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Knowledge and Attitudes of Nurses Regarding Pain in the Intensive Care Unit
Pa- tients in Rwanda

Article in Rwanda Journal · November 2016

DOI: 10.4314/rj.v3i1.4F

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http://dx.doi.org/10.4314/rj.v3i1.4F Rwanda Journal Series F: Medicine and Health Sciences Vol. 3 No. 1, 2016

Knowledge and Attitudes of Nurses Regarding Pain in the Intensive Care Unit Pa-
tients in Rwanda
Christine M. Ufashingabire1*, Etienne Nsereko2, Kato J. Njunwa3, Petra Brysiewicz4

1,2
University of Rwanda, College of Medicine and Health Sciences, School of Health Science
3
University of Rwanda, College of Medicine and Health Sciences, Directorate of Research, Innovation and Postgraduate studies
4
University of KwaZulu-Natal, School of Nursing and Public Health, South Africa

Abstract

Background: Pain is a significant burden experienced by patients admitted to the adult Intensive Care Unit (ICU). Acute
conditions associated with severe pain include surgical incision, traumatic wounds, effect of prolonged immobility, and
sometimes hidden infections in the body’s cavities and treatment by invasive procedures. Pain in ICU is difficult to assess due
to the nature of patients admitted to that unit. Pain assessement requires health care providers to have a good knowledge
of it, and involves a number of care providers including the nurses among others. However little is known about the nurses’
knowledge and attitudes related to pain management in ICU. The purpose of this study is to assess nurses knowledge and
attitudes toward pain management of ICU patients in three university teaching hospitals in Rwanda. Methods: The tool and
attitudes Survey Regarding Pain “developed by Ferrell and McCaffery was adapted to local context. The tool was used in the
three referral hospitals in Rwanda to assess knowledge and attitudes from 69 nurses practicing in ICU. We compared the pain
management performance in regard to the age, level of education, experience and history of training in pain management
between nurses. The researcher used one way ANOVA to compare nurses’ scores among hospitals with a significance level
α=0.05. A multiple linear regression analysis was used to highlight independent factors associated with best performance. A p
value ≤0,05 was considered as statistically significant. Results: The results from this study showed that nurses lack adequate
knowledge and have poor attitudes toward pain management. The level of nursing education (p<0.008) and the hospital
where nurses worked (P<0.0001) had a strong influence on attitudes toward pain management. In addition, knowledge gap
and inappropriate attitude towards pain management noticed among some ICU nurses could lead to their underestimation
of pain, and under medication. Conclusion: Poor performance in pain management in ICU is multifactorial. Continuous
Professional Training and improved working environment towards standard practice are key to pick up that performance.

Key words: Intensive care unit, pain management, nurses, knowledge attitude, medication

Introduction
worldwide problem, which raises a big concern. However
In critical care settings, moderate to severe pain has been there is evidence that positive change is taking place in
identified as a common cause of patient stress (Kabes, many countries. In Romania, for instance, the administrative
Graves, & Norris, 2009). Accurate assessment of pain is process to obtain medical opioids and to prescribe strong
paramount for appropriate pain management. Evidence opioids for patients with severe pain is becoming easier
indicates that substantial pain coupled with an ICU and easier thanks to the new narcotics legislation and
environment alters patients’ normal sensory stimuli and regulations, regardless of the underlying cause of the pain
increases their perception of pain (Gélinas, et al., 2004). that is being treated (Taylor et al., 2008). Poor understanding
Many patients admitted to ICUs are already compromised and lack of education regarding pain and pain medication
with chronic and acute conditions associated with severe are attitudinal barriers to its adequate treatment.
pain, and treating these conditions may escalate pain by
requiring painful procedures including but not limited to In both high and low income countries there is concern
catheterization, intubation, and chest tubes. that opioids used in routine pain management may lead to
addiction. However, it can also be a result of inadequate
Uncontrolled pain produces complications owing training in pain management, especially in resource poor
to stimulation of the sympathetic nervous system, areas where lack of training in pain management is marked.
hyperglycemia, lipolysis, muscles breakdown, and delayed Supplies of opioids are limited, and often restricted to
wound healing. In addition, anxiety, confusion, sleep specific health facilities (Taylor et al., 2008). In a study
disturbance, delirium, and paranoia also result from conducted by Rampanjato et al.(2007) in Central Africa,
unmanaged pain (Gélinas et al., 2004). Nurses’ ability to 8% of the nurses involved admitted to being unable to
identify and adequately manage pain is multifactorial and effectively assess pain, while 67% admitted to fearing
includes 1) ability to interpret verbal and non-verbal signs administering morphine to patients in emergency cases.
of pain, 2) cultural bias 3) knowledge gap and 4) excessive
concern about administering pain killers (Sloman,et al , According to Narayan (2010), to a great extent, an
2001). Narayan (2010) conducted a study and found that individual’s way of thinking and acting depends on the
registered nurses under-assessed severe pain. The author cultural group s/he belongs to. This author highlights
also revealed that participants had inadequate knowledge the importance of cultural aspect of pain management.
about pain, use of analgesics, addiction, and the risks of Therefore, when caring for their patients in general,
respiratory depression. and those experiencing pain in particular, nurses should
consider their cultural values, beliefs and behaviors. Despite
In a study conducted by Taylor, Gostin, and Pagonis (2008), the evidence that people feel or react to pain almost in the
it was found that inadequacy in the treatment of pain is a same way, the fact that members of some racial groups are

*Corresponding author, email: ufachry@yahoo.fr

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Rwanda Journal Series F: Medicine and Health Sciences Vol. 3 No. 1, 2016

more lenient to pain and able to bear it for a longer time management such as the American Pain Society, the World
than others is also well documented. For instance, Korol and Health Organization, and the Agency for Health Care Policy
Craig (2001) and Taylor et al.(2008), maintain that cultural and Research. The content validity of this questionnaire
patterns significantly control or manipulate individuals in all was established by a review of pain experts (Breu et al.,
their dimensions of life. This means that people’s reaction 2008), whereas construct validity was established by
to pain will differ depending on communities. In Rwanda, comparing scores of nurses at various levels of expertise
no cultural bias regarding stoicism has been documented such as students, new graduates, oncology nurses, graduate
so far. People may attempt to keep their faces covered and students, and senior pain experts. The tool was identified
try to hide the pain they are feeling by grimacing. Stoicism as discriminating between levels of expertise. Test-retest
may lead to nurses working in ICUs running the risk of not reliability was established (a > 0.80) by repeat testing in a
recognizing the suffering patient. They may be tempted to continuing education class of staff nurses (n=60) (Breu et
believe that those patients who do not show overt signs of al., 2008). The questionnaire was originally developed in
pain are not experiencing pain that requires treatment. With English in the United States. Rwandan participants were both
regard to pain management, nurses working in ICUs are English and French speaking, and participants were given a
nowadays faced with many challenges, For instance when choice as to which version to complete. A translation and
caring for critically ill patients, nurses may find it challenging back translation was performed by a professional translator
to simultaneously provide effective pain relief and cope from the University of Rwanda Language Center. Of the 38
with life threatening situations (Subramanian, et al., 2011). total items, four (10.5%) were adapted to fit the context
In addition, given that there is a shortage of skilled staff in of Rwandan ICU nurses. Three items were revised because
pain medication, it is unwieldy for them to give an efficient the medications mentioned are not available in Rwanda.
dose that meets a patient’s analgesic demands (Glynn & Concerning item 18, the original question mentioned a
Ahern, 2000). drug called Vicodine that is not available locally. Therefore,
the item was removed from the questionnaire. One item
Most literature documented about pain management in was revised to reflect the socioeconomic homogeneity of
Australia, the United States and Europe. Little is known the country .To ensure validity of the revised tool, a pilot
from sub-Saharan Africa and no literature to date addresses study involving 4 nurses was conducted. Considering that
the knowledge and attitudes of Rwandan ICU nurses in the tool did not have a good performance cut-off point for
regard to pain assessment and management. This study is good level of knowledge, 80% and above was adopted as
designed to fill that gap. Findings from this study can be good level based on other similar studies (Smart, 2005).
used to help to shape nursing education, nursing practice,
and nursing policy in Rwanda. Anonymity of participants was respected and permission
from the internal review board of each of three hospitals
The objectives of this study were: was obtained. Participants were given assurance that the
information they would give would be confidential and used
1. To assess the level of Rwandan nurses’ knowledge and for the sole purpose of the current study, after which they
attitudes regarding pain management of ICU patients. gave their informed consent to participate. Prior to data
collection, participants were provided with explanations
2. To identify barriers to the optimal management of pain regarding the aim of the study and how the researcher
among ICU nurses was going to proceed. The data collection process started
after obtaining the ethical clearance and permission from
Methods the referral hospitals to conduct the study. The researcher
made appointment on the phone and asked to the
A quantitative descriptive survey was conducted with the participants if they were ready to participate, after which
aim of assessing ICU nurses’ knowledge and attitudes toward they were informed of the schedule for data collection.
pain management in three referral hospitals in Rwanda, Participants were requested to fill in the questionnaire
two public and one private hospital. These hospitals were during their free time in the hospital setting. Participants
selected because they have ICU’s and treat critical cases completed questionnaires individually. All questionnaires
that need specialized care. These ICUs receive critically ill were completed anonymously and placed in a secure box
patients from within and from other hospitals and admit in the hospital lounge.
patients aged more than one month. Patients having a wide
variety of chronic and acute illnesses, are treated there. The The tool is divided into three sections. The first section
total number of the beds in three ICUs is 22. They were comprised of socio-demographic information including
69 nurse participants in this study classified into two main participant age, gender, area of clinical practice, level of
groups: enrolled and registered nurses. Enrolled nurses education, and pain management training status. Section
are nurses who underwent 6 years of secondary school two consisted of 22 true / false items and 14 multiple-
education with nursing components and have certificate. choice items. There were also 2 case studies where
While registered nurses are nurses who completed from a participants were asked to make a decision regarding
three-year university comprehensive nursing program and pain and medication. The third section dealt with specific
above (Advanced diploma, Bachelor and masters degree questions related to barriers to optimal pain management in
in nursing). They were 85.5% registered nurses and 14.5% ICUs. It had 5 items with a 4 rating scale ranging from “No
enrolled nurses. The study sample included all registered importance” to “Major importance”.
and enrolled nurses working in ICUs in the three hospitals
studied. Data coding, processing, and analysis was performed
using SPSS version 18. Descriptive statistics, including
A standardized questionnaire used, was developed by frequency tables, mean and standard deviation, maximum
Ferrell and McCaffery (2008) known as the “Knowledge and minimum observations calculation were used to
and Attitudes Survey Regarding Pain”. Permission to use summarize demographic data of participants. For items in
this tool was obtained from its developers. Concerning the second section of the data collection tool, data were
the established validity and reliability, the content of the summarized using a frequency table. This section combined
tool used was derived from current standards of pain both knowledge and attitudes as recommended by tool

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 Rwanda Journal Series F: Medicine and Health Sciences Vol. 3 No. 1, 2016

developers. In order to check whether working in one of Table 2. Number of participants who answered
the three referral hospitals influences the nurses’ judgments correctly to each ‘true”/”false” item on the Nurse’
on barriers to pain management, a set of items from the Knowledge and Attitude Survey Regarding Pain (N=69)
knowledge and attitude data collection tool was selected Item by item analysis
and rephrased to stand for potential barriers to optimal
pain management in ICUs. The researcher used one- Item content area Correct
way ANOVA to compare the nurses’ mean scores across answer
hospitals.. It was this mean score that was used to make a Frequency
(%)
comparison between hospital groups. The significance level
(α) was set to 0.05. A multiple linear regression was used 1. Vital signs are always reliable indicators of 43 62.3
to test whether socio- demographic characteristics (ICU the intensity of a patient’s pain (F)
experience, hospital site, on-job training and nurses’ level 2. Because their nervous system is 48 69.6
of education) influenced the participants’ judgments on underdeveloped, children under two years
potential barriers to optimal pain management (dependent of age have decreased pain sensitivity and
variable). limited memory of painful experiences (F)
3. Patients who can be distracted from pain 40 58
Results usually do not have severe pain (F)
4. Patients may sleep in spite of severe pain (T) 43 62.3
In this study, information regarding the socio-demographic
characteristics shown that the majority of participant were 5. Aspirin and other non-steroidal anti- 44 63.8
inflammatory agents are NOT effective
female (64.6%, n=45), with mean age of (34.1+/-5.2) had
analgesics for painful bone metastases (F)
advanced diploma in nursing (69.5%, n=48) with mean
working experience of 2.9+/-2.8 years. Participants who 6. Respiratory depression rarely occurs in 49 71
had attended on-the-job training represented 40.5% (n=28). patients who have been receiving stable
doses of opioids over a period of months (T)
Table 1. Participants’ Socio-demographic characteristics. 7. Combining analgesics that work by different 49 71
mechanisms (e.g. combining opioid with
an NSAID) may result in better pain control
Gender Frequency Percent with fewer side effects than using a single
Male 24 34.3 analgesic agent (T)
8. The usual duration of analgesia of 1-2 mg 55 79.7
Female 45 64.6
morphine IV is 4-5 hours (F)
Level of education: 9. Research shows that promethazine 54 78.3
1. Certificate (enrolled nurses) 10 14.5 (Phenergan) and hydroxyzine (Vistaril) are
Reliable potentiators of opioid analgesics (F)
2. Advanced diploma 48 69.5
10. Opioids should not be used in patients with 52 75.4
3. Bachelor degree 10 14.5 a history of substance abuse (F)

4. Masters degree 1 1.5 11. Morphine has a dose ceiling (i.e., a dose 44 63.8
above which no greater pain relief can be
On-the-job training on pain obtained) (F)
management: 12. Elderly patients cannot tolerate opioids for 46 66.7
1. Yes 28 40.5 pain relief (F)

2. No 41 59.4 13. Patients should be encouraged to endure 59 85.5

as much pain as possible before using an
Age (in years): mean=34.1; SD=5.2; Min=25; Max=45 opioid (F)
ICU years of experience: Mean= 2.9, SD=2.8; Min=1; Max=16
14. Children less than 11 years old cannot 47 68.1
Concerning the knowledge and attitudes of nurses, Table reliably report pain so nurses should rely
2 shows the “True” or “False” questions with which the solely on the parent’s assessment of the
participants were presented. The results indicate the child’s pain intensity (F)
percentage of the participants who correctly answered 15. Patients’ spiritual beliefs may lead them to 48 69.6
individual items of the data collection tool. From this table, think pain and suffering are Necessary (T)
it can be seen that 85.5% of the participants believe that
16. After an initial dose of opioid analgesic is 42 60.9
patients should not be encouraged to endure as much pain given, subsequent doses should be adjusted
as possible before using opioids (item 13). This item recorded in accordance with the individual patient’s
the highest number of correct answers. In the same table, response (T)
item 3 asked whether patients who can be distracted from
pain do not have severe pain. This is the item that recorded 17. Giving patients sterile water by injection 42 60.9
(placebo) is a useful test to determine if the
the lowest number of correct answers, with only 58 % of pain is real (F)
the participants providing correct answers to it. As for items
6, 7, 8, 9, and 10, about 70% of the participants answered 18. If the source of the patient’s pain is 47 68.1
unknown, opioids should not be used during
them correctly. the pain evaluation period, as this could
mask the ability to correctly diagnose the
cause of pain (F)

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Rwanda Journal Series F: Medicine and Health Sciences Vol. 3 No. 1, 2016

Table 2. Number of participants who answered To identify which group is different from the others, we
correctly to each ‘true”/”false” item on the Nurse’ conducted a PosHoc pair-wise difference. The results of the
Knowledge and Attitude Survey Regarding Pain (N=69) table 4 show that there are differences between groups,
Item by item analysis cont’d with Hospital A being significantly different from the other
two hospitals (p < 0.001 and CI= 0.8697- 1.2520).
Item content area Correct
answer Table 4. Comparison of nurses’ performance according to the
Frequency hospitals they work
(%)
19. Anticonvulsant drugs such as Phenytoin 52 75.4 Hospitals Difference in 95% CI P Value
produce optimal pain relief after a single compared performance
dose (F)
A versus B 1.06087 [0.8697-1.2520] <0.001*
20. Benzodiazepines are not effective pain 50 72.5
A versus C 1.01087 [0.8067-1.2151] <0.001
relievers unless the pain is due to muscle
spasm (T) B versus C -0.05 [0.2486-0.] 0.617
21. Narcotic/opioid addiction is defined 43 62.3
as a chronic neurobiological disease, *.The mean difference is significant at α=0.05 level
characterized by behaviors that include one
or more of the following: impair control over Table 5 presents the results of linear regression of the
drug use, compulsive use, continued use total score on questions related to potential barriers to
despite harm, and craving (T). pain management when a set of participants’ independent
socio-demographic variables is taken into account. The
22. Narcotic/opioid addiction is defined 43 62.3 results show that the overall model was significant at p <
as a chronic neurobiological disease,
characterized by behaviors that include one 0.001, the overall R2 was 52%, which means that 52% of
or more of the following: impair control over the variation of the total score was accounted for by the
drug use, compulsive use, continued use socio-demographic variables that were used in the model.
despite harm, and craving (T). With regard to individual coefficients, Table 5 shows that
working in one of the three hospitals predict significantly
To assess the extent to which participants pay attention the score on the barriers to optimal pain management (β=
to potential barriers to pain management, participants -0.663, p<0.001). The same goes for participants’ level of
were asked to rate five potential barriers to optimal pain education. The results above rightly suggest that having a
management in their respective ICUs on a 4-point Likert high level of education in nursing significantly predicts one’s
scale from ″no importance″ to ″major importance″. The perceptions of potential barriers to pain management (β=
researcher found that only 18% of the participants rated 0.247, p =0.008).
the said barriers as having “major importance”.
Table 5. Model predicting Total correct score using barriers
Table 3. Rating of the importance of barriers to optimal pain Dependent variables: total correct score
management in the respondent’s setting
Variables Coefficient SE T P
Item No Little Moderate Major
importance importance importance Importance ICU experience -0.083 0.054 -0.932 0.355
n % n % n % n % Working in one of -0.663 0.070 -7.058 <0.001**
the hospitals
1.Inadequate 9 13 33 48 9 13 18 26
assessment of On-the-job- 0.075 0.114 0.788 0.434
pain relief training on pain
2. Patient’s management
capacity to 9 13 27 39 28 40.5 5 7.2
report pain Level of education 0.247 0.083 2.755 0.008*
3.Inadequate 9 13 22 32 13 19 25 36 *Significant at α=0.01** Significant at α=0.001
staff
knowledge Discussion
of pain
management The purpose of this study was to assess the knowledge
4.Nursing staff 4 6 27 39 34 49 4 6 and attitudes of the Rwandan nurses regarding pain
reluctance to management of ICU patients and find out what might be
administer the barriers to providing optimal pain management. The
opioids
socio-demographics results show that the majority of
5.Lack of 9 13 24 35 24 35 12 17 the participants were young adults and mostly females,
equipment or confirming findings from other studies that nursing is a
skills in using
equipment female-dominated career (Ozdemir, Akansel, & Tunk, 2008).
The majority of the nurses had Advanced diploma training
Total
percentages 12% 35% 31% 18%
reflecting an increasing number of them relative to the
Certificate level enrolled nurses owing to capacity building
The knowledge and attitudes toward pain was assessed for efforts of the nursing staff.
the three hospitals. The results indicated that at least one
group of participants differs from the other two groups in Given that the content of the items 6, 7, 8, 9 and 10 in
paying attention to potential barriers that can hinder the the tool focuses mostly on opioids’ side effects, it can be
optimal pain management in ICU (F test= 74.1, p <0. 001) suggested that participants have concerns related to these
depending on their working hospitals. side effects. When it comes to item number 3, the results
show that it recorded the most failed by participants. It
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 Rwanda Journal Series F: Medicine and Health Sciences Vol. 3 No. 1, 2016

can be suggested that, probably, participants have been present study that experience, as well as level of education,
culturally influenced. In fact, in Rwandan culture, many independently contributes to the variation between the
people believe that remaining calm and focused when one scores of the participant.
is experiencing pain helps to alleviate it.
Conclusion
Concerning the Knowledge of nurses on the importance of
barriers to pain management shown in the table 3, results The present study has described ICU nurses’ knowledge
are different from those published by Smart (2005) where and attitudes towards pain management. It was conducted
only two of the barriers among eight were rated by 50% or in three referral hospitals in Rwanda. The overall results
more of the sample as being of major importance in their show that these nurses lack adequate knowledge and have
setting. Also in the study conducted by Fairbrother et al, poor attitudes as far as the items related to pharmacology,
(2003) responses to questions regarding the 5 barriers that clinical assessment and understanding of the importance of
are referred to are considered to be correct only if they barriers to pain management are concerned. A comparison
are rated as having “major importance’’. Given that the was made between the nurses based on the hospitals
big majority of the participants in the present study gave where they work. It was found that scores on barriers to
answers other than “Major importance”, the only logical pain assessment and management vary depending on the
conclusion to be drawn from the findings is that a great participants’ hospital site. One hospital was outstanding
number of nurses pay little importance to barriers to pain .Also level of education was a determining factor for all the
management or simply do not know them. participants in the three hospitals, that is, it influenced the
performance of the participants.
From the findings of the Table 4 , it can be seen that
there are differences between groups, with Hospital A It can be concluded that participants have knowledge gap
being significantly different from the other two hospitals about, and poor attitudes towards, pain assessment and
. The results from this study are comparable to the management. For this reason, protocols should be designed
findings published by other studies. Hsiang et al.( 2010), and implemented to increase nurses’ knowledge about,
reported a significant difference in perceiving barriers and improve their attitudes towards, pain management,
to pain management in specific ICU, and this difference for better satisfaction and well-being of the patients.The
was observed according to hospital accreditation. From organization of Continuous professional development
the results above, it can be concluded that the difference ,refresher courses and encourage the upgrading the level
observed between groups suggests that participants of education of nurses are also important.
working in Hospital A are more barriers cautious than those
from the other two hospitals. The difference observed is Limitation to the study
probably related to the accreditation level of the hospitals
since Hospital A is of high quality standards and organize This study used a self-report questionnaire to collect data.
regular refresher courses for its personnel. In addition, the original tool that was used was in English
and has been translated into French. It is this translated
The results of Table 5 shows that working in one of the three version of the tool that was used to collect data. It is
hospitals predict significantly the score on the barriers to known that the most demanding aspect of cross-cultural
optimal pain management. The same goes for participants’ translation is to adjust the instrument in a complete and
level of education. However, ICU experience and on-job- appropriate cultural form while keeping the meaning of
training did not significantly predict the participants’ score the original items. As well as linguistic problems that may
related to barriers on pain management. The results above arise, there is also the challenge to maintain accuracy and
rightly suggest that having a high level of education in to match the cultural differences of the two languages. It is
nursing significantly predicts one’s perceptions of potential therefore possible that some items in the translated version
barriers to pain management. These findings are similar to may have some semantic differences from the original
the study conducted by Smart (2005) which showed that tool, which may have influenced the instrument’s validity.
nurses educated at different level in Britain and Canada With regard to generalization, the current study recruited a
had significantly higher scores than those educated in the relatively small sample (69 participants) from three referral
Philippines. Furthermore, clinical educators and clinical hospitals. Extrapolation of such results to other nurses in
nurse specialists’ scores were significantly higher than district hospitals in Rwanda is limited.
those of registered nurses and registered nursing assistants.
Also, the scores of nurses with a masters or a baccalaureate Recommendation
level were significantly higher than those of nurses with a
diploma or a registered nursing assistant certificate. It was This study has identified areas of knowledge gap and poor
also found that the scores of nurses with a university level attitudes as far as ICU nurses are concerned. The results
of education were higher than those of nurses who have of this study can be used to improve the management of
not attended university. In another study, (Linda, 2008) patients experiencing pain. Unity managers and matrons
confirmed previous results and demonstrated the impact of should organize Continuous Professional Training on pain
education on pain management. This author concluded that management for nurses. Furthermore, the stakeholders
knowledge is established and carried on through additional should upgrade the educational level of nurses.
academic education and the clinical setting in which
nurses practice their nursing skills. The findings of Linda
lend support to the results of another study conducted by
Acknowledgment
Erkes & Veronica G. Parker( 2001), demonstrated that a
We are grateful to the New Partnership for Africa’s
continuous education program on pain management helps
Development (NEPAD) to sponsor this research study and
to increase awareness of, and skills, in that area. The views
nurses participated in the study.
above are shared by Lui, So, & Fong(2008).These researchers
maintain that knowledge is not only acquired by means of
formal education but also through daily practice as a way of
learning. Their observation accounts for the finding of the

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Rwanda Journal Series F: Medicine and Health Sciences Vol. 3 No. 1, 2016

Conflict of interest Rampanjato, R. M., Florence, M., Patrick, N. C., & Finucane,
B. T. (2007). Factors influencing pain management
All authors report no conflict of interest. by nurses in emergency departments in Central
Africa. Emergency Medicine Journal, 24, 475–476.
Authors’ contributions
Sloman, R., Ahern, M., Wright, A., & Brown, L. (2001).
PB and EN led the study conception, design, analysis and Nurses’ Knowledge of Pain in the Elderly Rod
interpretation of results. KJN has mentored the manuscript Sloman. Journal of Pain and Symptom Management
writing and editing. (Vol. 21). Sydney, New South Wales, Australia: The
University of Sydney, Sydney, New South Wales,
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