Cronbach’s alpha .760 .748 .623 .627 .603 .761

3 Results

The response rate among the Finnish prehospital personnel was 66/70 (94%), and among the Swedish personnel it was 127/634

(20%). The demographic and background data of the participants is presented in Table 2. A majority of the participants were experienced workers in the prehospital setting, and this was true for the Swedes to a greater extent than for the Finns as displayed in Table 2. The Finnish participants had participated in internal pain education given as a part of the official continuous medical education programme of the workplace more often than the Swedes. The educational backgroundof the groups varied, reflecting the current situation in both countries. Nearly half of the Swedish respondents (59/127, 46%) needed to assess patients’ pain and needed to administer analgesics on a daily basis. The majority (108/127, 85%) assessed pain a couple of times per week. For the Finnish participants, the figures were 13 percent (9/66) and 18 percent (12/66), respectively (p < 0.001).

Table 2

Demographic and background data of the participants.

Finnish group (n = 66) Swedish group (n = 127)
Gender (male/female) 5/50 76/51
Age (years)
20–30 9 (13.4%) 8 (6.3%)
31–40 33 (49.3%) 49 (38.6%)
41–50 18 (26.9%) 50 (39.4%)
>50 5 (7.5%) 20 (15.7%)
Missing data 1 (1.5%)
Educational background
Registered nurse 20 (29.9%) 113 (89.0%)
Emergency medical technician 38 (56.7%) 14 (11.0%)
Fireman 3 (4.5%)
Missing data 5 (5.6%)
Years as a clinician in prehospital setting
<3 5 (7.5%) 17 (13.4%)
3–5 9 (13.4%) 16 (12.6%)
5–10 17 (25.7%) 24 (18.9%)
10–15 13 (19.4%) 28 (22.0%)
>15 22 (32.8%) 42 (33.1%)
Missing data
Participated in pain education at work place
Last year 22 (32.8%) 12 (9.4%)
Less than five years ago 27 (40.3%) 28 (22.0%)
More than five years ago 2 (3.0%) 13 (10.2%)
No participation 15 (22.7%) 74 (58.3%)
Missing data
Participated in pain education outside work place
Last year 15 (22.4%) 6 (4.7%)
Less than five years ago 10 (14.9%) 26 (20.5%)
More than five years ago 9 (13.4%) 38 (29.9%)
No participation 32 (48.4%) 57 (44.9%)
Missing data
Consider administering analgesics to a patient
Daily 8 (12.5%) 59 (46.5%)
A couple of times a week 12 (18.8%) 49 (38.6%)
Once in a week 5 (39.1%) 14 (11.0%)
A couple of times a month or more seldom 19 (29.7%) 5 (3.9%)
Missing data 22 (33.3%)

The Finnish participants had participated in pain education given by their own unit significantly more often compared to the Swedish participants (p < 0.01). The Swedish participants showed statistically significantly more Hesitation compared to the Finnish participants (Swedish mean 2.01 SD 0.539 vs. 1.67 SD 0.530, p < 0.001). The participants who had frequently received internal pain education showed statistically significantly less Hesitation than the ones who had not received pain education [F(4, 193)=3.753, p < 0.01]. The Finnish participants used different pain rating scales more often when assessing their patients’ pain (Table 3). The Swedish participants felt that they had to consider assessing pain and need of analgesics inthe field significantly more often than the Finns(p < 0.01). The workingexperience did not have any significant effect on the use of scales.

Table 3

Assessment of pain in trauma patients and complaints, such as acute myocardial ischaemia (multiple answers were possible).

Finnish group (n = 66) Swedish group (n = 127)


Trauma Other Trauma Other
Assessing pain with pain scale (VAS) 34(51.1%) 45(68.2%) 62(48.8%) 84(66.1%)
Using own scale 9(13.6%) 10(15.2%) 1 (0.1%) 3(0.2%)
Assessment by asking patient, no scale 33(50.0%) 31 (47.0%) 17(13.4%) 8(6.3%)
Assessment based on patient’s body language 47(71.2%) 24(36.4%) 10(7.8%) 3(0.2%)
Assessment based on the patient’s reports 32(48.4%) 33(50.0%) 3(0.2%)
Other 5(7.6%) 4(6.0%) 34(26.8%) 29(22.8%)

Male participants hadsignificantly morestoicperceptionsabout need for pain medication than females (male mean 1.71 SD 0.34 vs. female 1.84SD0.51)(p < 0.05). The younger participants were more positive about assessingthe need forpainmedicationthantheolder ones [F(4, 139) =2.491, p < 0.05].

There was a statistically significant negative correlation between the scales Hesitation and Side effects (Table 4) showing that the respondents hesitated to administer analgesics due to fear of side effects of the drugs (p < 0.01). There was also a correlation between the items developed by Stalnikowicz et al. [21] [scale Perceptions and scale Hesitation (p < 0.01)] indicating that a stoic attitude towards pain was associated with indifference to possible side effects of pain medication (p < 0.05).

Table 4

Correlations between the six scales.

2 3 4 5 6
1. Hesitation administering pain medication .023 –.410[**] .030 .195[*] .076
2. Encouragement of patients .181 –.189[*] .113 .079
3. Side effects of drugs –.034 –.204 –.014
4. Evaluation of pain –.075 –.189
5. Perceptions of pain –.115
6. Pain metre

In the open questions, the Finnish participants identified demented/unconscious (mentioned 15 times) and young children/elderly people (15 mentions) as the most difficult groups as regards assessment and management of pain. The Swedish group identified the same groups, demented/unconscious (43 times) and children/elderly people (29 mentions).

4 Discussion

The results show that there were significant correlations between extent of education and the prehospital personnel’s attitudes to pain management. There were differences among prehospital personnel in Helsinki and Stockholm, but there were also similarities. A main discrepancy was that the participants from Stockholm showed statistically significantly more hesitation to administer pain medication compared to the participants from Helsinki (Swedish mean 2.01 SD 0.539 vs. 1.67 SD 0.530, p < 0.001). This difference could be explained by the high percentage of RNs (89%) responding to the questionnaires in Stockholm, compared to only 30 percent in Helsinki. The RNs may have had better knowledge about pain and opioid analgesia, or the differences may have been due to organizational or cultural factors. The hesitation could also have been caused by the patients (e.g. elderly, less educated, male) being reluctant to report their pain because they were afraid that a pain complaint might distract the healthcare personnel from their real problem [21,24]. At present there are no studies revealing differencesinpain reportinginFinland and Sweden andfurther studies are neededto investigate why Swedish prehospital personnel hesitate to administer pain medication. Whether or not these differences mean patients in Helsinki are more likely to receive adequate pain relief needs to be further investigated.

A similarity between the prehospital personnel in Stockholm and Helsinki was the use of different strategies when assessing patients’ pain. This may indicate that they were aware of the difficulties in assessing pain. The participants identified demented/unconscious patients as the most challenging group to take care of in terms of pain assessment and management. Pain assessment in patients with dementia is known to be difficult and indicates the importance and needofcontinuous painmanagement education [25,26]. The results show that the Finnish participants had participated in education to a greater extent in the previous year (33% vs. 9%), and it is known that educational programmes improvepain managementintheED[27]. Whetherornot thisisthe same in the prehospital setting is not known, but the result of this study indicates it is. In this study the participants with less education hesitatedtoadminister pain medication more often than those who had received more pain education. A recent study showed that prehospital personnel felt that vital sign abnormalities were highly correlated with pain level. This association has never been proven. However, the study did not evaluate the educational level of the personnel [13]. The less education the personnel have, the more they disagree that analgesic medication facilitates the examination of the patient. Trials have suggested that opioid analgesic administration in patients with acute abdominal pain facilitates examination since it reduces the patient’s discomfort and pain [28,29]. Better knowledge of facts and evidence concerning pain management through education might explain our findings.

The result shows that the respondents hesitated to administer analgesics due to fear of side effects of the drugs (p < 0.01). Concern about adverse effects of opioids might contribute to the belief that patients prefer to cope with pain than with the side effects of drugs. Continuous medical education may be important in order to overcome hesitation related to fear of side effects when administering analgesics. In the prehospital setting, the healthcare personnel are empowered to administer pain medication according to their unit’s protocol without always consulting the emergency physician first. Pain protocols are useless if the personnel do not have the tools to judge the patient’s pain or they do not have an adequate knowledge base to make decisions about pain management. It is important to urge the patient to talk about his or her pain, since this can facilitate the assessment of the pain [29]. The less education the respondents’ have, the more they believe that a patient needs to be encouraged to talk about his/her pain. This may be a way to distract the patient from the pain instead of administering analgesic. However, whether or not this is true is not known and further studies are needed. In this study the male participants had significantly more stoic perceptions about need for pain medication than female participants, and the younger participants were more positive towards assessing the need for pain medication than the older ones. Whether and how this affects the management of pain in the prehospital setting is not answered in this study, but needs to be further investigated due to the goal of providing equal care in the Health Care organization.

4.1 Limitations

There are some limitations of the study to be considered when interpreting the results. One is the relatively low response rate of 20 percent (127/634) of the prehospital personnel in Stockholm. This was probably caused by differences in the distribution of the questionnaires, which may have caused a selection bias. Whether and how the selection bias affected the results is not known since the results to some extent indicated that there was no selection bias. The low response rate may also have caused non-response bias, meaning that the respondents’ answers in the questionnaire might differ significantly from what the non-respondents’ would have answered. However, the distribution of men and women among respondents and non-respondents was equal, which may have reduced the non-respondent bias to some extent. Another limitation may be the different sizes of the investigated groups (Finland n=66 vs. n=127). This may not have affected the results to a large extent since the groups were heterogenic according to age, gender and years as a clinician. However, there was also a difference between the two groups, namely the level of education among the personnel who answered the questionnaire. There were more RNs in the Swedish group with a higher medical education and this may have affected the results. The extent of this effect is not known but needs to be considered when interpreting the results. The differences between Finland and Sweden concerning organization, cultural matters and the level of education may have affected the results and need to be further investigated. However, it is believed that the health care systems of these two countries are relatively similar.

5 Conclusion

The results show that there were significant correlations between extentofpain management education and the prehospital personnel’s attitudes to pain management in the prehospital setting. Gender and age among the prehospital personnel also affected attitudes to pain management. The main discrepancy between the Swedish and Finnish personnel was that the participants from Stockholm showed statistically significantly more hesitation about administering opioid analgesia compared to the participants from Helsinki. Whether this was caused by organizational or cultural differences is not known and needs to be further investigated.

6 Implications

The results of the study highlight the need for continuous medical education(CME) for prehospital personnel.CME and discussions among the personnel may be a way to change the personnel’s attitudes concerning pain and pain management in the prehospital context. The results also reveal the need for deeper understanding of the prehospital personnel’s attitudes to pain; otherwise it will be difficult to improve patient care in this respect.

Highlights

  • We compared Swedish and Finnish prehospital personnel attitudes to pain management.

  • There is a correlation between extent of education and attitudes to pain management.

  • Gender and age affect the attitudes to pain management

  • Swedish prehospital personnel hesitates to administrate pain medication.


DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2015.05.001.



Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, 11883 Stockholm, Sweden. Tel.:+46 86161000; fax: +4686162933

  1. Author’s contributions: The planning and design of the study was conducted in collaboration between MC and LNM. The data collection was conducted by JHB in Sweden and LNM in Finland. The analysis was initiated by JHB and MC, VL and LNM assessed and finalized the analyses. JHB and VL drafted the manuscript, while MC and LNM reviewed the manuscript and participated actively throughout the writing. All the authors read and approved the final manuscript.

  2. Funding: No funding was received. Conflicts of interest

  3. Conflicts of interest: The authors have no conflicts of interest to declare.

Acknowledgements

The authors would like to acknowledge: Professor Sari Ponzer and Anne Edgren at Karolinska Institutet, Department of clinical science and education, Södersjukhuset, for their participation in translating the questionnaire.

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Received: 2014-08-26
Revised: 2015-01-24
Accepted: 2015-02-03
Published Online: 2015-07-01
Published in Print: 2015-07-01

© 2015 Scandinavian Association for the Study of Pain

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