Why is pain management so difficult in the Emergency Department? A systematic mixed studies review and thematic synthesis of staff perceptions of enablers and barriers to pain management within the Emergency Department

Introduction: Pain is the most common presenting feature within the ED, yet undertreatment of pain in the ED is a well-documented problem worldwide. Despite the development of interventions to address this problem, there is still limited understanding of how pain management can be improved within the ED. This systematic mixed studies review aims to identify and critically synthesise research exploring staff views of barriers and enablers to pain management to understand why pain continues to be undertreated in the ED.

Methods: We systematically searched five databases for qualitative, quantitative and mixed methods studies reporting ED staff views of barriers and enablers to pain management in the ED. Studies were quality assessed using the Mixed Methods Appraisal Tool. Data were extracted and qualitative themes were generated by deconstructing data then developing interpretative themes. Data were analysed using convergent qualitative synthesis design.

Results: We identified 15 297 articles for title/abstract review, reviewed 138 and included 24 in the results. Studies were not excluded due to low quality, although lower scoring studies contributed less data to the analysis. Quantitative surveys focused more on environmental factors (eg, high workload and bureaucratic restrictions), while qualitative studies revealed more insight about attitudes. We developed five interpretative themes from the thematic synthesis: (1) pain management is seen as important but not a clinical priority; (2) staff do not recognise the need to improve pain management; (3) the ED environment makes it difficult to improve pain management; (4) pain management is based on experience, not knowledge; and (5) staff lack trust in the patient’s ability to judge pain or manage it appropriately.

Conclusions: Overly focusing on environmental barriers as principal barriers to pain management may mask underlying beliefs that hinder improvements. Improving feedback on performance and addressing these beliefs may enable staff to understand how to prioritise pain management.