Critical care nurses' use of non-pharmacological pain management methods in

Egypt
,1
⁎
Nahla Shaaban Khalil
Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University, Egypt

ARTICLEINFO ABSTRACT
Keywords: Aim: To examine Critical Care Nurses’ Practices of Non-pharmacological Pain Management Interventions in Egypt.
Critical care nurses Methods: Descriptive exploratory design was utilized in the current study with a convenience sample of 60 critical care nurses
Practices working in three intensive care units at Al Manial university Hospital, Egypt. The questionnaires included; nurses' demographic
Non-pharmacological
data, non-pharmacological pain management checklist utilizing likert scale, and perceived barriers to the practice of non-
Pain
pharmacological pain management interventions. Comparisons were made between the nurses' responses about practices of
Management interventions
non-pharmacological pain management and selected demographic variables.
Results: The non-pharmacological methods used by few nurses were putting the patient in comfortable position, communication
with the patients and their families and using comfort devices. Moreover, nurses’ education, work experience and the work area
showed no statistically significant association with the few of non-pharmacological pain relief interventions they used. Finally,
the barriers that hindered non-pharmacological pain practices from being used by nurses were lack of nurses' knowledge, lack
of time, nurses' workload and patients' instability.
Conclusion: Most of the critical care nurses didn't apply non-pharmacological pain interventions practices with their patients in
pain. The approaches used by a few nurses were changing position and the use of some comfort devices. Moreover, no significant
correlations were found between nurse' application of non-pharmacological pain measures and either educational level and work
area.
Recommendations: Barriers need to be explored and continuing education is needed to eliminate some of these perceived
barriers. Moreover, theoretical and practical non-pharmacological pain management interventions should be incorporated in
nursing curricula.

1. Introduction Furthermore, inappropriate acute pain management may potentiate

Pain is one of the principal complaints of many patients seen in critical care
and emergency units. Although appropriate relief from pain is a human right
(Sallum, Garcia, & Sanches, 2012; Souza, da Costa, Barbosa, and Pereira,
2013), nurses' knowledge and performance of pain assessment, relief, and
monitoring at these units is still rare. The paucity of studies hinders the spread
of knowledge concerning the significance of pain assessment, feasible
catecholamine release, which causes rapid pulse, elevated blood pressure, and
increased myocardial oxygen consumption demands, causing myocardial
ischemia. These changes may compromise the clinical picture of patients in
emergency situations (Dunwoody, Krenzischek, Pasero, Rathmell, &
Polomano, 2008). Although there is more evidence about the reality of pain in
the ICU, pain remains undertreated for many patients (Topolovec-Vranic et al.,
2010; Van Gulik et al., 2010). Therefore, there is a need to search for other

⁎ Faculty of Nursing, Cairo University, Giza, Egypt E-mail

address: nahlakhalil28@yahoo.com.
1 Home address: 1 Mohamed Hassan, Talbia, Giza.

https://doi.org/10.1016/j.apnr.2018.09.001
Received 14 January 2015; Received in revised form 1 July 2018; Accepted 16 September 2018
0897-1897/ © 2018 Elsevier Inc. All rights reserved.
management control techniques, and overcoming the perceived hindrances to strategies to maximize patients' comfort and induce pain relief in critical care
the practice of evidence-based nursing (Calil & Pimenta, 2010). settings (Lavery, 2004).
N.S. Khalil
In this issue, non-pharmacological approaches are interesting strategies to
explore. Non-pharmacological interventions are therapies and measures that do
not involve taking medication and are used in common practice by nurses—
e.g., breathing exercises, massage,
positioning, and music therapy (Boldt, Eriks-Hoogland, Brinkhof, Bie, and von
Elm, 2011), as well as diet, exercise, relaxation techniques, and prayer (Tracy
et al., 2005). Moreover, using a calming voice, providing information, and deep
breathing were the most frequently used practices during painful procedures
(Faigeles et al., 2013).
Non-pharmacological pain intervention measures used by critical care
nurses aim to treat the affective, cognitive, behavioural and sociocultural
dimensions of the pain (Yavuz, 2006). They are likely to complement
pharmacological interventions and may provide alternative therapeutic
measures to treat symptoms of diseases, including pain (Bausewein, Booth,
Gysels, and Higginson, 2009). These measures increase the tolerance of
experienced pain, decrease physical stress, reduce the feeling of weakness, and
reduce the use of analgesic drugs (Yıldırım, 2006).
Although non-pharmacological measures such as deep breathing, massage,
music therapy, and positioning were noted to be used by critical care nurses for
the management of pain in the ICU (Faigeles et al., 2013; Tracy et al., 2005),
scarce studies have attended to their effectiveness at pain reduction in critically
ill patients (Erstad et al., 2009). “One non-pharmacological pain relief
intervention is music therapy. It decreases pain intensity and the frequency of
analgesic drug administration in postoperative ICU patients during
mobilization and following percutaneous coronary interventions (Chan, 2007).
Moreover, two previous studies investigated the effect of listening to music on
pain and recorded remarkable results (Cooke, Chaboyerw, Foster, Harris, and
Teakle, 2010; Iblher et al., 2011).
Another non-pharmacological nursing intervention for pain management
tested in the ICU is ice therapy. The most common implementation is ice pack
applications, which have been mentioned by many authors to relieve post-
operative pain (Algafly & George, 2007), which has been explained by the fact
that application of local ice packs blocks nerve conduction velocity and
increases pain tolerance. Recently, Khalil (2017) investigated the effect of
applying local ice packs for 10 min on reducing arterial puncture pain and
recorded remarkable decrease in pain scores among the experimental group.
As well, deep breathing has also produced remarkable relief of pain when
used in combination with analgesics following chest tube removal compared
with those who only received an analgesic (Friesner, Miles Curry, and
Moddeman, 2006). Another non-pharmacological pain management
intervention is applying body massage. It relieves the mind and muscles and
increases the pain threshold (Karagz, 2006). Because non-pharmacological
practices are useful for pain relief in the ICU, and because they are cheap,
feasible, and safe, many nurses can apply them with ease (Erstad et al., 2009).
To this day, few non-pharmacological approaches for pain relief have been
investigated in an ICU context (Lindquist, Tracy, Savik, and Watanuki, 2005;
Tracy et al., 2005).
The utilization of such complementary care approaches relies on critical
care nurses' knowledge, experience, and training (Tagharrobi, Kermanshahi &
Mohammadi, 2016). Additionally, Lindberg and Engström (2011) found that
critical care nurses believe that pain is mainly handled with drug therapy, but
when this type of treatment is not adequate, they try various non-
pharmacological approaches. Indeed, a large number of nurses were found to
be eager to learn more about less traditional interventions for pain control
(Tracy et al., 2005).
Moreover, the nurse has a responsibility to find out the experience of pain
and initiate pain relief measures that help patients learn to cope with it.
However, guidelines for use of these measures are commonly inadequate or
absent. Nurses can educate patients and their families to utilize non-
pharmacological measures to relieve pain, such as relaxation, massage, and
heat/cold applications (Horgas & Yoon, 2008; Williams, Davies, & Griffiths,
2009). As a result, the dosage of analgesic drugs needed can be reduced,
Applied Nursing Research 44 (2018) 33–38
decreasing the side-effects of the treatment and reducing healthcare costs by
reducing doctor visits and reliance on costly medications. Therefore, the aim of
this study was to describe current critical care nurses' use of non-
pharmacological pain management interventions and perceived barriers to the
use of such approaches.
2. Aim of the study
The aim of this study was to examine critical care nurses' use of
nonpharmacological pain interventions methods and perceived barriers to the
use of non-pharmacological pain Interventions methods as reported by critical
care nurses.
3. Material and methods
3.1. Research design
A descriptive exploratory design was utilized in the current study.
3.2. Sample
All critical care nurses working at selected medical, neurosurgery, and
emergency critical care units were recruited to participate in the study.
3.3. Research questions
1. What methods of non-pharmacological pain interventions do nursesuse in
practice?
2. What is the relationship between nurses' practices and nurses' background
regarding non-pharmacological pain interventions?
3. What are the perceived barriers that prevent nurses from using
nonpharmacological interventions with their patients in pain?
3.4. Data collection and instruments
Background data were collected that covered critical care nurses' age, sex,
educational level, working areas, and years of experience in the ICU (tool 1).
A non-pharmacological pain management checklist was utilized to investigate
the frequency of critical care nurses' use of non-pharmacological pain
interventions methods with their patients in pain. This checklist was developed
and created by the researcher after a literature review. It consisted of a list of
16 interventions methods related to non-pharmacological pain management
(tool 2).
The checklist was reviewed and validated by a panel of experts in critical
care nursing and pain management. The nurses were asked to complete that
checklist and mention the frequency of use of nonpharmacological pain
interventions methods on a Likert scale that ranging from frequently to never
use. Test and retest were carried out, and the correlation coefficient was 0.7.
Finally, data related to nurses' self-reported barriers to the use of non-
pharmacological pain interventions were collected (tool 3).
3.5. Pilot study
A pilot study was carried out on seven critical care nurses to test the
feasibility, objectivity, and applicability of the study tools. Based on the results
of the pilot study, needed refinements and modifications were made.
3.6. Ethical consideration and protection of human rights
After the approval of the Institutional Review Board for the Protection of
Human Rights at the Faculty of Nursing, Cairo University was obtained, the
nurses were contacted, and each potential subject in the study was informed
about the purpose, procedure, benefits, and nature of the study. They ensured
that participation in this study was voluntary, the confidentiality and anonymity
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of each subject were assured through coding of all data, and the subjects had Most of the nurses didn't perform non-pharmacological pain interventions
the right to withdraw from the study at any time without any rationale. Then, practices. Moreover, no statistically significant differences were found among
their written consent was obtained. them by their area of work (see Table 3).
Table 1
Demographic characteristics of the participants (n = 60).
3.7. Research procedures
Sample variables Study sample n = 60

The current study was conducted in two phases. Sex

Male
10 16.7
3.7.1. Preparation phase Female 50 83.3
This phase was concerned with constructing, testing, and piloting the data Age
collection tools. In addition, the managerial arrangements were made to conduct 20–25 28 46.7
the current study. Nurses who agreed to participate in the study were 26–30 16 26.7
interviewed individually by the researcher to explain the nature and purpose of 31–35 4 6.7
the study, and finally, written consent was obtained. 36–40 8 13.3
41–45 4 6.7
Mean + SD 28.47 ± 6.905
3.7.2. Implementation phase
Data were collected from October 2013 to October 2014. The researcher Educational level
visited the selected critical care and intensive care units daily during morning Bachelor 13 21.7
Technical 18 30
and afternoon shifts. Each nurse was interviewed for 15–20 min to fill out his
Secondary school diploma 29 48.3
or her background data. Then, the nurses were asked to complete the non-
Years of experience in nursing
pharmacological pain Interventions checklist and mention the frequency of use
1–5 28 46.7
of non-pharmacological pain Interventions methods on a Likert scale ranging
6–10 13 21.7
from frequently to never used. Later, the nurses were asked to state the barriers
11–15 5 8.3
that hindered the implementation of non-pharmacological pain interventions
16–20 7 11.7
Practices (if any).
21–25 7 11.7
Mean ± SD 9.133 ± 7.338
3.8. Data analysis Years of experience in ICU
1–5 31 51.7
Simple descriptive statistics were utilized. The data were analysed using 6–10 13 21.7
SPSS version 20 by using frequency and percentage distribution. Moreover, the 11–15 3 5
chi-square test was utilized to explore the correlation between different 16–20 6 10
categories of nurses in relation to their educational levels, years of experience, 21–25 7 11.7
and areas of work. Mean ± SD 8.208 ± 7.511
Working areas
Medical critical care unit 32 53.4
4. Results
Emergency care unit 14 23.3
Neurosurgery unit 14 23.3
4.1. Demographic characteristics of the subjects
4.4. Perceived nurses' barriers regarding applying non-pharmacological
Out of 60 participating critical care nurses, most of them were female interventions practices with their patients
(83.3%), and their age was between 20 and 25 years with a mean of 28.4 years.
Regarding educational level, nearly half of nurses (48.3%) were secondary More than half of the subjects (75%, 63.3%, and 58.3%, respectively)
school diploma graduates, while the rest were technical and baccalaureate perceived that the factors that might affect their abilities to use non-
nurses (30% and 21.7%, respectively). In relation to years of experience in pharmacological interventions practices were lack of education, nursing
nursing and in the ICU, approximately half of subjects (46.7% and 51.7%, workload, and patient instability, e.g., unstable hemodynamic (see Fig. 1).
respectively) had mean years of experience of 9.13 and 8.20, respectively.
Finally, more than one-third of subjects (38.3%) worked in the medical critical
units (see Table 1). 5. Discussion

The present study described the current nurses' performance of

4.2. Comparison of nurses' practices by educational level
The majority of nurses didn't apply non-pharmacological pain management
approaches. Moreover, the only non-pharmacological interventions used by a
few nurses (6.7%) were putting the patient in a comfortable position. In
addition, no statistically significant differences were found among nurses'
practices of non-pharmacological pain interventions practices by their
educational level (see Table 2).
4.3. Comparison of nurses' practices by work area
nonpharmacological pain management approaches in different critical care
units at Cairo University Hospital as reported by nurses through completing the
non-pharmacological pain management checklist and stating the frequency of
use of non-pharmacological pain management methods on a Likert scale
ranging from frequently to never use. Although the sample was smaller than
desired, valuable insights about nurses' use of non-pharmacological methods
were discovered.
In the current study, the majority of nurses didn't apply most of the list of
non-pharmacological pain management approaches; the only non-
pharmacological approach used by a few nurses was putting the patient in
comfortable position. This study finding is supported by Basak (2010) and
Matthews and Malcolm (2007), who reported that pain management practices,
were infrequently performed by nurses and indicated that nurses may not have
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adequate knowledge regarding nonpharmacological methods. Furthermore, Table 3

Ojong, Ojong-Alasia, and Nlumanze (2014) revealed that although the nurses postoperative period such as massage and relaxation techniques. On the other
had good knowledge of pain assessment and management, there were still some hand, this finding is partially contradicted by Wang et al. (2008), who revealed
shortcomings in nurses' practice of pain assessment and management. Along the efficiency of non-pharmacological pain management approaches such as
the same lines, Bicek (2004) revealed that half of nurses didn't audio-visual distraction and routine psychological intervention, which were
Table 2
Nurses' reported practices of the non-pharmacologic pain management interventions by their educational level (n = 60).

Put the patient in comfortable position 2 3.33 1 1.66 1 1.66 1.1 0.06
Apply hot or cold local packages 1 1.66 0 0 0 0 0.4 0.01
Encourage patient to drink herbal drinks 0 0 0 0 0 0 0 0
Apply breathing techniques 0 0 0 0 0 0 0

Conduct hydrotherapy (partial bath) 1 1.66 0 0 0 0 0.8 0.01

Apply movement restriction-resting 0 0 0 0 0 0 0 0
Communicate with patient, &family 1 1.66 0 0 1 1.66 0.4 0.03
Use therapeutic touch 0 0 0 0 0 0 0 0
Apply massaging techniques 0 0 0 0 0 0 0

Distract the patient by listening to light music/watching TV 0 0 0 0 0 0 0 0

Help the patient to pray 0 0 0 0 0 0 0 0
Apply guided imagery technique 0 0 0 0 0 0 0 0
Provide quiet and comfortable room 1 1.66 0 0 0 0 0 0.01
Use comfort devices (special mattress) 1 1.66 1 1.66 0 0 0.4 0.03
Counseling/Provides education for patient and his family 1 1.66 0 0 0 0 0.4 0.01
Acupuncture/acupressure/reflexology 0 0 0 0 0 0 0 0

use non-pharmacological measures, and the most common therapy used was a
change of position (53.2%). On the other hand, this finding is contradicted by
earlier studies such as Polkki, Vehvilainen-Julkunen, and Pietila (2001), who
revealed that 57% of nurses used non-pharmacological therapies routinely.
In the present study, a few nurses in the different critical care units applied
other non-pharmacological approaches such as communication with the
patients and their families and used comfort devices, such as air and water
mattresses, which are aimed to provide comfort to very obese and very thin
patients and those who are prone to pressure sores, air rings, pillows (3.33%),
and partial baths as a part of morning care not intended for relieving pain
(1.6%). This finding is contradicted by Hg he, Polkki, Vehvilainen-Julkunen
and Pietila (2005), who studied Chinese nurses' use of non-pharmacological
methods for relieving children's postoperative pain and found the most
commonly used nonpharmacological methods were giving preparatory
information, comforting/reassurance, creating a comfortable environment,
distraction, and positioning. On the other hand, the non-pharmacological pain
management approaches that weren't applied by nurses in the current study
were breathing techniques, massage techniques, distracting the patient with
light music, applying guided imagery/visualization techniques, providing a
quiet and comfortable room, patient education, and encouraging patients to
drink herbal drinks. A possible interpretation of this finding is that nurses have
too great a workload and too little time, a lack of knowledge, and unstable
patients.
The current study finding is consistent with Elshamy and Ramzy (2011),
who studied the impact of a “Postoperative Pain Assessment and Management
Monitoring Program on Surgical Nurses' Documentation, Knowledge,
Attitudes, and Patients' Satisfaction at Mansoura University Hospitals” and
revealed limited nurses' notes pertinent to the application of some non-
pharmacological interventions in the
used by the nurses in a paediatric department.
Many variables and factors may have relevance to nurses' applying non-
pharmacological pain interventions practices, such as years of experience and
educational level—i.e., the higher educational level and the more years of
experience, the better the knowledge and practice. However, this study finding
unexpectedly revealed that nurses' education, work experience, and the unit in
which they worked showed no statistically significant association with the few
non-pharmacological pain relief approaches they used. However, the present
study revealed that a few nurses with more experience (over 20 years) used
more nonpharmacological pain interventions practices than those with 2–4
years of experience.
This finding may have relevance, as most of the nurses in the current study
were younger, with lower educational level (secondary nursing school
graduates) and fewer years of experience. This finding would be in accord with
Lui and Fong (2008), who revealed that there is no substantial relationship
between the level of education and practice score of nurses in regard to
management of pain. As well, Wong (2012) found no statistically significant
differences among the studied subjects' age and years of experience in relation
to practice scores of non-pharmacological management approaches.
On the other hand, many previous studies contradicted the present findings,
such as Wilson (2007), who stated that nurses' education and clinical experience
contribute to the knowledge necessary for competency in pain management.
Similarly, this finding contradicts Ali, Ibrahim, and Mohamed (2013), who
revealed the nurses had satisfactory attitudes and performance regarding
applying non-

Frequency distribution and average mean of reported nurses' practices of the non-pharmacologic pain management interventions by their area of practice.

N % N % N %

Put the patient in comfortable position 2 3.33 1 1.66 1 1.66 1.1 0.06

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N.S. Khalil Applied Nursing Research 44 (2018) 33–38

Apply hot or cold local packages 1 1.66 0 0 0 0 0.4 0.01

Conduct hydrotherapy (partial bath) 1 1.66 0 0 0 0 0.4 0.01
Communicate with patient& family 1 1.66 0 0 1 1.66 0.4 0.03
Provide quiet and comfortable room 1 1.66 0 0 0 0 0.4 0.01
Use comfort devices (special mattress, ring, pillow) 1 1.66 1 1.66 0 0 0.4 0.03
Provides education for patient and his family 1 1.66 0 0 0 0 0.4 0.01

Fig. 1. Percentage distribution of barriers to the utilization of non-pharmacological pain management interventions as reported by the nurses (n = 60).
Note: more than one barrier was reported by one nurse.
pharmacological pain management approaches. As well, Olmstead, Scott,
Mayan, Koop, and Reid (2014) and Stanley and Pollard (2013) recognized that
nurses' experience is influential in the management of pain, and older nurses are
more likely to use non-pharmacological techniques than younger nurses.
Furthermore, they found a statistically significant correlation between nursing
experience and knowledge of pain management techniques. Nurses with more
years of nursing experience were found to have a higher level of knowledge on
pain management compared with those with fewer years of nursing experience
(Stanley & Pollard, 2013).
5.1. Nurses' perceived barriers to applying non-pharmacological pain
interventions practices
stated that there were 13 potential barriers to pain assessment and management,
of which the four most frequently mentioned by nurses were patients'
instability, patients' inability to speak, and nurses' workload. Moreover, few
nurses are acquainted with evidence-based guidelines for pain relief measures.
6. Conclusion
Most of the critical care nurses didn't apply non-pharmacological pain
interventions practices with their patients in pain. The approaches used by a few
nurses were changing position and the use of some comfort devices. Moreover,
no significant correlations were found between nurses' application of non-
pharmacological pain measures and either educational level or work area.
Finally, the frequently reported barriers by nurses were inadequate knowledge,
inadequate time, nurses' workload, patients' instability, and patients' inability to
communicate. Barriers need to be explored and handled properly to eliminate
them.

In the present study, the frequent barrier that prevented critical care nurses
from applying non-pharmacological pain management approaches was
inadequate knowledge and lack of education. This finding is congruent with
Thomas (2009) and Basak (2010), who revealed that few nurses apply non-
pharmacological methods to reduce pain. This indicates that nurses may not
have adequate knowledge regarding nonpharmacological methods.
Additionally, this finding is consistent with the findings of an earlier study by
Lui et al. (2008), who showed that nurses have inadequate knowledge about
non-pharmacological interventions for patients complaining of pain.
Other reported barriers that prevent critical care nurses from applying non-
pharmacological approaches to pain management are lack of time and nurses'
workload. This finding is congruent with Morgan (2012) and Wang et al.
(2008), who revealed that nurses perceived time as one of the hindering factors.
The time required to apply non-pharmacological approaches is long,
discouraging most nurses from applying them, even if they are supportive of
their application.
The other barriers perceived by more than half of the studied sample that
may affect their abilities to apply non-pharmacological pain management
approaches were patients' instability (e.g., unstable hemodynamic), lack of
availability of pain management equipment, and patients' inability to
communicate. The current finding is supported by Kizza (2012), who showed
that most nurses perceived a lack of availability of pain assessment tools and
patients' inability to communicate as barriers to the application of non-
pharmacological pain management approaches. Finally, Rose et al. (2011)
7. Recommendations
- Nurses and patients need to understand non-pharmacological pain
management interventions.
- Barriers need to be explored and continuing education is needed to
eliminate some of these perceived barriers.
- Theoretical and practical non-pharmacological pain management methods
should be incorporated in nursing curricula.
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