Applied Nursing Research 44 (2018) 33–38

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Original article

Critical care nurses' use of non-pharmacological pain management methods T

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

A R T I C LE I N FO A B S T R A C T

Keywords: Aim: To examine Critical Care Nurses’ Practices of Non-pharmacological Pain Management Interventions in
Critical care nurses Egypt.
Practices Methods: Descriptive exploratory design was utilized in the current study with a convenience sample of 60
Non-pharmacological critical care nurses working in three intensive care units at Al Manial university Hospital, Egypt. The ques-
Pain
tionnaires included; nurses' demographic data, non-pharmacological pain management checklist utilizing likert
Management interventions
scale, and perceived barriers to the practice of non-pharmacological pain management interventions.
Comparisons were made between the nurses' responses about practices of non-pharmacological pain manage-
ment 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-phar-
macological 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 pressure, and increased myocardial oxygen consumption demands,

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 management control techni-
ques, and overcoming the perceived hindrances to the practice of evi-
dence-based nursing (Calil & Pimenta, 2010).
Furthermore, inappropriate acute pain management may potentiate
catecholamine release, which causes rapid pulse, elevated blood
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 un-
dertreated for many patients (Topolovec-Vranic et al., 2010; Van Gulik
et al., 2010). Therefore, there is a need to search for other strategies to
maximize patients' comfort and induce pain relief in critical care set-
tings (Lavery, 2004).
In this issue, non-pharmacological approaches are interesting stra-
tegies 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,

⁎
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.
N.S. Khalil
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 prac-
tices 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 so-
ciocultural dimensions of the pain (Yavuz, 2006). They are likely to
complement pharmacological interventions and may provide alter-
native 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). More-
over, 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 man-
agement tested in the ICU is ice therapy. The most common im-
plementation 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. Re-
cently, 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-phar-
macological 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. In-
deed, 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 relaxa-
tion, massage, and heat/cold applications (Horgas & Yoon, 2008;
Williams, Davies, & Griffiths, 2009). As a result, the dosage of analgesic
drugs needed can be reduced, decreasing the side-effects of the treat-
ment and reducing healthcare costs by reducing doctor visits and re-
liance on costly medications. Therefore, the aim of this study was to
describe current critical care nurses' use of non-pharmacological pain
34
Applied Nursing Research 44 (2018) 33–38
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 non-
pharmacological 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 nurses
use 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 non-
pharmacological 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 re-
lated 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 non-
pharmacological 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 inter-
ventions 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 of each subject were as-
sured through coding of all data, and the subjects had the right to
N.S. Khalil Applied Nursing Research 44 (2018) 33–38

withdraw from the study at any time without any rationale. Then, their Table 1
written consent was obtained. Demographic characteristics of the participants (n = 60).
Sample variables Study sample n = 60
3.7. Research procedures
Sex
Male 10 16.7
The current study was conducted in two phases. Female 50 83.3

Age
20–25 28 46.7
3.7.1. Preparation phase
26–30 16 26.7
This phase was concerned with constructing, testing, and piloting 31–35 4 6.7
the data collection tools. In addition, the managerial arrangements 36–40 8 13.3
were made to conduct the current study. Nurses who agreed to parti- 41–45 4 6.7
cipate in the study were interviewed individually by the researcher to Mean + SD 28.47 ± 6.905

explain the nature and purpose of the study, and finally, written con- Educational level
sent was obtained. Bachelor 13 21.7
Technical 18 30
Secondary school diploma 29 48.3
3.7.2. Implementation phase Years of experience in nursing
Data were collected from October 2013 to October 2014. The re- 1–5 28 46.7
searcher visited the selected critical care and intensive care units daily 6–10 13 21.7
during morning and afternoon shifts. Each nurse was interviewed for 11–15 5 8.3
16–20 7 11.7
15–20 min to fill out his or her background data. Then, the nurses were 21–25 7 11.7
asked to complete the non-pharmacological pain Interventions checklist Mean ± SD 9.133 ± 7.338
and mention the frequency of use of non-pharmacological pain
Years of experience in ICU
Interventions methods on a Likert scale ranging from frequently to 1–5 31 51.7
never used. Later, the nurses were asked to state the barriers that hin- 6–10 13 21.7
dered the implementation of non-pharmacological pain interventions 11–15 3 5
16–20 6 10
Practices (if any).
21–25 7 11.7
Mean ± SD 8.208 ± 7.511
3.8. Data analysis Working areas
Medical critical care unit 32 53.4
Simple descriptive statistics were utilized. The data were analysed Emergency care unit 14 23.3
Neurosurgery unit 14 23.3
using SPSS version 20 by using frequency and percentage distribution.
Moreover, the chi-square test was utilized to explore the correlation
between different categories of nurses in relation to their educational 4.4. Perceived nurses' barriers regarding applying non-pharmacological
levels, years of experience, and areas of work. interventions practices with their patients

4. Results
4.1. Demographic characteristics of the subjects
Out of 60 participating critical care nurses, most of them were fe-
male (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 school diploma graduates, while the rest were
technical and baccalaureate nurses (30% and 21.7%, respectively). In
relation to years of experience in nursing and in the ICU, approximately
half of subjects (46.7% and 51.7%, 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).
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 in-
terventions 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 in-
terventions practices by their educational level (see Table 2).
4.3. Comparison of nurses' practices by work area
Most of the nurses didn't perform non-pharmacological pain inter-
ventions practices. Moreover, no statistically significant differences
were found among them by their area of work (see Table 3).
More than half of the subjects (75%, 63.3%, and 58.3%, respec-
tively) perceived that the factors that might affect their abilities to use
non-pharmacological interventions practices were lack of education,
nursing workload, and patient instability, e.g., unstable hemodynamic
(see Fig. 1).
5. Discussion
The present study described the current nurses' performance of non-
pharmacological pain management approaches in different critical care
units at Cairo University Hospital as reported by nurses through com-
pleting 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 adequate knowledge regarding non-
pharmacological methods. Furthermore, Ojong, Ojong-Alasia, and
Nlumanze (2014) revealed that although the nurses had good knowl-
edge of pain assessment and management, there were still some
shortcomings in nurses' practice of pain assessment and management.
Along the same lines, Bicek (2004) revealed that half of nurses didn't

35
N.S. Khalil Applied Nursing Research 44 (2018) 33–38

Table 2
Nurses' reported practices of the non-pharmacologic pain management interventions by their educational level (n = 60).
Non pharmacological methods Bachelor Technical Diploma Chi square Mean
χ2
N % N % N %

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-phar-
macological 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 non-
pharmacological methods were giving preparatory information, com-
forting/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 tech-
niques, 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' Doc-
umentation, Knowledge, Attitudes, and Patients' Satisfaction at Man-
soura University Hospitals” and revealed limited nurses' notes pertinent
to the application of some non-pharmacological interventions in the
postoperative period such as massage and relaxation techniques. On the
other hand, this finding is partially contradicted by Wang et al. (2008),
who revealed the efficiency of non-pharmacological pain management
approaches such as audio-visual distraction and routine psychological
intervention, which were 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 ex-
perience 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' educa-
tion, 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 non-
pharmacological pain interventions practices than those with 2–4 years
of experience.
This finding may have relevance, as most of the nurses in the cur-
rent 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 compe-
tency in pain management. Similarly, this finding contradicts Ali,
Ibrahim, and Mohamed (2013), who revealed the nurses had satisfac-
tory attitudes and performance regarding applying non-

Table 3
Frequency distribution and average mean of reported nurses' practices of the non-pharmacologic pain management interventions by their area of practice.
Non pharmacological methods Medical Emergency Neurosurgery Chi square Mean
ICU ICU ICU χ2

N % N % N %

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
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

36
N.S. Khalil
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 ex-
perience were found to have a higher level of knowledge on pain
management compared with those with fewer years of nursing experi-
ence (Stanley & Pollard, 2013).
5.1. Nurses' perceived barriers to applying non-pharmacological pain
interventions practices
In the present study, the frequent barrier that prevented critical care
nurses from applying non-pharmacological pain management ap-
proaches 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 non-
pharmacological 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 inter-
ventions for patients complaining of pain.
Other reported barriers that prevent critical care nurses from ap-
plying 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-phar-
macological approaches is long, discouraging most nurses from ap-
plying 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 commu-
nicate as barriers to the application of non-pharmacological pain
management approaches. Finally, Rose et al. (2011) 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 re-
lief measures.
37
Applied Nursing Research 44 (2018) 33–38
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 be-
tween 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.
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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