To our knowledge, this is the first study investigating prehospital acute pain knowledge, attitudes and practices in an African prehospital setting, 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 attitudes 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. Given the vast differences between nursing curricula and that of 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 limited.
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 (45–57). Studies from North America (58–60), Norway (61) and Australia (62) 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 attitudes deficits along with regular in-service pain education (58,60,62). Research among nurses has shown that knowledge and attitudes regarding pain predict pain management practices, with attitudes contributing more to variances in pain management practices than knowledge (63). Additionally, adequate pain knowledge and favourable attitudes among nurses also correlate positively with patient satisfaction (58). Although pain education is paramount to altering attitudes and improving pain knowledge, the opinion of some is that education alone may not suffice (59). In addition to pain education, organisational culture must promote effective pain management practices, provide leadership and support, encourage a culture of continuous learning and promote interdisciplinary teamwork (59). Further, the implementation of a continuous quality improvement programme (64,65) and pain protocols or guidelines as well as removing the need to obtain medical control authorisation (13) have likewise improved the provision of prehospital analgesia.
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. This relationship has been confirmed by many international studies (47,48,54,57,59,61,66,67). However, the effect of years of experience on scores is uncertain with many differing findings across studies (53,54,58,59,61,66,67). As would be thought, prior pain education usually results in higher knowledge and attitudes regarding pain scores (48,58) yet our findings echoed that of an Ethiopian study by Germossa et al. (46) which showed higher scores amongst those not having attended further pain education.
Gaps in pain knowledge, attitudes and pain management practices:
After contrasting participant responses, gaps in knowledge and attitudes regarding pain were identified. Comprehension of the rudimentary principles of pain, pain physiology, pain assessment, indicators of pain severity and pain management was questionable.
Some respondents believed it to be appropriate to administer sterile water to test whether the pain is real, while some believed that pain relief should not be provided if (in their opinion) the condition is not painful. Mistakenly, vital signs were perceived to be a reliable indicator of pain severity (68) while some respondents believed that their prior experience dealing with patients in pain, allows them to score pain more accurately than patients themselves.
Although most respondents indicated that non-pharmacological approaches to pain management 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 aged 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 and opioids).
Despite strong evidence that culture, ethnicity and spirituality plays a significant role in both pain expression and pain behaviour, making behaviour a poor indicator of pain severity (69), comprehension on the part of survey respondents were poor. These misconceptions were further evident in the case scenarios. Respondents considered behavioural indicators of pain more important than self-reported pain. All of which suggests a lack of trust in patients to accurately self-report pain. Further, pain management practices described by respondents for the case studies suggest that the patients will not receive ideal pain relief during the prehospital phase. The practice of administrating sterile water (placebo) to test whether the pain is real, is questionable and likely a violation of the ethical principles (70).
As mentioned, knowledge deficit and practitioners’ perceptions, beliefs and attitudes are barriers to pain assessment and management frequently highlighted in the literature (13,18,21,22,71). 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 (13,18,21,22,71). 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 emergency care education 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.
The study by Germossa et al. (46) additionally 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. Surprisingly, similar to our findings, the authors reported that in both the pre- and post-intervention testing, nurses with no previous in-service training in pain obtained significantly higher KASRP scores compared to those who received prior pain education (46). This finding could not be explained due to a lack of further information about the in-service training; however, the authors suggested 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 (72) in 2006. The authors 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 (72).
Respondents in this study who reported receiving training on pain assessment and management as part of continuing medical education also performed more poorly than others. Like, Germossa et al. (46) reported, this finding could not be explained due to a lack of further information. Continuing 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. Literature also suggests that knowledge gained from pain education will likely decline over time (73).
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 (74,75). 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 (76), frequently dealing with more than one patient at a time which may influence the delivery of pain care. Availability of higher qualified emergency care practitioners as the foremost enabler of pain management is also likely 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 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 pain management. Although more than half of the respondents identified that pain management is important, the influence of EMS and emergency department culture and leadership support on pain prioritisation and 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 have all occurred in HIC (18–21,71). The South African prehospital setting is unique in terms of the various levels of qualification and coinciding limitations in scopes of practice, skillset and experience of ALS 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 (77).
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, which may have left the study underpowered to determine significant relationships between demographic groups. Tracking questionnaire distribution and calculating a response rate was unanticipatedly problematic. In the future, survey response rates will have to be carefully assessed, in light of the POPI act and may also be mitigated through technology assisting better tracking of the number of surveys disseminated by third parties, in an anonymous way.
Non-response bias may have been introduced if the respondents that declined to participate were systematically different from those that agreed or if some eligible participants were not reached (78). The survey 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 further 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 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 study findings are further limited by the lack of a validated prehospital 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 English, it may not be the home language (79) of a significant proportion of respondents leading to the possible misinterpretation of statements or questions answered in the survey.