Procedural Analgesia in a Pediatric Emergency Department: Nurses’ Perceptions, Decision-Making Processes, and Organizational Barriers

Introduction. Procedural pain is a common reason for pediatric emergency department visits and remains frequently undertreated despite the availability of evidence-based recommendations. Nurses play a key role in pain assessment and management; however, limited evidence is available regarding the factors influencing their clinical decision-making in everyday practice. This study aimed to describe nurses’ perceptions, self-reported practices, decision-making criteria, and perceived barriers related to procedural analgesia in a tertiary pediatric emergency department. Methods. A cross-sectional observational study was conducted in February 2026 in the emergency department of a tertiary pediatric hospital in Italy. An anonymous online questionnaire was administered to nurses working in the department. The survey explored procedural pain perception, analgesia and sedation decision-making, pain assessment practices, organizational barriers, and self-perceived competence. Descriptive statistics were performed, while exploratory analyses included Fisher’s exact test, Mann–Whitney U test, and Spearman’s correlation coefficient. Results. Twenty-five nurses completed the survey (response rate 75.8%). Most participants had received specific training on procedural pain management within the previous 24 months (68%) and reported the availability of local protocols (88%). Procedural pain management was considered a high priority by 68% of respondents, although 48% believed procedural pain was frequently underestimated in their workplace. Clinical judgment combined with team consultation represented the most common decision-making approach (80%). Procedural invasiveness was the main criterion guiding analgesic escalation (44%). Workload and crowding were identified as the principal barriers to effective analgesia (72%). Emergency department experience was positively associated with perceived competence (rho=0.428; p=0.037) and negatively associated with the perceived impact of crowding on clinical decisions (rho=-0.417; p=0.043). Discussion. Organizational constraints and reliance on subjective clinical judgment continue to influence procedural analgesia practices. Decision-support tools, targeted training, and strategies to strengthen nursing autonomy may improve the consistency of pediatric procedural pain management.