paraphrase of 3800 words

Proposal Coversheet

Trainee’s name: Nouf Yaseen Aloufi

Registration No: 202462793

Trainee’s email: [email protected]

Names of The Rest Group Members (for group work) : NA

Date:30 APRIL 2026

Centre’s name: KING FAHAD HOSPITAL -Medina

Program director’s name: Bader Abdullah Alahmadi

Program director’s email: ………………………………………..

Module of study name: Nursing Research & Evidence Based Practice

Proposal title: Nurses’ Knowledge and Attitudes Regarding Pain Management in Critical Care Units: A Cross-Sectional Study

Due date for the first draft: 10 : 30 AM 30/ 04/ 2026

Time & date for final submitted: HR : MIN AM / PM XX/ XX/ XXXX

Academic Honesty

All forms of plagiarism and unauthorised collusion are regarded as academic dishonesty by the SCFHS, resulting in penalties including failure of the unit of study and possible disciplinary action.

In submitting this assignment, I acknowledge the following:

· I certify that this work is substantially my own, and where any part of this work is not my own, I have indicated as such by acknowledging the source of that part or those parts of the work.

· The proposal has not been submitted previously for assessment in another center.

· The assignment conforms to the requirements in the module outlines .

· I have retained a duplicate copy of the assignment.

Trainee’s name: Nouf Yaseen Aloufi Date: 30/04/2026

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Page 1 of 2

Table of Contents

1. Introduction	1
1.1 Background of the Clinical Problem	1
1.2 Statement of the Problem	2
1.3 Aim and Objectives	3
1.4 Research Questions	3
1.5 Research Hypotheses	4
1.6 Research Significance	4
1.7 Operational Definitions	5
2. Literature Review	6
3. Methodology	11
3.1 Study Design	11
3.2 Study Setting	11
3.3 Sampling Method	12
3.4 Data Collection Instrument	13
3.5 Research Variables and Levels of Measurement	14
3.6 Reliability and Validity	15
3.7 Ethical Considerations	16
3.8 Data Analysis Plan	16
References	18
Appendices	21
Appendix (A): Research Questionnaire	21
Appendix (B): Informed Consent Form	25

1. Introduction

Pain is often referred to as the fifth vital sign highlighting its fundamental importance in clinical care. In the high-stakes environment of a critical care unit, patients are frequently unable to speak for themselves due to severe illness, the use of ventilators, or heavy sedation. This makes the nurse the primary advocate for the patient’s comfort. According to Xi et al. (2026), the quality of pain relief depends heavily on the nurse’s ability to recognize and interpret subtle signs of distress. However, managing pain is a complex task that requires more than just clinical skill; it requires a deep foundation of evidence-based knowledge and a supportive professional attitude (Ahmadi et al., 2023). While there is a vast amount of global research on this topic, the unique challenges of critical care demand that we look closely at how nurses apply their training in real-world settings (Kara & Çamlı, 2025).

Furthermore, the clinical environment of critical care units is uniquely demanding, requiring nurses to possess specialized competencies that go beyond general nursing care (Shahin et al., 2026). Because patients in the ICU often face life-threatening conditions, the ability to balance pain relief with other complex treatments, such as sedation, is essential for maintaining patient safety and comfort. Research by Alhamyani et al. (2026) suggests that the competency of nurses in handling these intricate medication regimes is a vital component of effective critical care within the Saudi Arabian healthcare system. When nurses lack updated, evidence-based knowledge, it can lead to hesitation in clinical decision-making, which directly impacts the speed of a patient’s recovery and their overall experience in the hospital.

In the context of Saudi Arabia, the healthcare system has seen massive improvements, yet managing pain remains a significant challenge for nursing staff, particularly within high-acuity environments. Recent empirical evidence underscores the magnitude of this gap; for instance, Jamal et al. (2023) identified that 48.2% of ICU and emergency department nurses in Saudi Arabia demonstrated a "poor" level of pain management knowledge. Similarly, research by Almutairi et al. (2022) in governmental hospitals revealed a mean awareness score of only 22.59 using the NKASRP tool, signaling a critical deficiency in evidence-based behavior. These data suggest that while nurses are highly committed, systemic inconsistencies persist in how pain is assessed and treated across different regions. Furthermore, Alsalman et al. (2023) observed that educational background and clinical experience are pivotal, as nurses with limited specialized training often report lower confidence levels—a factor that may contribute to why nearly 70% of ICU patients in the region still experience moderate to severe undertreated pain (Alhamyani et al., 2026).

By exploring these factors specifically within King Fahad Hospital in Medina, this study seeks to identify whether current nursing behaviors and attitudes align with the high-quality, evidence-based standards required in modern intensive care settings.

1.1. Statement of the Problem

Despite the availability of advanced medical protocols, many patients in intensive care units still suffer from undertreated pain. This is a serious issue because untreated pain can lead to slower recovery, psychological distress, and long-term health complications. The problem often stems from a gap in the specialized knowledge required to assess pain in patients who cannot communicate. For instance, Al-Sayaghi et al. (2022) found that many nurses in Saudi Arabia hold misconceptions about the risks of pain medications, which can lead to the under-treatment of patients. Furthermore, the complexity of managing sedation alongside pain often creates confusion in critical care settings (Alhamyani et al., 2026).

Local studies in Saudi Arabia consistently demonstrate that nursing knowledge and professional attitudes often deviate from evidence-based standards. For instance, Shahin et al. (2026) observed that even in tertiary hospitals, nurses' baseline knowledge remains at a moderate level, with significant gaps specifically regarding the pharmacology of analgesics. Furthermore, Jamal et al. (2023) highlighted that nearly 48.2% of critical care nurses in the Kingdom possess "poor" levels of technical expertise, often struggling with the specific competencies required to manage pain in the complex ICU environment. This lack of proficiency is frequently compounded by attitudinal barriers; Almutairi et al. (2022) emphasized that misconceptions regarding opioid addiction and a lack of ongoing specialized education remain pervasive obstacles that hinder effective bedside practice across governmental hospitals.

In light of these findings, there is an urgent need to identify the specific knowledge gaps and negative attitudes unique to the Medina region. This study aims to provide a site-specific baseline that is currently missing from the Saudi literature. By pinpointing localized deficits at King Fahad Hospital, this research will contribute to the development of a tailored, evidence-based instructional program. Ultimately, this study serves as a necessary foundation for improving clinical outcomes and ensuring that every patient in Medina’s critical care units receives the compassionate and effective pain care mandated by Saudi Arabia’s Vision 2030 healthcare standards.

1.2. Aim and Objectives

The primary aim of this study is to investigate the levels of knowledge and attitudes regarding pain management among nurses working in critical care units at King Fahad Hospital (KFH) in Medina.

The objectives of the research are:

1. To assess the current level of evidence-based knowledge concerning pain management among nurses working in the critical care units at KFH in Medina.

2. To examine the prevailing attitudes and professional beliefs of the nursing staff at KFH in Medina regarding their clinical role and responsibilities in managing patient pain.

3. To determine if there are statistically significant differences in the nurses' levels of pain management knowledge and attitudes based on their demographic and professional characteristics.

1.3. Research Questions

This research seeks to answer the following questions:

1. What is the current level of knowledge concerning pain management among nurses working in the critical care units at KFH in Medina?

2. What are the prevailing attitudes and professional beliefs of the nursing staff at KFH in Medina regarding their role in managing patient pain?

3. Are there significant differences in pain management knowledge and attitudes based on nurses’ demographic and professional characteristics?

1.4. Research Hypotheses

Below are the research hypotheses:

H1: There is a statistically significant difference in the levels of pain management knowledge among nurses at KFH based on their demographic and professional characteristics.

H2: There is a statistically significant relationship between the attitudes of KFH nurses and their demographic and professional characteristics.

1.5. Research Significance

This study is highly significant as it addresses a critical gap in localized healthcare data within the Medina region. By identifying the specific strengths and weaknesses in nursing knowledge, the hospital can develop focused educational interventions that align with Saudi Arabia’s national healthcare standards (Al-Sayaghi et al., 2022). Furthermore, understanding nursing attitudes allows for the creation of a more supportive clinical environment, ultimately ensuring that patients in critical care receive the most compassionate and effective treatment possible. This research serves as a foundation for improving nursing quality at KFH, bringing its practices in line with the high benchmarks set by the Saudi ministry of health in order to fulfil the goals of Vision 2030.

1.6. Operational Definitions

Pain Management: The nurses’ clinical practice of identifying, evaluating, and alleviating physical distress in patients at KFH using a combination of pharmacological and non-pharmacological strategies.

Critical Care: The specialized medical environment of the Intensive Care Unit (ICU) at KFH where nurses provide continuous monitoring and life-saving interventions for patients with complex or unstable health conditions.

Knowledge: The theoretical understanding and clinical comprehension of pain assessment methodologies, analgesic pharmacology, and evidence-based pain management principles, as quantified by the total score obtained on the Pain Management Principles Assessment Test (PMPAT).

Attitudes: The professional beliefs, perceptions, and predispositions held by nursing staff regarding their role in alleviating pain, the legitimacy of patient reports, and the ethics of analgesic administration, as measured by the Nurse Attitude Survey (NAS).

2. Literature Review

Pain management is one of the most critical aspects of healthcare, as it directly impacts a patient’s recovery, comfort, and overall quality of life (Alhamyani et al., 2026). For nurses, especially those working in high-pressure environments like Intensive Care Units (ICUs) and emergency departments, understanding how to assess and treat pain is a fundamental responsibility. Because pain is a complex and subjective experience, there is a vast amount of research dedicated to evaluating whether nurses have the right knowledge and the proper attitudes to manage it effectively. The following review examines recent studies, highlighting a global trend of knowledge gaps and the urgent need for better professional training.

Xi et al. (2026) aimed to evaluate the knowledge and attitudes of nurses in Japan using the Japanese version of the Knowledge and Attitudes Survey Regarding Pain (J-KASRP). This descriptive, cross-sectional study involved 856 valid responses from nurses at three university-affiliated hospitals in Western Japan. The findings revealed a significant deficit, with a mean correct response rate of only 59.8% and a particularly low understanding of cancer-related pain. The researchers concluded that prior clinical education and experience with opioids were key factors in higher scores, suggesting that Japanese nursing curricula need to be strengthened in the areas of pharmacology and specialized pain care.

Moving from Japan to the African context, Kaminsa (2025) conducted a quantitative cross-sectional study to assess the knowledge, attitudes, and practices of 53 nurses in the intensive care units of Kasama General Hospital in Zambia. Using a census sampling method and self-administered questionnaires, the study found that gender and years of experience significantly influenced how well nurses managed pain, with female nurses and those with over a decade of experience showing better practices. The study implies that positive attitudes and high knowledge levels are directly linked to better patient care, highlighting a need for intensified professional development programs in Zambian ICUs.

Focusing on the Middle East, Alanizi et al. (2025) investigated the knowledge and attitudes of 161 registered nurses in Riyadh, Saudi Arabia. This quantitative cross-sectional study used the KASRP tool to find that nurses possessed only a moderate level of knowledge, with fewer than 25% reaching a "good" score. Interestingly, nurses in surgical and emergency units performed better, likely due to the frequent use of pain protocols in those settings. The study concludes that educational strategies must be enhanced to address misconceptions regarding opioid dependency and the ethics of using placebos in pain management.

In Thailand, Chaleewong et al. (2024) explored similar themes by surveying 158 critical care nurses in a tertiary hospital. This cross-sectional research found that the participants generally possessed inadequate knowledge and negative attitudes toward pain management, identifying the inability of patients to communicate as a primary barrier. The results showed that specialized certification in intensive care nursing improved performance. Consequently, the study recommends using innovative training methods, such as virtual reality and case simulations, to help nurses overcome communication barriers in the ICU.

Exploring the specific environment of university hospitals in Saudi Arabia, Jamal et al. (2023) assessed 112 nurses working in ICUs and emergency departments. This descriptive cross-sectional study used the KASRP survey and discovered that a staggering 48.2% of the nurses had a poor level of knowledge. The findings indicated a strong link between a nurse’s specific position in the ICU and their level of expertise. The researchers emphasized that it is mandatory for hospitals to continuously monitor nursing knowledge and implement educational programs that are tailored to the realities of critical care nursing.

Ahmadi et al. (2023) conducted a descriptive-analytical study involving 400 nurses across 23 hospitals to determine their readiness for pain control in emergency departments. Using the Nurse Attitude Survey and a specialized principles test, the study found that 84.8% of participants had low knowledge levels. Surprisingly, the research noted that older nurses and those with more work experience often had more negative attitudes and lower knowledge scores. This implies that long-term experience does not always equal updated knowledge, stressing the need for modern, scientific retraining courses to refresh the skills of veteran staff.

Sweity et al. (2022) used an online cross-sectional survey to analyze the knowledge, attitudes, and practices of 191 ICU nurses. The study revealed significant gaps, particularly a widespread reluctance to prescribe opioids (nearly 80%) and a general lack of proficiency in pain management. Despite these gaps, the nurses indicated they were diligent about evaluating pain during their rounds. The conclusion drawn is that Palestinian ICU settings require robust interventional programs to foster better attitudes and align nursing practices with international evidence-based standards.

Similarly, Almutairi et al. (2022) looked at the Al-Qassim region of Saudi Arabia, conducting a cross-sectional correlational study across five governmental hospitals. By surveying nurses using the NKASRP tool, the researchers found a mean awareness score of 22.59, which indicates a deficit in both knowledge and behavior. The study found that while age and total clinical experience were positively correlated with better scores, factors like religion and education level did not make a significant difference. The main implication is that regular, standardized pain management programs are essential for ICU nurses throughout the region to overcome identified barriers.

Rababa et al. (2021) provided a broader perspective through a systematic review of existing literature, following PRISMA guidelines to identify barriers and facilitators in adult critical care. This study categorized obstacles into four groups: nurse, patient, physician, and system-related factors. Key barriers included a lack of standardized guidelines and the inability of patients to communicate, while facilitators included effective collaboration and nurse-to-nurse handovers. The review highlights that while individual knowledge is important, the entire healthcare system must support pain management through clear protocols and multidisciplinary teamwork.

Furthermore, Liyew et al. (2020) conducted a stratified random sampling of 422 nurses at the University of Gondar Hospital to assess their pain management profiles. This institution-based cross-sectional study found that while 66.9% of nurses had "good" knowledge, their attitudes remained relatively low compared to international benchmarks. The research suggests that even when nurses understand the theory of pain management, they may lack the "favorable attitude" necessary to apply it effectively. This implies that educational initiatives in Ethiopia should focus not just on facts, but on shifting the professional culture and mindset regarding patient suffering.

Finally, Majeed et al. (2020) carried out a descriptive cross-sectional study among 100 nurses in Baghdad, Iraq, across various surgical and intensive care units. Using a modified version of the NKASRP, the study found that the majority of participants were young males with relatively short work experience. The results indicated that while the nurses had overall positive attitudes toward helping patients, their actual technical knowledge about pain management was poor. The study serves as a call to action for Iraqi teaching hospitals to bridge the gap between the desire to provide good care and the technical knowledge required to do so.

2.1. Research Gap

While the eleven studies reviewed provide a comprehensive global and regional overview of nurses' knowledge and attitudes regarding pain management, they reveal a clear research gap that the current study at King Fahad Hospital (KFH) in Medina seeks to fill. Most of the existing Saudi Arabian research, such as the work by Alanizi et al. (2025) and Almutairi et al. (2022), focuses on Riyadh or the Al-Qassim region. There is a lack of recent, site-specific data concerning the healthcare landscape in Medina, which has its own unique organizational culture and patient demographics. Furthermore, while previous studies often highlight a general lack of knowledge, they frequently miss the specific intersection of "knowledge" and "attitude" within the high-acuity environment of KFH's critical care units.

The current study is innovative because it applies a cross-sectional approach specifically to the nursing staff at KFH in Medina, using a tailored questionnaire to capture the nuances of local practice. By focusing on this specific setting, the research moves beyond generalities and provides a localized snapshot that is essential for developing targeted hospital policies. Unlike the systematic reviews or multi-center studies that generalize findings, this study pinpointed the unique barriers faced by nurses in Medina, offering a fresh perspective on how regional differences affect the quality of pain care in Saudi Arabia.

3. Methodology

3.1. Study Design

This research utilizes a descriptive, cross-sectional research design. This approach is appropriate for capturing a "snapshot" of the current levels of knowledge and professional attitudes regarding pain management among nurses at a single point in time. By using this design, the researcher can identify specific areas where nursing staff may require additional training or support.

3.2. Study Setting

The research will be conducted at King Fahad Hospital (KFH) in Medina, Saudi Arabia. KFH is a major healthcare facility in the region that provides comprehensive medical services, including specialized adult care. This setting is ideal as it houses various Critical Care Units (ICUs) where nurses manage complex cases requiring precise pain assessment and pharmacological interventions.

3.3. Sampling Method

3.3. Sampling Method

The research population consists of all nurses currently working in the Critical Care Units (ICUs) at King Fahad Hospital (KFH) in Medina (N = 70). Given the relatively small size of the population, a complete census sampling approach will be employed. This means the researcher will invite the entire population to participate, rather than a subset, to maximize the statistical power of the study and ensure a comprehensive representation of local nursing expertise.

Inclusion Criteria:

To be eligible for participation, nurses must meet the following requirements:

· Employment Status: Full-time bedside nurses currently employed at KFH.

· Clinical Setting: Assigned to provide direct patient care within the adult Intensive Care Units.

· Experience Level: Have completed at least six continuous months of service in the KFH ICU to ensure sufficient familiarity with the hospital’s pain management protocols.

Exclusion Criteria:

The following individuals will be excluded from the study:

· Temporary Staff: Nursing interns, students, and agency or locum nurses whose training may not reflect KFH’s specific organizational standards.

· Nurses on Leave: Staff members who are on extended annual, maternity, or sick leave during the four-week data collection period.

· Administrative Staff: Nursing managers or supervisors who do not provide direct, daily bedside clinical care to patients.

· Voluntary Exclusion: Any nurse who does not provide written informed consent to participate.

Non-response Strategy:

To promote a high response rate and minimize non-response bias, bi-weekly reminders will be distributed through the hospital’s internal communication system (official email and department-specific messaging groups) over a four-week period.

3.4. Data Collection Instrument

The study will utilize a structured survey adapted from the validated instruments used by Ahmadi et al. (2023) . The tool is divided into three main sections:

· Section 1: Demographic Data: Collects basic information such as age, gender, marital status, education level, years of work experience, and prior participation in pain management training.

· Section 2: Knowledge Domain (31 items): Uses the Pain Management and Control Principles Assessment Test (PMPAT). This section assesses the nurse's understanding of the concept of pain, assessment techniques, and the use of analgesics.

· Section 3: Attitude Domain (25 items): Uses the Nurse Attitude Survey (NAS). This section evaluates professional beliefs regarding patient reports of pain, the use of opioids, and the importance of regular pain assessment.

In knowledge section, each question has only one correct option. A score of 1 point is awarded for every correct answer, while 0 points are given for incorrect answers

Items in the Attitude section are scored on a 4-point Likert scale, ranging from "Completely Disagree" to "Completely Agree". Higher scores in both domains indicate more positive attitudes and advanced knowledge of pain management.

3.5. Research Variables

The variables for this study are organized to evaluate how personal and professional backgrounds influence nursing expertise.

Table 3.1

Research Variables

Variable Type	Variable Name	Level of Measurement
Independent	Demographic Characteristics	Nominal / Ordinal
Dependent	Knowledge	Interval
Dependent	Attitude	Interval

3.6. Reliability and Validity

The instruments have undergone rigorous validation. The original PMPAT and NAS instruments were validated by a panel of experts consisting of specialists in nursing education, clinical anesthesia, and pharmacology (Ahmadi et al., 2023). Content Validity was established by ensuring the items comprehensively cover the clinical domains of pain assessment and management. For the current study at KFH, the instrument will be reviewed by a local committee of senior nursing researchers to ensure Face Validity and cultural appropriateness for the Saudi healthcare context.

In the original research, the scale demonstrated high internal consistency with a Cronbach’s alpha of 86%, confirming that the items are reliable for measuring nursing perceptions. To maintain the rigor of the current study, several biases will be managed:

· Self-Report Bias: Participants may overestimate their competency. To mitigate this, the survey is anonymous, and participants are encouraged to provide honest responses without fear of professional evaluation.

· Social Desirability Bias: Nurses might provide answers they believe are "academically correct" rather than reflecting their actual practice. Emphasizing confidentiality in the informed consent helps reduce this pressure.

3.7. Ethical Considerations

Ethical approval will be obtained from the appropriate Institutional Review Board (IRB). Participation is entirely voluntary, and all nurses will be provided with an informed consent form. No identifying information, such as names or staff IDs, will be collected to ensure total anonymity.

All collected data will be treated as strictly confidential. Digital data files, including SPSS databases and electronic survey responses, will be stored on a secure, encrypted, and password-protected drive accessible only to the primary researcher. Any hard-copy documents (such as signed consent forms) will be kept in a locked filing cabinet within a secure office at the research site.

3.8. Data Analysis

The data will be analyzed using SPSS version 26. Descriptive statistics will be employed to provide a comprehensive summary of both the sample characteristics and the primary research variables. Categorical demographic data, including gender, educational level, and years of professional experience, will be reported using frequencies (n) and percentages. For the continuous variables of knowledge and attitude, the data will be summarized through means (M) and standard deviations (SD). To provide clinical context, the resulting scores will be qualitatively categorized into levels—such as "Poor," "Moderate," or "Good"—according to the predetermined cutoff thresholds established by the original validated instruments.

To address the primary research hypotheses ( H1 and H2), a series of inferential statistical tests will be performed, provided the data meets the assumptions of normal distribution. An Independent Samples T-test will be utilized to compare mean scores of knowledge and attitudes across binary categorical variables, such as gender or prior participation in pain management training. For variables containing three or more categories, such as age groups or various levels of work experience, a One-Way ANOVA will be conducted. In instances where the ANOVA yields statistically significant results, a Tukey HSD post-hoc test will be applied to pinpoint the specific nature of the differences between the groups.

Furthermore, a Pearson correlation coefficient (r) will be calculated to investigate the strength and direction of the potential relationship between the nurses' theoretical knowledge and their professional attitudes toward pain management. For all inferential procedures, the threshold for statistical significance will be strictly maintained at p < 0.05. All findings will be reported alongside a 95% Confidence Interval (CI) to ensure the precision and clinical reliability of the estimated parameters.

References

Ahmadi, S., Vojdani, P., & MortezaBagi, H. R. (2023). The study of nurses’ knowledge and attitudes regarding pain management and control in emergency departments.  BMC emergency medicine,  23(1), 26.‏

Alanizi, A. W., Shaqiqi, W., Cabaldo, L. C., Awaji, R. M., Alotaibi, R. A., & Alanazi, A. M. (2025). Nurses’ Knowledge and Attitudes Toward Pain Assessment and Management: A Cross‐Sectional Study.  Nursing Research and Practice,  2025(1), 6646998.‏

Alhamyani, M. M., Youssef, N. F., & Almutairi, A. S. (2026). Competency Of Critical Care Nurses In Sedation Administration: A Cross-Sectional Survey In Saudi Arabia.  The Review of Diabetic Studies, 10-25.‏

Almutairi, A. M., Pandaan, I. N., Alsufyani, A. M., Almutiri, D. R., Alhindi, A. A., & Alhusseinan, K. S. (2022). Managing patients’ pain in the intensive care units: Nurses’ awareness of pain management.  Saudi Medical Journal,  43(5), 514.‏

Alsalman, A., Mansour, M., & Almobarak, F. (2023). Nurses' knowledge and attitudes regarding pain management: Cross‐sectional survey in the Eastern Province of Saudi Arabia.  Nursing Open,  10(8), 5306-5313.‏

Al-Sayaghi, K. M., Fadlalmola, H. A., Aljohani, W. A., Alenezi, A. M., Aljohani, D. T., Aljohani, T. A. & Khan, M. F. (2022, March). Nurses’ knowledge and attitudes regarding pain assessment and management in Saudi Arabia. In  Healthcare (Vol. 10, No. 3, p. 528). MDPI.‏

Chaleewong, N., Chaiviboontham, S., & Christensen, M. (2024). Knowledge, attitudes, and perceived barriers regarding pain assessment and management among Thai critical care nurses: A cross-sectional study.  Intensive and Critical Care Nursing,  84, 103764.‏

Jamal, K., Alameri, R. A., Alqahtani, F. M., AlGarni, R. S., Alamri, N. A., Elshnawie, H. A. & Hussien, A. M. (2023). Knowledge and attitudes of critical care nurses regarding pain management in Saudi Arabia.  Medical Archives,  77(1), 49.‏

Kaminsa, C. (2025).  Nurses knowledge, attitudes and practices towards pain assessment and management in intensive care units at Kasama General hospital, Zambia (Doctoral dissertation, The University of Zambia).‏

Kara, H., & Çamlı, D. Ç. (2025). From knowledge to practice, intensive care nurses’ pain management behaviors in Turkey: a cross sectional study.  BMC nursing,  24(1), 1469.‏

Liyew, B., Dejen Tilahun, A., Habtie Bayu, N., & Kassew, T. (2020). Knowledge and attitude towards pain management among nurses working at university of Gondar comprehensive specialized hospital, Northwest Ethiopia.  Pain Research and Management,  2020(1), 6036575.‏

Majeed, H. M., Hassan, A. F., & Abid, R. I. (2020). Evaluation of nurses’ knowledge and attitudes toward pain management at Baghdad Teaching Hospitals.  Indian J Forensic Med Toxicol,  14(2), 1574-9.‏

Rababa, M., Al-Sabbah, S., & Hayajneh, A. A. (2021). Nurses’ perceived barriers to and facilitators of pain assessment and management in critical care patients: a systematic review.  Journal of pain research, 3475-3491.‏

Shahin, M. A. H., Alamoudi, F., Ramadan, M. Y., Abdalla, A., Al Ojaimi, S. F., Al Saadi, N. S. & Alfahd, H. (2026, March). Nurses’ Knowledge and Attitudes Toward Pain Management at a Tertiary Hospital in Saudi Arabia: Impact of an Evidence-Based Instructional Program. In  Healthcare (Vol. 14, No. 6, p. 729). MDPI.‏

Sweity, E. M., Salahat, A. M., Sada, A. A., Aswad, A., Zabin, L. M., & Zyoud, S. E. H. (2022). Knowledge, attitude, practice and perceived barriers of nurses working in intensive care unit on pain management of critically ill patients: a cross-sectional study.  BMC nursing,  21(1), 202.‏

Xi, M., Kajiwara, Y., Hiramatsu, T., & Morimoto, M. (2026). Knowledge and Attitudes Toward Pain Management Among Nurses in University‐Affiliated Hospitals in Western Japan: A Cross‐Sectional Study. In  Nursing Forum (Vol. 2026, No. 1, p. 9991157). Wiley.‏

Appendices

Appendix (A)

Research Questionnaire

Dear Participant,

Thank you for agreeing to participate in this important study. The aim of this research is to explore the knowledge and attitudes regarding pain management among nurses working in the critical care units at King Fahad Hospital (KFH) in Medina. Your insights will contribute significantly to understanding the current state of clinical practice and identifying the educational needs of nursing staff within our healthcare system.

This questionnaire consists of three sections. The first section collects basic sociodemographic and professional information. The second section assesses your knowledge of pain management principles, and the third section evaluates your professional attitudes toward pain control. Your responses will remain strictly confidential and anonymous.

Thank you for your valuable participation!

Section 1: Sociodemographic Information

Please check the box or fill in the blank as appropriate.

Age: __________

Sex:

[ ] Male

[ ] Female

Marital Status:

[ ] Single

[ ] Married

[ ] Widow

[ ] Divorced

Education Level:

[ ] Bachelor

[ ] MA

Years of Work Experience:

[ ] < 3 years

[ ] 4–7 years

[ ] 8–11 years

[ ] 12–15 years

[ ] 16–19 years

[ ] > 20 years

Employment Status:

[ ] Un-Formal

[ ] Contractual

[ ] Formal

Have you participated in pain management training courses?

[ ] Yes

[ ] No

Part Two: Pain Management Principles Assessment Test (PMPAT)

Please select the most appropriate response for each of the following 31 knowledge-based questions.

1. Percentage of cancer patients who experience pain at some point during their illness: _____

2. Percentage of cancer patients who suffer pain for longer than a month: _____

3. If the patient still complains of pain despite receiving the maximum dose of medication to relieve the pain, what should the nurse always do? _____

4. What is the best way to prescribe narcotic analgesics in cancer patients? _____

5. What is the best time to seek medication in a patient on prescription analgesia to relieve cancer pain? _____

6. Who can make the most accurate and reliable judgment about the pain intensity of cancer patients? _____

7. What percentage of patients who take narcotic analgesics on a scheduled basis become addicted to these drugs? _____

8. Which of the following statements correctly describes the mechanism of action of analgesics? _____

9. What type of pain can be treated with skin irritations? _____

10. Which of the following statements correctly describes the philosophy of using analgesics in patients with advanced cancer? _____

11. Which group of symptoms is most associated with chronic pain? _____

12. Which of the following drugs has the longest duration of action? _____

13. Which cases are usually associated with acute pain? _____

14. Which of the following is perceived as itching and throbbing pain? _____

15. According to pain control gate theory, what is the area responsible for this function in the nervous system? _____

16. By what is pain regulated? _____

17. Ms. Colton is a 72-kilogram, 24-year-old woman. She underwent hysterectomy and received 8mg of morphine at 4 p.m. It is now 4:16 p.m. and she has complained of pain and is asking for more drugs. What is her pain most related to? _____

18. What should be your goal in managing pain in Ms. Colton after an abdominal hysterectomy? _____

19. Mr. West has prostate cancer that has metastasized to the bone. What is the first factor we need to consider when caring for him? _____

20. In assessing the patient's pain, what variables should the nurse consider that are effective in expressing pain? _____

21. How does naloxone work? _____

22. The researchers showed that: _____ (re: Physician/Nurse prescribing habits)

23. What is one of the main disadvantages of meperidine? _____

24. Which of the following methods of prescribing narcotic analgesics produces a fixed level of analgesia? _____

25. What are the primary benefits of having a consistent level of pain control? _____

26. The nurse's decision to give analgesics should be based on all of the following, other than: _____

27. Who has the most control over the patient's pain management program? _____

28. Definition of Tolerance: After repeated doses, the effect of a drug decreases and the patient needs higher doses. This decline begins with: _____

29. Ms. Stone has metastatic breast cancer and painful lesions in the spinal cord. Using a back massage and a hot pack is an example of: _____

30. Focusing on techniques such as reading books or knitting to manage pain is called: _____

31. Which of the following is sufficient to manage pain for Ms. Strick (72-year-old with metastatic cancer and severe arthritis)? _____

Part Three: Nurse Attitude Survey

Please put a (√) mark in the slot that fits your opinion for each statement.

No	Statements	Completely Disagree	Disagree	Agree	Completely Agree
1	Giving opioids on a regular schedule is preferred over PRN.
2	A patient should experience discomfort prior to receiving the next dose of pain medication.
3	Continuous assessment of pain and medication effectiveness is necessary for good pain management.
4	Patients (or their family members) have the right to request pain medication before the pain returns.
5	Patients may be hesitant to ask for pain medication due to fear of the use of opioids.
6	Patients receiving opioids on a PRN basis are likely to develop "clock watching" behaviors.
7	Estimation of pain by a physician or nurse is a more valid measure of pain than by patient report.
8	Patients in pain can tolerate high doses of opioids without sedation or respiratory depression.
9	Patients can be maintained in a pain-free state.
10	If a patient reports pain relief and euphoria, a lower dose should be given the next time.
11	Patients with chronic pain should receive medication at regular intervals with or without the presence of pain.
12	Patients receiving around-the-clock opioids are at risk for sedation and respiratory depression.
13	Patients with severe chronic pain need higher doses of medication compared to acute pain.
14	Patients should be maintained in a pain-free state.
15	Lack of pain expression does not necessarily mean lack of pain.
16	Cancer pain can be relieved with anti-cancer drugs, radiation therapy, and/or pain medications.
17	If the patient continues to have pain after medication, the nurse should contact the physician.
18	Patients receiving around-the-clock opioids for cancer are likely to become addicted.
19	Distraction and diversion can decrease the perception of pain.
20	A constant level of analgesic should be maintained in the blood to control pain effectively.
21	Increasing analgesic requirements and physical symptoms are signs of addiction.
22	The cancer patient and family should have more control over the schedule for analgesics than the health professional.
23	The nurse can make a more accurate assessment of the patient's pain than the patient.
24	Cutaneous stimulation (heat, massage, ice) are only effective for mild pain.
25	Best time to seek medication for a patient on cancer who is on prescription pain medication.

Appendix (B)

Informed Consent

Study Title: Nurses’ Knowledge and Attitudes Regarding Pain Management in Critical Care Units: A Cross-Sectional Study.

Setting: King Fahad Hospital (KFH), Medina, Saudi Arabia.

Introduction and Purpose:

You are cordially invited to participate in a research study aimed at exploring the knowledge and professional attitudes of nurses regarding pain management within the critical care units at King Fahad Hospital. The goal of this research is to identify current strengths and areas for improvement in clinical practice. By understanding your perspectives, we can better determine the specific educational needs and training programs required to enhance patient care and outcomes in the Medina region.

Procedures:

If you agree to take part, you will be asked to complete a research questionnaire that includes three main parts:

1. Section One: Questions about your professional and demographic background, such as age and years of experience.

2. Section Two (Knowledge): A series of multiple-choice questions regarding pain assessment principles and medications.

3. Section Three (Attitude): A survey where you will indicate your level of agreement with various statements about your beliefs and role in managing pain. Completing the entire questionnaire is expected to take approximately 15 to 20 minutes.

Voluntary Participation and Right to Withdraw:

Your participation in this study is entirely voluntary. You have the right to refuse to participate or to withdraw from the study at any time without any penalty or impact on your professional status at King Fahad Hospital. You are also free to skip any questions you do not feel comfortable answering.

Confidentiality and Anonymity:

To protect your privacy, this study is completely anonymous. No names or identifying personal information will be linked to your responses. All data collected will be stored securely and will be accessible only to the research team for analysis. Results will be reported as group data, ensuring that individual responses cannot be identified.

Risks and Benefits:

There are no known physical or psychological risks associated with participating in this research. While there may be no direct personal benefit to you, your contribution is vital in helping the nursing profession in Saudi Arabia move toward more evidence-based practices. The findings will help shape future training initiatives at KFH, ultimately benefiting the patients we serve.

Statement of Consent

By signing below, I confirm that I have read and understood the information provided above. I have had the opportunity to ask questions, and I voluntarily agree to participate in this study.

Participant Signature: ______________________________

Date: ____________________

Researcher Signature: ______________________________

Date: ____________________

CRITERIA FOR EVALUATION OF RESEARCH PROPOSAL

The body of your research proposal should be no longer than 25 pages (excluding the cover sheet, table of contents, references and appendix). Appendix materials may include data collecting instruments and informed consent form. APA format, 6th edition should be used. Use headings to identify sections of the proposal.

Criteria:

1. Research Problem: Background and significance; Purpose, Research questions,

Variables, Definition of terms, Hypotheses (30 points)

· The problem area and its significance to nursing are clearly defined.

· The purpose of the study is clearly stated.

· Questions and hypotheses ( if appropriate) are clearly stated.

· All essential variables are conceptually and operationally defined.

2. Review of Literature and Conceptual/Theoretical Framework (15 points)

· Literature review consists of conceptual and data-based articles and is related to the problem.

· Literature review is logically organized and provides a summarizing paragraph at the end of the section.

· Conceptual/Theoretical framework is clearly explained with justification on its use in the proposed study.

3. Methodology: Research Design, Sampling, Data Collection Tools and Plan for

Data analyses (35 points)

· Research design is adequately described and appropriate for the purpose of the study; validity threats are addressed.

· the area or setting where the study will be conducted is described.

· study subjects inclusion and exclusion criteria is idetified

· Sampling techniques and sample size are described with appropriate rationale.

· Data collection instruments are clearly described including validity and reliability.

· Plan for data analysis is clearly explained including level of data and statistical analysis indicated to answer research questions.

4. Ethical Considerations (5 points)

· Protection of human subjects is adequately addressed. Sample of informed consent is provided in appendix.

· Protection of participant’s privacy, Data Storage & Confidentiality is discussed.

5. Clarity, Format and Style (15 points)

· The proposal is clearly written and organized in research format. The proposal is appropriately concise and always relevant (to the topic being covered). All facts presented in the proposal are accurate and research related to citations is also discussed in an accurate fashion

· The proposal is free from errors in grammar and typing (evidence of careful proofreading).

· The proposal is perfectly formatted according to APA formatting guidelines.

SCIENTIFIC NURSING RESEARCH EVALUATION CRITERIA	FULL MARKS	SCORED
1. Research Problem: Background and significance; Purpose, Research Questions, Variables, Definition of terms, Hypotheses (30 points)
Background (10 Points)
Background information to the clinical problem well discussed.	5
The importance of conducting the research is explained.	5
Problem Statement: (10 Points)
The problem statement problem is formulated either in question or declarative form.	5		Rewrite as a clear declarative statement: e.g., "Pain remains undertreated in Saudi ICUs due to gaps in nursing knowledge and attitude.
The problem statement is well discussed and supported with current data.	5
Research Objectives/Question/hypotheses (6 Points):
The purpose of the intended research is clearly stated.	2
The objectives are stated in measurable manners	2
Questions and hypotheses ( if appropriate) are clearly stated.	2
Operational Definitions (4 Points):
The main concepts in the topic and variables are defined.	4		Add operational definitions for: (1) Knowledge, (2) Attitudes, and (3) ICU Nurses, using literature-based definitions
TOTAL / 30	30
2. Review of Literature / Conceptual/Theoretical Framework (15 points)
Literature review consists of conceptual and data-based articles and is related to the problem.	4
Literature review is logically organized and provides a summarizing paragraph at the end of the section.	4		Add a brief summarising paragraph at the end of the literature review section that synthesises the key themes and explicitly links them to the current study.
The best/most relevant evidence was collected to support the data.	4		Prioritise studies from ICU settings and Saudi/Gulf contexts.
The sources are up to date (within 5 years, except classical sources).	3
TOTAL / 15	15
3. Methodology: Research Design, Sampling, Data Collection Tools and Plan for Data analyses (35 points)
·         Research design is adequately described and appropriate for the purpose of the study; validity threats are addressed.	6
·         the area or setting where the study will be conducted is described.	6
·         study subjects inclusion and exclusion criteria is idetified	6		Add explicit exclusion criteria (e.g., agency nurses, nurses on leave….
·         Sampling techniques and sample size are described with appropriate rationale.	6		State the specific calculated sample size. Include the formula use
·         Data collection instruments are clearly described including validity and reliability.	6		Explain the validity of the tool Describe any cultural/linguistic adaptation of the tools. If translated to Arabic, describe the back-translation process and any pilot testing conducted at KFH.
·         Plan for data analysis is clearly explained including level of data and statistical analysis indicated to answer research questions.	5
TOTAL / 35	35
4. Ethical Considerations (5 points)
Protection of human subjects is adequately addressed. Sample of informed consent is provided in appendix.	3
Protection of participant’s privacy, Data Storage & Confidentiality is discussed.	2
TOTAL / 5	5
5. Clarity, Format and Style (15 points)
         The proposal is clearly written and organized in research format. The proposal is appropriately concise and always relevant (to the topic being covered). All facts presented in the proposal are accurate and research related to citations is also discussed in an accurate fashion	5
         The proposal is free from errors in grammar and typing (evidence of careful proofreading).	5
         The proposal is perfectly formatted according to APA formatting guidelines.	5
TOTAL / 15	15
TOTAL / 100	100

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