To our knowledge, this is the first study investigating prehospital acute pain knowledge, attitude and practices in an African setting and therefore the findings will be valuable in terms of making recommendations for pain education and further research.
Knowledge and attitudes regarding pain:
Our findings show that there are significant gaps in knowledge and attitude regarding pain in this cohort of prehospital providers. Research investigating acute pain KAP in Africa and around the world are more commonly conducted in hospitals among nurses and other HCPs, limiting comparison with the present study results. Given the vast differences between nursing curricula and the curricula for prehospital practitioners in South Africa, variances between the in-hospital and out-of-hospital setting and the fact that the questionnaire used was only face validated, makes direct comparison difficult and restricted.
The low scores obtained by the respondents in the present study are similar to those reported in studies conducted among nurses and other HCPs from various countries including the African region (41,42,51,52,43–50) Studies from Northern America (53–55), Norway (56) and Australia (57), found substantially higher (72% to 79%) knowledge and attitudes scores among nurses. Still, these studies recommend targeted pain education to overcome specific areas of knowledge and attitude deficits, notably pharmacological pain, pain assessment and non-pharmacological pain management approaches along with regular in-service pain education (53,55,57). Research among nurses has shown that knowledge and attitudes regarding pain predict pain management practice, with attitudes proven to contribute more to variances in pain management practices than knowledge (58). Additionally, adequate pain knowledge and favourable pain attitudes among nurses has also been found to correlate positively with patient satisfaction (53). Although pain education is paramount to changing attitudes and improving pain knowledge, the opinion of some is that education alone may not suffice (54). In addition to pain education, organizational culture must promote effective pain management practices, provide leadership and support, encourage a culture of continuous learning and promote interdisciplinary teamwork (54).
Factors influencing knowledge and attitudes regarding pain:
Our findings show that the level of qualification is a key factor influencing provider knowledge and attitudes regarding pain. The relationship between the level of qualification and knowledge and attitudes regarding pain has been confirmed by many international studies (47,50–52,54,56,59,60). However, the effect of years of experience on KAP scores is uncertain with many differing findings across other studies (46,47,53,54,56,59,60). As would be thought, prior pain education usually results in higher knowledge and attitudes regarding pain scores (52,53) yet our findings echoed that of an Ethiopian study by Germossa et al. (42) which showed higher scores amongst those not having attended further pain education.
Gaps in pain knowledge, attitudes and pain management practices:
When comparing the percentage of correct responses, gaps in knowledge and attitudes regarding pain can be identified, showing overall poor to average basic pain and pain physiology knowledge and attitudes. A high proportion of respondents agreed that pain assessment using a pain assessment tool is necessary, and allows for quick and easy pain measurement, and even that the patient is the best judge of pain severity. In contrast, a surprisingly high proportion (40%) of respondents believed it to be appropriate to administer sterile water to test whether the pain is real, and almost 40% believed that pain relief should not be provided if (in their opinion) the condition is not painful. Despite evidence indicating that vital signs are not a reliable indicator of pain severity (61), about 70% of respondents believed the contrary. Further, more than 65% of respondents believed that their prior experience dealing with patients in pain, allows them to score pain more accurately than patients themselves. The above demonstrates highly questionable knowledge and attitudes regarding pain assessment and indicators of pain severity.
Although most respondents indicated that non-pharmacological approaches to pain management like splinting are effective methods to assist pain relief, answers to other statements related to non-pharmacological approaches like distraction and emotional support from parents were less positive. Most were correct with regards to pharmacological pain management, however, more than 70% held the belief that infants less than 6 months cannot tolerate opioids (poor performance on this item must be considered in terms of the scope of many practitioners limiting their familiarity with infants).
Understanding of the influence of culture and spirituality on pain experience and expression was poor, despite strong evidence that culture, ethnicity and spirituality plays a significant role in both pain expression and pain behaviour, making pain behaviour a poor indicator of pain severity (62). These misconceptions were further evident in the case scenarios. Respondents considered behavioural indicators of pain more important than self-reported pain. Suggesting a lack of trust in patients to accurately self-report pain. Further, pain management practices described by respondents for the two case studies suggest that the patients will not receive ideal pain relief during the prehospital phase suggesting deficient pain management practices. The practice of administrating sterile water (placebo) to test whether the pain is real, is questionable and likely a violation of the ethical principles (63).
As mentioned, knowledge deficit and practitioners’ perceptions, beliefs and attitudes are barriers to pain assessment and management frequently highlighted in the literature (13,18,21,22,64). The inadequacies of pain knowledge in emergency care providers have been attributed to limited focus during initial training, as well as the lack of continuous pain education (13,18,21,22,64). The extent of pain education during the initial training of emergency care providers in SA is hard to gauge and varies between training institutions and level of qualification. Nevertheless, all levels of emergency care providers are qualified to provide analgesia in some form. It is imperative that initial training of emergency care providers in South Africa incorporates the topic of pain with pain capabilities specified to include competency in pain assessment, non-pharmacological and scope-specific pharmacological pain management.
Educational interventions:
A 2018 study by Germossa et al. (42) showed a significant increase in the mean percentage (41.4% to 63%) for the KASRP scores obtained by nurses after an educational intervention, suggesting that educational initiatives are effective in improving knowledge and attitudes regarding pain. The study further found that nurses with no previous in-service training on pain obtained significantly higher pre-test as well as post-test KASRP scores compared to those who received prior pain education before the educational intervention. This finding could not be explained due to a lack of further information about the in-service training; however, the study does suggest that nurses can change prior knowledge and attitudes regarding pain by attending pain educational programmes and that further tailored continuous education is needed. The positive effects of educational initiatives on pain care were also reported in the prehospital research by French et al in 2006 (65). The study found that although paramedics attended an average of 2.2 hours of pain education prior to the educational intervention on prehospital pain care, a significant improvement was found in all features of pain assessment and management after the educational intervention (65).
Respondents in this study who reported receiving training on pain assessment and management as part of continued medical education, also performed more poorly than others. Like the study above this finding could not be explained due to a lack of further information. Continued medical education may occur in an array of formal and informal formats. Various factors could have affected the acquisition and retention of the knowledge respondents received during educational initiatives, such as the extent, content, depth and form of education which were not the focus of the current study. It is also indicated in the literature that knowledge gained from pain education will likely decline over time (66).
The current findings suggest that pain education should focus on all aspects relating to pain in order to improve knowledge and attitudes among emergency care providers in SA and that pain education must be continuous. Further research investigating instructional methodologies and strategies to improve pain knowledge acquisition, reinforcement and retention may be beneficial.
Barriers and enablers:
As elsewhere in the world, language barriers, and alcohol/drug use were identified as key barriers to prehospital pain management (67,68). Workload and lack of time with patients appear to be barriers specific to the South African prehospital setting. Public EMS, in particular, have a significant workload burden, (69) frequently dealing with more than one patient at a time which is likely to influence the delivery of pain care. The focus on the availability of higher qualified emergency care practitioners as the foremost enabler of pain management is also likely to be specific to the SA prehospital setting and due to the structure of the EMS workforce in SA, pain management limitations in the scopes of practice of different levels of prehospital qualifications and resource (medication) limitations. The unavailability of the inhaled analgesic medication, Entonox®, in the SA prehospital setting significantly limits the provision of pain management. It is essential that prehospital providers have access to the resources required to facilitate the management of pain. Although more than half of respondents identified that pain management is important, the influence that organisational culture, EMS leadership support and emergency department culture and pain prioritisation may have on the provision of pain care in the prehospital setting must not be underestimated or overlooked (19,20). Studies investigating barriers and enablers of prehospital pain assessment and management previously conducted have all occurred in high-income countries (18–21,64). The South African prehospital setting is unique in terms of the various levels of qualification and coinciding limitations in scopes of practices, skillset and experience of advanced life support practitioners, organisational culture, the threat of violence against EMS staff, workload outweighing resource (ambulance) availability, resource limitations, vast distances to health care in rural areas, lack of universal health coverage and disparities in health care, high trauma burden etc. all which may influence prehospital care. Consequently, research to further investigate and describe the barriers to, and enablers of pain assessment and management in this environment are essential (70).
Study limitations:
Being the first survey of its kind in the African prehospital setting, this study is an important point of departure for acute pain research. Observational studies have limitations, and in this study, participation was poor despite additional recruitment and extended data collection. The small sample size (partly because organisations were unwilling to share staff contact details and disseminated the survey internally only) may well have left the study underpowered to determine significant relationships between demographic groups. The generalisability of these findings is not clear, but we believe that despite the small number of respondents, and limited diversity of respondents in terms of the level of qualification, the role within EMS and the region of origin within the province (which may weigh rural practitioners disproportionately), the findings nevertheless create a foundation towards the understanding of the assessment and management of acute pain in the prehospital setting in SA.
Reporting bias may have originated from participants responding in what they perceive to be a professionally desirable manner, instead of exclusively based on personal beliefs, but we believe this bias was reduced by anonymity of the survey, the wide range of questions in different formats and the case study scenarios. The survey also suffered a 35% dropout rate by the end which may have been secondary to the length of the survey, technical difficulties, work requirements or a lack of interest. The high dropout rate may have introduced non-response bias in the results due to the under-representation of certain categories of respondents. Respondents who failed to complete the survey were predominantly male (77.1%), had ≤10 years’ experience (68.6%) and were ILS (45.7%) qualified. The study findings are further limited by the lack of validated knowledge and attitudes survey regarding pain. However, to maximise validity the questionnaire was based on existing validated questionnaires, received expert input and was piloted. Finally, although emergency care providers are required to be fluent in the English language, it is not the home language (71) of a significant proportion of respondents which may have led to the misinterpretation of statements or questions answered in the survey.