Journal of Pain Management & Medicine

Knowledge of Pediatric Pain Assessment and Management between Pediatric Emergency Physician in Saudi Arabia: A Cross-Section-Quantitative Study

Ahmad Khobrani^1*, Ahmad AAL-Ibrahim¹, Muna Aljahany¹, Haya Hamdan Al-Anazi², Malak Mohammed Al- Shabi² and Ghuzlan Ahmed Zubaidi^{2 1}Department of Emergency, King Abdullah bin Abdulaziz University Hospital, Princess Nourah bint Abdurhman University,Riyadh, Saudi Arabia
²College of Medicine, Almaarefa University, Riyadh, Saudi Arabia
^*Correspondence: Ahmad Khobrani, Department of Emergency, King Abdullah bin Abdulaziz University Hospital, Princess Nourah bint Abdurhman University,Riyadh, Saudi Arabia, Email:

Received: 04-Jul-2022, Manuscript No. JPMME-22-17300; Editor assigned: 08-Jul-2022, Pre QC No. JPMME-22-17300 (PQ); Reviewed: 22-Jul-2022, QC No. JPMME-22-17300; Revised: 28-Jul-2022, Manuscript No. JPMME-22-17300 (R); Published: 04-Aug-2022, DOI: 10.35248/2684-1320.22.8.176

Introduction

Pain is an important public health problem and a common undertreated condition among children. It is a common entity causing unpleasant sensation that influences the nervous system. By definition, pain is an unpleasant emotional and sensory experience that can be associated with existing tissue damage or can be a consequence of such damage [1,2]. In general, approximately 40% of children and adolescents suffer from pain that occurs once per week, while 15-20% of children experience chronic pain [3,4]. Pain takes place due to a wide range of chronic conditions that involve the bone, joints, muscles, and abdomen.

Pain management is a critical component of pediatric medicine, and it encompasses pharmacological and non-pharmacological options as well as invasive approaches [5]. Inadequate management causes long-term consequences due to pain experience, which would eventually impact the emotional and psychological health of patients throughout their lives. Therefore, pain assessment should be meticulously performed, and this practice is effectively applied via monitoring the pain intensity [5]. However, pain evaluation and management remain highly dependent on the unique challenges in pediatric patients, including the child’s age, cognitive and communication skills, developmental levels, personal beliefs and previous pain experiences [6].

In Saudi Arabia, there no formal guidelines or protocols for the management of pediatric pain [7,8]. Concomitantly, the implementation of official protocols improves the outcomes of pain management on the national level [9,10]. Indeed, misconception of pain knowledge, methods of pain assessment and the ideal managemental approaches by healthcare professionals may represent an important barrier in pain management [11]. Importantly, there is accumulated evidence regarding the lack of adequate knowledge about pediatric pain management, and the proportions of patients who suffer from avoidable pain continue to increase [12-14]. Therefore, there is an urgent need to address this under-treated condition by identifying the current gaps in clinical practice. The aim of the present study is to assess the levels of knowledge, attitudes and practice of physicians working in a Pediatric Emergency Department (PED) regarding pain assessment and management. The results of the current analysis would help understand the gap in knowledge from a clinical perspective, and this would reveal the reasons of why pain is an undertreated and under-recognized entity.

Methodology

Study design and population

A cross sectional, survey-based study was conducted in Riyadh, Kingdom of Saudi Arabia during the period between 01 June and 31 December 2020. Saudi Arabia lies in Western Asia, making up most of the Arabian Peninsula and is the second largest sovereign state in the Arab world, with a growing population of 34.14 million. Riyadh is the capital of the Kingdom, and it is the largest city in the Arabian Peninsula. This study was conducted by fourth year medical students of Almaarefa University under the supervision and guidance of senior PEM consultants at KAAUH. Eligible participants included physicians (consultants, specialists, fellows, and residents) working in PEDs across the Kingdom. Participants of any nationality and both genders were eligible. Non-physicians (nurses, respiratory therapists, general physicians) and pediatric physicians working in the pediatric department were excluded. All healthcare professionals working in the PED were included; therefore, no sampling technique was utilized.

Study instrument

A structured questionnaire was developed based on previous studies [15-18]. The survey was uploaded on a specifically designated online platform for data collection (SurveyMonkey). The research team shared the survey link with pediatric emergency physicians via social media platforms and email messages. The questionnaire consisted of three sections: 1) Demographic and practice-related data, such as gender, age, years of practice, participation in a formal courses and workshops for pain assessment, etc.; 2) knowledge regarding pediatric pain assessment: 12 true or false questions to assess participants’ knowledge levels plus four items graded on a four-point Likert-scale (from strongly disagree to strongly agree); 3) attitudes and beliefs towards pediatric pain assessment: 12 items to assess participants’ responses (from strongly disagree to strongly agree). More details about the included items are demonstrated in Annex 1.

Data analysis

Each item in the knowledge domain (for the items with a “true” or “false” response) was coded as 1 (correct) or 0 (incorrect). Regarding the items with a four-point Likert grade, true responses were considered as “strongly agree” or “agree”, whereas false responses were considered as “strongly disagree” or “disagree”. Knowledge scores were computed by summing up the correct responses of the 16 items in the knowledge domain. Therefore, the raw knowledge score ranged between 0 and 16, with higher scores indicating better knowledge. To be easily interpretable, raw scores were transformed to percentage score using the following formula: percentage score=(raw score*100)/16. These percentage scores were expressed as median and interquartile ranges, and they were integrated into the subsequent analysis. The difference in knowledge scores was assessed using an independent-samples Kruskal-Wallis test. Tests of pairwise comparisons were presented as the difference in knowledge between pairwise groups and significance values were adjusted by the Bonferroni correction for multiple tests. Besides, data regarding the correct responses of each individual item in the knowledge and beliefs domains were expressed as frequencies and percentages. Tests of probability were considered statistically significant at p<0.05.

Ethical considerations

The research group provided a verbal explanation of the study objectives and the collected data, a verbal consent to participate was obtained from each physician. Additionally, a written informed consent was collected. Data was kept confidential and no personal information was shared with a third party an IRB approval from local research committee of Almaarefa University.

Results

Demographic and practice-related characteristics

Initially, 139 responses were obtained on the online platform. The primary outcome variables were missing in the records of 56 participants. Therefore, the complete responses of 83 physicians were ultimately analyzed (accounting for a response rate of 59.7%). These included 25 residents (30.1%), 19 specialists (22.9%), 10 fellows (12.0%) and 29 consultants (34.9%). The majority of participants were males (62.7%) and aged 25-40 years (71.1%). Almost half of the participants had an experience of 1-5 years in the PED (42.2%). More than one-third (37.3%) of the respondents declared that they had participated in a formal course or workshop intended for pediatric pain assessment and management during training. The majority of healthcare professionals (90.4%) indicated that they are aware about pediatric pain assessment scales and tools. About 66% of the respondents mentioned that dedicated policies and guidelines on pediatric pain assessment and management were used by the hospital emergency department (Table 1).

Table 1: Demographic and practice-related characteristics of participants.

Demographic and practice-related differences between the occupational groups

Higher proportions of residents and fellows had 1-5 years of experience (72.0% and 70.0%, respectively), while most specialists had 5-10 years of experience (42.1%) and most consultants had 10-20 years of experience (55.2%). Between-group differences in experience levels were statistically significant (p<0.0001). In addition, the difference in age was statistically significant (p<0.0001), where most residents and fellows aged 25-30 years (44.0% and 60.0%, respectively), most specialists aged 5-10 years (42.1%) and the majority of consultants aged 10-20 years (55.2%). Self-reported awareness about pediatric pain assessment scales and tools differed significantly (p=0.024), with the highest awareness among the consultants (100%), followed by specialists (94.7%), fellows (90.0%) and residents (76.0%, Table 1).

Participants’ knowledge regarding pediatric pain assessment

The median (IQR) percentage score of respondents’ knowledge was 62.5 (50.0-75.0). The median (IQR) knowledge score was 56.3 (37.5-68.8) for residents, 62.5 (56.3-68.8) for specialists, 62.5 (42.2-87.5) for fellows and 68.8 (62.5-75.0) for consultants (Figure 1). The difference in knowledge scores between these categories was statistically significant (p=0.046). The analysis of pairwise comparisons showed significantly lower knowledge scores among residents compared to consultants (difference=-18.12, p=0.033, (Table 2).

Figure 1: A boxplot depicting percent knowledge scores of the different categories of healthcare professionals.

Table 2: Pairwise comparisons of the occupational groups of healthcare professionals in terms of their knowledge scores about pediatric pain assessment.

Regarding the outcomes of individual items, the detailed categorical responses of healthcare professionals regarding their knowledge are depicted in (Figures 2-4), and the percentages of correct answers in each occupational group are demonstrated in Table 3 and Table 4. The highest percentages of correct answers were reported for the withdrawal symptoms after sudden interruption of opioids (True, 85.5%) and the reliance of healthcare professionals on pain assessment by children’s parents because children under 11 cannot reliably report pain (False, 81.9%, Table 3). The lowest percentages of correct answers were related to the statements indicating that morphine has a maximum dosage limit above which no additional pain relief could be attained (False, 30.1%) and patients who can be distracted from pain would not experience severe pain (False, 31.3%, Table 4). Statistical differences between the occupational groups existed in three statements. Consultants provided correct answers more frequently than other groups for the items concerning that pain distraction would not indicate severe pain (p=0.008), whereas fellows and consultants had correctly perceived that opioids may be used even if the cause of pain is unknown during the assessment (p=0.004). Additionally, 70.0% of fellows disagreed or strongly disagreed that about one-quarter of patients receiving narcotics around the clock become addicted (p=0.027, Table 4).

Figure 2: participants’ responses to the “true or false” questions for the assessment of their knowledge regarding pediatric pain assessment. Note: () True, ( )False

Figure 3: participants’ responses to the Likert-graded questions for the assessment of their knowledge regarding pediatric pain assessment. Note: ( ) Strongly Agree, ( )Agree, ( ) Disgree, ( ) Strongly Disgree.

Figure 4: participants’ responses to the Likert-graded questions for the assessment of their attitudes and beliefs regarding pediatric pain assessment. Note: ( ) Strongly Agree, ( )Agree, ( ) Disgree, ( ) Strongly Disgree.

Table 3: Highest percentages of correct answers to items that assess participants’ knowledge regarding pediatric pain assessment and management.

Table 4: Lowest percentages of correct answers to items that assess participants’ knowledge regarding pediatric pain assessment and management.

Participants’ attitudes and beliefs towards pediatric pain assessment

The majority of healthcare professionals agreed or strongly agreed that the most accurate judge of pain intensity comes from the patient (95.0%). Furthermore, 86.3% of them have correctly disagreed or strongly disagreed that narcotics should not be given to the pediatric population because they can cause respiratory depression (Table 5). As demonstrated in Table 6, the lowest percentage of correct answer was reported for the disagreement about pain estimation by a medical practitioner or a registered nurse as a valid measure of pain because the patient provides a self-reported measurement (32.5%). Residents (8.7%) and fellows (22.2%) reported the lowest percentages of correct answers for such an item, and the difference to other categories was statistically significant (p=0.012). Similarly, only 37.5% of the respondents disagreed or strongly disagreed that diversional activities are indicated rather than actual pain medications because children cry all the time. The majority of consultants (62.1%) provided correct responses, and this was significantly higher than those of other categories (p=0.006), (Table 6).