Chest pain accounts for 2% – 4% of all new attendances at emergency departments in the United Kingdom. Chest pain can be the presenting complaint in a myriad of disorders ranging from life threats such as acute myocardial infarction to mild self-limiting disorders such as muscle strain ⁽⁶⁾.

Current research suggests that pain is a relatively common phenomenon with 60–90% of patients presenting to emergency departments reporting pain (e.g., chest pain, trauma, extremity fractures and migraine headache) that require treatment ⁽⁷⁾.

Complaints of chest pain represent between 20 and 30% of all medical admissions and, of these, only a third will be diagnosed as having an acute coronary syndrome ⁽⁸⁾. In Pottle’s (2005) study of 454 patients, 66.4% of those had ‘atypical’ chest pain. Presentations of acute, undifferentiated chest pain are thus a common occurrence and a challenge for busy clinicians ⁽⁹⁾.

Nurses play a vital role in management of chest pain through nursing practice, research, and patient education ⁽¹⁰⁾.

The process of responding to patient need is considered to begin when patients first come into contact with emergency services. Paramedics are expected to perform an initial assessment of symptoms en route to hospital ⁽¹¹⁾.

The nurse play an important role in the management of chest pain during care of patient during his / her critical situation for these reasons the researcher has under taken this research .

METHODOLOGY:

Design of the study: Quantitative design (a descriptive study) was carried out to evaluate of nurses' knowledge concerning chest pain management that are provided for patients in the emergency unit. Starting from August 3^rd 2014 up to the 30^thof September 2014.

The setting of the study: The study was conducted in emergency units at four Teaching Hospitals in Baghdad city (Baghdad Teaching Hospital, Al-Karama Teaching Hospital, Al-Kindi Teaching Hospital, and Al-Yarmouk Teaching Hospital). These hospitals provide emergency nursing care for patients which suffering from chest pain.

The sample of the study:

A non-probability (purposive) samples of (80) a nurse who was consisted of all nurses who provide emergency nursing care for patients which suffering from chest pain and according to special criteria (Nurses different level of education, Both sexes, and nurses who provided emergency nursing care for adults' patients' age 18 year and above who have been suffering from chest pain), as it is shown in the following figure.

Instrument construction:

After extensive review of relevant literature which includes the emergency nursing care for patients which suffering from chest pain. The questionnaire was constructed for the purpose of the study consisted of (37) items which include two parts:

Part I: Patients’ demographic characteristics, consisted of (9) items.

Part II: Questionnaire concerning nurses knowledge to management of chest pain for patients in the emergency unit consisted of (28) items.

The knowledge were ordinal according to the three level scale which were scored as (I'm uncertain = 1, I don’t know = 2, I know = 3) for each level respectively so the cutoff point was (2).

Validity of the instrument: Content validity was determined through the use of panel of experts.

Conducting pilot study: Before starting the data collection a pilot study was carried out for the following purposes:-

1. Determine the reliability of the questionnaire as an observation checklist.

2. Estimate the time required for the data collection.

3. Obtain the clarity and the content adequacy of the questionnaire and observation.

Reliability of the instrument: Pilot study was conducted during the 1^st to 30^th of June, 2014 on (10) nurses in emergency unit by the researcher who used test - retest;” twice within two weeks” person correlation coefficient was computed for each determination. The results indicated that the correlation coefficient was r = 0.80 at the level (P ≤ 0.05) which was statistically acceptable.

Data collection: The data were collected by self-report with a nurses who provide emergency nursing care for patients which suffering from chest pain in emergency units from August 3^rd 2014 up to the 30^th of September 2014.

Data analysis: The researcher used the appropriate statistical means in the data analysis which include the following:

1. Descriptive data analysis: This approach was performed through the determination of:

a. Frequencies (f)

b. Percentage (%)

c. Mean (x)

d. Mean of score (MS): A mean of score equal to (1.5-2.5) was considered (Moderate Significant), greater than (2.5) was considered high (Highly significant), less than 1.5 was considered low (Not significant).

2. Inferential data analysis:

a. Chi-square (X²) tests: This statistical procedure was used to determine the significance. Statistical association between the demographic characteristics and the nurse's knowledge. In the chi-square divided the patients’ knowledge to three levels of knowledge by:

Range of score = maxims - minimums = 71 - 49

Range = 22 / 3 = 7.3

(49 – 56.3) Poor knowledge

(56.4 – 63.7) Fair knowledge

(63.8 – 71) High knowledge

b. The reliability estimates.

RESULTS:

The table 1 shows that the distribution of age indicated that the majority of nurses’ ages were (20-29) years old that were accounted for (36.2 %).Most of them (55 %) were female. The level of education represents that most of them (50%) were from nursing high school graduate. most of them (56.2%) were married. (40 %) for (1-5) years were employment in nursing, Majority of them (41.2%) were employee (1 – 5 years) in the emergency unit. (58.8 %) of them have training sessions in the management of chest pain for patients in the emergency unit, and finally most of nurses had (51.2%) no pursue education by continuing education.

Table 1. Distribution of nurses by their characteristics

No.	Variables
1.	Age ( years )	F.	%
1.1.	Less than 20 year	6	7.5
1.2.	20- 29 year	29	36.2
1.3.	30- 39 year	26	32.5
1.4.	40- 49 year	17	21.2
1.5.	50 year and more	2	2.5
	Total	80	100
2.	Gender	F.	%
2.1.	Male	36	45
2.2.	Female	44	55
	Total	80	100
3.	Level of education	F.	%
3.1.	Nursing Intermediate School graduate	2	2.5
3.2.	Nursing High School graduate	40	50
3.3.	Nursing college graduate	14	17.5
3.4.	Other	24	30
	Total	80	100
4.	Marital status	F.	%
4.1.	Single	21	26.2
4.2.	Married	45	56.2
4.3.	Widowed	8	10
4.4.	Divorced	4	5
4.5.	Separated	2	2.5
	Total	80	100
5.	Years of employment in Nursing (years)	F.	%
5.1.	Less than one year	8	10
5.2.	1 – 5	32	40
5.3.	6 – 10	19	23.8
5.4.	11 -15	8	10
5.5.	16-20	6	7.5
5.6.	21 and more	7	8.8
	Total	80	100
6.	Number of years of experience in the emergency unit (years)	F.	%
6.1.	Less than one year	13	16.2
6.2.	1 – 5	33	41.2
6.3.	6 – 10	23	28.8
6.4.	11 -15	5	6.2
6.5.	16-20	4	5
6.6.	21 and more	2	2.5
	Total	80	100
7.	Training sessions in the management of chest pain for patients in the emergency unit	F.	%
7.1.	No	47	58.8
7.2.	Yes	33	41.2
	Total	80	100
8.	Pursue education by continuing education	F.	%
8.1.	Yes	39	48.8
8.2.	No	41	51.2
	Total	80	100

Sources of nurses’ know3ledge about management of chest pain for patients in the emergency unit

Figure 2. Sources of nurses’ knowledge about management of chest pain for patients in the emergency unit

The figure 2 show that sources of nurses' knowledge about management of chest pain for patients in the emergency unit was 29 (36.2%) from working with patient which suffering from chest pain.

Table 2. The mean of scores and significant of nurses' knowledge to management of chest pain for patients in the emergency units

No.	Items	I know		I do not know		I'm uncertain		MS	Sig.
No.	Items	F	%	F	%	F	%	MS	Sig.
1.	Loosening tight clothing.	0.0	0.0	80.0	100	0.0	0.0	2.0	M.S
2.	Checking airway.	3.0	3.75	77.0	96.2	0.0	0.0	2.037	M.S
3.	Checking the sound of breathing for patient.	7.0	8.75	73.0	91.2	0.0	0.0	2.087	M.S
4.	Checking the pattern, frequency, depth, and rhythm of breathing for patient.	14.0	17.5	66.0	82.5	0.0	0.0	2.175	M.S
5.	Checking the pulse of peripheral arteries and carotid arteries.	16.0	20.0	62.0	77.5	2.0	2.5	2.175	M.S
6.	Observing the patient use a respirator muscles for breathing.	15.0	18.7	63.0	78.7	2.0	2.5	2.162	M.S
7.	Observing the signs of decrease of oxygen.	13.0	16.25	67.0	83.75	0.0	0.0	2.1625	M.S
8.	Checking the level of conscious for patient.	11.0	13.7	67.0	83.7	2.0	2.5	2.112	M.S
9.	Observing vital signs for patient.	13.0	16.2	63.0	78.7	4.0	5.0	2.112	M.S
10.	Defining the location of pain.	15.0	18.7	60.0	75.0	5.0	6.25	2.125	M.S
11.	Defining the prevalence of pain.	17.0	21.2	56.0	70.0	7.0	8.75	2.125	M.S
12.	Defining the nature of pain.	22.0	27.5	52.0	65.0	6.0	7.5	2.2	M.S
13.	Determining pain characteristics.	28.0	35.0	45.0	56.2	7.0	8.75	2.262	M.S
14.	Determining chronological of pain.	27.0	33.7	44.0	55.0	9.0	11.2	2.225	M.S
15.	Determining factors that reinforce of pain.	16.0	20.0	58.0	72.5	6.0	7.5	2.125	M.S
16.	Providing complete bed rest for patient.	9.0	11.2	71.0	88.7	0.0	0.0	2.112	M.S
17.	Changing position of patient to Fowler position or semi-Fowler position.	8.0	10.0	69.0	86.2	3.0	3.75	2.062	M.S
18.	Performing (12) lead electrocardio- gram if necessary (24) leads	14.0	17.5	57.0	71.2	9.0	11.2	2.062	M.S
19.	Providing oxygenation for patient.	10.0	12.5	67.0	83.75	3.0	3.75	2.0875	M.S
20.	Asking if the patient takes any chest pain medication for a known heart condition.	9.0	11.2	67.0	83.7	4.0	5.0	2.062	M.S
21.	Administering of drugs analgesics, tranquilizers, nitroglycerin, and calcium antagonists for patient.	16.0	20.0	58.0	72.5	6.0	7.5	2.125	M.S
22.	Observing of drug side effects.	13.0	16.2	62.0	77.5	5.0	6.25	2.1	M.S
23.	Providing cannula for patient.	3.0	3.75	76.0	95.0	1.0	1.25	2.025	M.S
24.	Installing a drip and give peace to patient.	6.0	7.5	72.0	90.0	2.0	2.5	2.05	M.S
25.	Taking blood samples.	9.0	11.2	69.0	86.2	2.0	2.5	2.087	M.S
26.	Reducing environmental stimulation.	9.0	11.2	64.0	80.0	7.0	8.75	2.025	M.S
27.	Be calm in the works.	8.0	10.0	67.0	83.7	5.0	6.25	2.037	M.S
28.	Observing signs of complications.	7.0	8.75	68.0	85.0	5.0	6.25	2.025	M.S

f= Frequency; %= percentage; MS= Mean of scores; M.S= Moderate significant; S. = Significant; Sig. = Significance

Figure 3. Levels of nurses’ knowledge concerning chest pain management in emergency units

Table 3. Association between nurse's knowledge scores and the demographic characteristics (age, gender, level of education, years of experience in emergency unit, and training session)

Scores Age	High knowledge	Fair knowledge		Poor knowledge	Total	χ² obs.	Sig.
	F	F		F	F
Less than 20 year	3	2		1	6	22.578	S
20- 29 year	4	21		4	29
30- 39 year	0	13		13	26
40- 49 year	2	7		8	17
50 year and more	0	2		0	2
Total	9	45		26	80
P= 0.004 df = 8
Scores Gender	High knowledge		Fair knowledge	Poor knowledge	Total	χ² obs.	Sig.
	F		F	F	F
Male	2		23	11	36	2.642	NS
Female	7		22	15	44
Total	9		45	26	80
P= 0.267 df = 2

Scores Level of Education	High knowledge	Fair knowledge	Poor knowledge	Total	χ² obs.	Sig.
Scores Level of Education	F	F	F	F	χ² obs.	Sig.
Nursing Intermediate School graduate	0	0	2	2	9.792	NS
Nursing High School graduate	7	20	13	40
Nursing college graduate	2	9	3	14
Other	0	16	8	24
Total	9	45	26	80
P= 0.134 df = 6

Scores Years of Experience in emergency unit	High knowledge	Fair knowledge	Poor knowledge	Total	χ² obs.	Sig.
Scores Years of Experience in emergency unit	F	F	F	F	χ² obs.	Sig.
Less than one year	4	4	5	13	14.177	NS
1 – 5	5	19	9	33
6 – 10	0	17	6	23
11 -15	0	2	3	5
16-20	0	2	2	4
21 and more	0	1	1	2
Total	9	45	26	80
P= 0.165 df = 10
Scores Training Sessions	High knowledge	Fair knowledge	Poor knowledge	Total	χ² obs.	Sig.
Scores Training Sessions	F	F	F	F	χ² obs.	Sig.
No	3	28	16	47	2.706	NS
Yes	6	17	10	33
Total	9	45	26	80
P= 0.258 df = 2

The table 2 depicts that the mean of scores is moderate significant on all items.

The figure 3 indicates a highly percentage of nurses (56.2 %) have fair knowledge about chest pain management in emergency unit.

The table 3 indicates that there is significant association between age of sample and nurses’ knowledge scores. While there is no significant association between genders, level of education, years of experience in emergency unit, training sessions and nurses’ knowledge scores.

DISCUSSION OF THE RESULTS:

Through the data analysis distribution of demographic variables (table 1), the present study reported the age majority is (20-29) years old which accounted for 29 (36.2 %). Most of the sample are female 44 (55 %), 40 (50.3%) were graduated from high school. 45 (56.2%) of the nurses were married.

These results agree with study done by Bird, (2005) that reveals the age majority is (20-29) years old. Most of the sample are female and graduated from high school. The majority of the nurses were working in Al-Kindi Teaching Hospital⁽¹²⁾. 32 (40 %) for (1-5) years were employment in nursing and majority of them 33 (41.2%) were employee for (1 – 5 years) in the emergency unit.

Concerning training sessions 47 (58.8 %) of them have training sessions in the management of chest pain for patients in the emergency Unit, and finally most of nurses 41(51.2%) of them had no pursued education by continuing education.

These results agree with study done by David, (1990) that indicates most of nurses have training sessions in the management of chest pain for patients in the emergency Unit, and finally most of nurses no have pursued education by continuing education⁽¹³⁾.

Figure (2) show that sources of nurses’ knowledge about management of chest pain for patients in the emergency unit was 29 (36.2%) obtained by working with patient which suffering from chest pain.

These results disagree with study done by Buntinx, et al., (2001) that indicates most of nurses obtained knowledge about management of chest pain for patients in the emergency unit from reviewing literature ⁽¹⁴⁾.

The result of the present study table 2. reveals that all items concerning with knowledge to management of chest pain for patients in the emergency unit are moderate significant (Checking the pulse of peripheral arteries and carotid arteries, Observing the patient use a respirator muscles for breathing, Determining factors that reinforce of pain, Changing position of patient to Fowler position or semi-Fowler position, Performing (12) lead electrocardiogram if necessary (24) leads, Asking if the patient takes any chest pain medication for a known heart condition, and Administering of drugs analgesics, tranquilizers, nitroglycerin, and calcium antagonists for patient, Loosening tight clothing, Checking airway, Checking the sound of breathing for patient, Checking the pattern, frequency, depth, and rhythm of breathing for patient, Observing the signs of decrease of oxygen, Checking the level of conscious for patient, Observing vital signs for patient, Defining the location of pain, Defining the prevalence of pain, Defining the nature of pain, Determining pain characteristics, Determining chronological of pain, Providing complete bed rest for patient, Providing oxygenation for patient, Observing of drug side effects, Providing cannula for patient, Installing a drip and give peace to patient, Taking blood samples, Reducing environmental stimulation, Be calm in the works, and Observing signs of complications). This result agree with results obtained from study done by Stanphope, and Loncaster (1996) which indicated that most of items concerning with knowledge to management of chest pain for patients in the emergency unit was moderate level mean of score ⁽¹⁵⁾.

The result of the present study indicates a highly percentage of nurses (56.2 %) have fair knowledge about chest pain management in emergency unit. Figure (3)

This result disagree with results obtained from study done by Cooper; Hodgkinson; and Oliver, (2000) which indicated that most nurse have high knowledge about chest pain management in emergency unit⁽¹⁶⁾.

Table (3) indicates that there is significant association between age of sample and nurses’ knowledge scores.This result disagree with results obtained from study done by Hogan , (2005) which indicated that there is no significant association age of sample and nurses’ knowledge scores⁽⁷⁾.

While there is no significant association between genders, level of education, years of experience in emergency unit, training sessions and nurses’ knowledge scores.

This result disagree with results obtained from study done by Launbjerg, et al., (2005) which indicated that there is significant association between level of education, years of experience in emergency unit and nurses’ knowledge scores⁽¹⁷⁾.

CONCLUSION:

The researcher can conclude most of nurses that work in emergency unit have inadequate knowledge about chest pain management in emergency unit.

Nurses’ Knowledge Concerning Chest Pain Management in Emergency Units

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