Pain assessment by emergency nurses at triage in the emergency department: A qualitative study

Abstract

Aims and objectives: To investigate the assessment of pain intensity in the specific context of triage.

Background: Acute pain affects most patients admitted to emergency departments, but pain relief in this setting remains insufficient. Evaluation of pain and its treatment at the time of patient triage expedites the administration of analgesia, but may be awkward at this time-pressured moment. The assessment of pain intensity by a validated pain scale is a critical initial step, and a patient's self-reporting is widely considered as the key to effective pain management. According to good practice guidelines, clinicians must accept a patient's statement, regardless of their own opinions.

Design: A qualitative methodology rooted in interactionist sociology and on the Grounded theory was used to provide an opportunity to uncover complex decision-making processes, such as those involved in assessing pain.

Methods: A sociologist conducted semi-structured interviews during the 2013-2014 winter months with twelve nurses and trained in the use of an established protocol, focusing on the assessment of pain intensity. The interviews were recorded, fully transcribed and analysed.

Results: The most frequently used pain scale was the Verbal Numerical Rating Scale. Discrepancies between self-assessment and evaluation by a nurse were common. To restore congruence between the two, nurses used various tactics, such as using different definitions of the high-end anchor of the scale, providing additional explanations about the scale, or using abnormal vital signs or the acceptance of morphine as a proof of the validity of severe pain ratings.

Conclusions: Nurses cannot easily suspend their own judgement. Their tactics do not express a lack of professionalism, but are consistent with the logic of professional intervention.

Relevance to clinical practice: This article presents triage nurses' reality in a time-pressured environment, and understanding this conflict may outline new educational targets to further improve pain management in ED.

Keywords: Grounded theory; emergency department; nurses practice; pain assessment; qualitative analysis; triage nurses.