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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
  1. Fiona C Sampson,
  2. Maxine Johnson
  1. School of Health and Related Research, The University of Sheffield, Sheffield, UK
  1. Correspondence to Fiona C Sampson, The University of Sheffield, Sheffield, S1 4DA, UK; f.c.sampson{at}


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.

  • pain management
  • Systematic Review
  • qualitative research
  • emergency department

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  • Handling editor Mary Dawood

  • Twitter @fcsampson

  • Contributors FCS conceived and designed the study, undertook data collection, data analysis and interpretation and drafted the manuscript. MJ undertook data collection, analysis and interpretation of the data and critically revised the manuscript. FCS takes responsibility for the paper as a whole. FCS is guarantor.

  • Funding FCS was funded by a National Institute for Health Research (NIHR) doctoral research fellowship research grant ((DRF 2011-04-124) for this research project. This paper presents independent research funded by the NIHR. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.