Knowledge and Attitudes of Nurses towards Postopera tive Pain Management in Southern Ethiopia

Introduction: Effective management of postoperative pain can lead to comfort, better mobility, improved recovery and a short stay in the hospital while untreated pa in h s harmful impacts on the patients as hopelessn es , hinder their response to treatment, and negatively affect their quality of life. Inadequate knowledge and undesirable attitudes toward postoperative pain management were reported as one of the major difficulties to implement effec tive pain management among nurses. Objective: The main purpose of this study was to assess the kn owledge and attitudes of nurses towards postoperative pain management working at Hawassa Un iversity comprehensive specialized hospital. Methods: Institution based cross-sectional study was conduc te among two hundred three nurses working at the surgical, gynecology, obstetric wards, ophthalmic u nit and operation theater from April 1-30, 2019. Da ta were collected through standardized worldwide accepted “ Knowledge and Attitudes Survey Regarding Pain” (KAS RP) tool it contains 37 items questionnaire of two doma ins: knowledge and attitude towards pain management . The collected data was analyzed using SPSS version 20. A chi-square test was done and significantly associ ated factors were identified. Result: One hundred and eighty-seven questionnaires were re turned giving a response rate (92.1%). The mean sco re of correct answers was (22.5%) with a minimum and m axi um score of (18.2%) and (75.4%) respectively. A fter categorizing the level of knowledge and attitude, ( 82.2 %) of nurses possessed very low knowledge and negative attitude towards postoperative pain management. Pri or training on pain management (X 2 = 14.935, P=0.001) and reading of medical books or journals about pain (X 2 = 5.019, P=0.025) were significantly associated wi th knowledge and attitude of nurses towards post-operative pain ma agement. Conclusion: Nurses had a very low level of knowledge and a neg ative attitude towards post-operative pain management. The hospital provides in-service traini ng and avail reading medical books to improve nurse ’s knowledge and attitude towards post-operative pain management. The federal ministry of Health of Ethio pia enriches the pain content of the nursing curriculum .


Introduction
Post-operative pain is defined as a complex response to tissue trauma during surgery and it is an expected and annoying yet controllable problem (Kehlet H 2006). An earlier study stated that illmanaged post-operative pain may have lengthier stays in hospitals, higher readmission rates, late healing of wounds, more recurrent outpatient visits, and altered immune tasks. Such unwell treated pain has deep long-lasting concerns and it rises emotional and behavioral replies during future painful occasions (Smart 2005).
Effective postoperative pain management has numerous benefits include reducing the patient's pain, faster postoperative recovery, improved sleep, increased mobility, increased patient satisfaction, and leads to shorter hospital stays (Smart 2005).Ineffective pain management is quite a common phenomenon across the globe (Dunwoody CJ 2008) and remains to be a grievance of hospitalized patients despite the weight laid on the patient's right to proper pain treatment and the augmented alertness of the unfavorable properties of pain that is inadequately treated and managed (Idvall 2002). For the effective management of pain in post-operative patients, strong clinical knowledge, attitudes, and skills in the assessment of pain are essential for nurses. They must also perform well in the control of and effective administration of pain medication. However, several obstacles to this have been identified, knowledge deficit on the use of appropriate pain measures and negative attitudes are the major problems (Smart 2005).
One of the most crucial and immensely provides aspects of a patent's pain management is the role of nurses. Having such an important and unavoidable role; nurses must have an adequate level of knowledge and a positive attitude in the delivery of post-operative pain management based on effective training (Al . Even if pain management has been an integral part of nursing practice for many years, yet there are still too many who lack the basic knowledge necessary to manage pain appropriately (McCaffery 2000). Numerous nurses are still trusted their private view about patient's pain, rather than using their documented assessment to support them and to select suitable opioid doses. Proper pain investigation tools are not applied on a consistent basis in acute care situations and this also pays to under-treatment of pain (McCaffery 2000).
Although studies have shown that pain education programs increase nurses' knowledge and improve attitudes towards pain management, the management of postoperative pain by nurses still remains a problem and also insufficient education and training for nurses were amongst the issues reported as poor postoperative pain management (Goodrich 2006). Even if Ethiopia developed a national pain management guideline in 2007 (Health 2007), many studies demonstrated that pain was untreated adequately due to various reasons among which nurses' inadequate knowledge and inappropriate attitude were the leaders (Eyob, Mulatu et al. 2013) and (Woldehaimanot, Saketa et al. 2014). Until now, there is no enough proof to understand the real gap in Ethiopia. Thus, this study was planned to define nurses' knowledge and attitude towards postoperative pain management. The finding delivers well-timed and baseline information related to nurses' knowledge and attitudes towards postoperative pain management at HUCSH. These results may be used as a basis for comparisons in upcoming research and interventional studies could be planned on pain management. This is the first study done in HUCSH and the Southern part of Ethiopia in general.

Study design, period and study area
A health institution based cross-sectional study was conducted on April 1-30, 2019. The study was conducted in Hawassa University comprehensive specialized hospital. The hospital was established in 2004 by a collaboration of the federal ministry of health, regional government health bureau and Hawassa town community. The hospital is found in the south-western part of Hawassa town and is bordered to the east by Hawassa town, to the north by Tabor Mountain, to the west by Hawassa Lake and to the south by private local residents.
It delivers a variety of both outpatient and inpatient services for about 20 million people from all over southern regional states (SNNPR) and neighboring Oromia region. Currently, it has 400 beds and provides patient care in a broad range of services to over 90, 200 outpatients, 18,116 hospitalized patients, and 1,092 emergency cases annually. It offers services at general and specialty levels. The hospital is also center for different initiated projects and the vision is to make the hospital a center of training and research for tropical diseases in addition to curative services.

Sample size and sampling procedure
No specific sampling strategy was employed in this study, all nurses working surgical, obstetrics, gynecology wards, ophthalmology unit and operation theater during the data collection period were involved in the study. These wards were purposefully selected because nurses have exposure to patients with post-operative pain therefore, adequate knowledge and positive attitude are needed from nurses to manage postoperative pain.

Exclusion criteria
-Nurses in maternity, annual and sick leave during the data collection period.

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Nurses who are not willing to participate.

Data collection instruments
To collect the data, two questionnaires were used: (I) Form of nurse information and (II) Knowledge and Attitudes Survey of Nurses Regarding Pain.

Form of Nurse information
This form was prepared by investigators and comprised of questions on the nurses' sex, age, current unit of employment, level of nursing educational, year of experience in caring patients, reading experience of any books or journals about pain, Experience of pain management training and personal experience of pain which required antipain medication.

Knowledge and Attitudes Survey Regarding Pain (KASRP) was used as an instrument.
The KASRP is a 39-item questionnaire developed by Ferrell, McGuire, and Donovan (Ferrell 1993) to assess nurses' knowledge and attitudes toward pain management. It consists of 21 true/false questions, 14 multiple-choice and 2 case studies.
Howell acknowledged that KASRP is the only available instrument to measure nurses' knowledge and attitudes about pain management (Howell and Stearns 2000). The content validity of KASRP was established by a panel of pain experts.
The KASRP content was based on the pain management guidelines of the American Pain Society, WHO, and the Agency for Health Care Policy and Research. The KASRP Cronbach alpha is 0.70 and test-retest reliability > 0.80 (Howell and Stearns 2000).
The KASRP was revised in 2012 and used by worldwide researches to assesses the Knowledge and Attitudes of health professionals regarding pain management (Hope 2012). According to the KASRP tool, the high score indicates a higher level of knowledge and a positive attitude while the low score indicates a lower level of knowledge and a negative attitude.
The questionnaire was administered in English because Ethiopian nurses are capable to understand and answer questions in the original language of the KASRP (all nursing education, curricula, and examination in Ethiopian nursing institutions are conducted in English).

Data collection procedures
Data were collected through a self-administered questionnaire. Questionnaires were distributed to each nurse and they were asked to tick the best answer. Adequate time was given to read and understand the questions and then submit their responses.
The data collectors stayed with the participants until they filled the questionnaire. Trained diploma nurses with previous data collection experience have collected the data. An average time spent to complete one questionnaire per nurse was 30-40 minutes.

Data quality control measures
Data collectors and supervisors were trained on data collection processes and procedures for half a day. Filled questionnaires were checked on a daily basis for completeness, clarity, and accuracy. Data cleaning was undertaken before entry and analysis.

Data analysis
Data were coded and entered into Epi data version 3.1 and exported to SPSS version 20 statistical software for analysis.
Descriptive statistics was made using frequency tables, mean, standard deviation, graphs, pie charts, and other narrative explanations. A chisquare test was applied for finding an association among the variables.

Operational definitions:
The researcher categorized the level of knowledge and attitude into 5 levels using McDonald's percent correct score of cutoff points. Participants were also informed that participation was on a voluntary basis and they can withdraw from the study at any time if they are not comfortable with the questionnaire. To ensure the confidentiality of respondents, their names were not written on the questionnaire.

Results
Nurses socio-demographic characteristics The response rate of this study was (92.1 %) meaning 187 respondents completed and returned the questionnaire while 16 respondents (7.9%) did not, despite they were given the questionnaire. More than half (52.9%) were male nurses and (40.1 %) in the age range of 25-29 years. Nurses working in Operation theatre were (31.6 %) and most (68.4) of participants were Bachelor degree holders.
The professional experience of (58.8%) participants in caring patients was between 1 to 5 years. In addition, (75.9 %) of nurses experienced reading any books or journals about pain but only (26.7 %) participated in pain management training. Furthermore, (77.0 %) of nurses reported the personal experience of pain. Table 1.

Nurses' Knowledge and Attitudes regarding postoperative pain management
The mean score of nurses' knowledge and attitude towards postoperative pain management was (22.5%) with a minimum and maximum score of (18.2%) and (75.4%) respectively. Item analysis was made to determine which items answered correctly by more nurses and which items answered correctly by fewer nurses. The result also found five items that the lowest number of nurses answered correctly on KASRP in ascending order were (I) the right time of morphine administration to moderate pain (18.2%); (II) the correct pain score of talking and joking patient (19.7%); (III) risk of respiratory depression with opioid analgesics (20.3%); (IV) the correct pain score of quietly lying patient with grimaces (20.8 %) and (V) the accurate clinical manifestation of opioid physical dependence (21.9%) Table 2.

Level of Knowledge and Attitude
Further item analysis was computed after categorization of the level of knowledge and attitude according to operationally stated. A great proportion of nurses (82.1%) were found with a very low level of knowledge and negative attitude followed by low (10.2%) and no single nurses identified with high or very high levels of knowledge and positive attitude. Graph 1.

Factors associated with Nurses' Knowledge and Attitudes
In order to make a better understanding of the variables, the researchers conducted additional data analysis to determine which factors may contribute to the knowledge and attitude level of nurses towards post-operative pain management. The chisquare test revealed that prior training on pain management (X 2 = 14.935, P=0.001) and reading of medical books or journals about pain (X 2 = 5.019, P=0.025) significantly associated with nurses' level of knowledge and attitude towards post-operative management Table 3.  The time to peak effect for morphine given orally is (1 -2 hours) 65 34.8

35
Following abrupt discontinuation of an opioid, physical dependence is manifested by the following: (Sweating, yawning, diarrhea and agitation with patients when the opioid is abruptly discontinued) 41 21.9

36A
Patient A: Andrew is 25 years old and this is his first day following abdominal surgery. As you enter his room, he smiles at you and continues talking and joking with his visitor. Your assessment reveals the following information: BP = 120/80; HR = 80; R = 18; on a scale of 0 to 10 (0 = no pain/discomfort, 10 = worst pain/discomfort) he rates his pain as 8.
A. On the patient's record, you must mark his pain on the scale below. Circle the number that represents your assessment of Andrew's pain (8) 37 19.7 36B B. Your assessment, above, is made two hours after he received morphine 2 mg IV. Half hourly pain ratings following the injection ranged from 6 to 8 and he had no clinically significant respiratory depression, sedation, or other untoward side effects. He has identified 2/10 as an acceptable level of pain relief. His physician's order for analgesia is "morphine IV 1-3 mg q1h PRN pain relief." Check the action you will take at this time (Administer morphine 3 mg IV now) Patient B: Robert is 25 years old and this is his first day following abdominal surgery. As you enter his room, he is lying quietly in bed and grimaces as he turns in bed. Your assessment reveals the following information: BP = 120/80; HR = 80; R = 18; on a scale of 0 to 10 (0 = no pain/discomfort, 10 = worst pain/discomfort) he rates his pain as 8.
On the patient's record, you must mark his pain on the scale below. Circle the number that represents your assessment of Robert's pain: (8) 39 20.8 37B B. Your assessment, above, is made two hours after he received morphine 2 mg IV. Half hourly pain ratings following the injection ranged from 6 to 8 and he had no clinically significant respiratory depression, sedation, or other untoward side effects. He has identified 2/10 as an acceptable level of pain relief. His physician's order for analgesia is "morphine IV 1-3 mg q1h PRN pain relief." Check the action you will take at this time:

Discussion
Post-operative pain is upsetting to patients experiencing surgical events. Nurses with adequate knowledge and positive attitude play a key role in alleviating post-operative pain. The contribution of inadequate knowledge and nurse's negative attitudes towards the pain experience has been implicated in the nurses' inadequate management of patients in pain (Dalton and Greer 2001).
This study showed that the mean correct answer score was (22.5%) meaning nurses were able to correctly answer only (22.5%) the questions on average. The result was much lower than study conducted in other parts of the world for example it was (65.64%) on Pakistan nurses (Zeb 2019), (59.05%) on Bangladesh nurses (Basak 2010), (64.5%) on Indian nurses (Manwere, Chipfuwa et al. 2015) and (47.72%) on Hong Kong nurses (Lui 2008). Among several factors contributing to this finding, lack of in-depth pain contents in undergraduate nursing education and inadequate in-service training on pain topics in Ethiopia seem to play an important role. Also, the other likely explanation may be nurses from these countries possess a higher level of knowledge about pain management incomparable to the Ethiopian context.
This study also identified that (82.2%) nurses had a very low level of knowledge and positive attitudes regarding postoperative pain management. This inadequate knowledge contributes to the possibility of under-treatment of patients' post-operative pain. This finding was surprisingly low even if it was supported by different studies throughout the world. For example, the researcher found that the level of low knowledge among Indonesian nurses was (50%) (Tarjuman 2006). Only (7.7 %) of nurses had a moderate level of knowledge and positive attitudes. This also low as compared to (69%) Malaysia nurses scored a moderate level of knowledge towards post-operative pain management (Ho, Choy et al. 2009).
Several factors might contribute to the very low level of knowledge and negative attitudes among nurses in this study. Firstly, only (26.7 %) participants had received pain management training and it is given for a small proportion of nurses in the Ethiopian context because of the budget issue. Secondly, it seems likely that pain management content is not given in-depth on the nursing curriculum in the Ethiopian context.
According to the result, the five ranking orders of the least correctly answered items (lower than 21.9%) were identified and indicated that nurses had very low knowledge and negative attitudes in some parts of pain management. These included appropriate pain score assessment, fear of addiction, right dose and the right time of pharmacologic pain medications (Table 2). These results were amusingly very low and inconsistent even if earlier studies reported relative low findings in these important areas of pain management (Lui 2008, Yava, Cicek et al. 2013, Al Qadire and Al Khalaileh 2014, Manwere, Chipfuwa et al. 2015, Woldehaimanot, Saketa et al. 2014. Therefore, these areas may add more barriers to pain management and prevent patients from receiving adequate pain management. This study clearly pointed to the fact that nurses' knowledge and attitudes of postoperative pain management are associated with certain factors. Thus, prior training on pain management and reading of medical books or journals about pain is very important to nurses for improving their knowledge and attitude in providing care for postoperative pain. This result was consistent with results reported by earlier studies (Al Qadire and Al Khalaileh 2014).

Conclusion and Recommendation
This study concluded that nurses retained a very low level of knowledge far from an optimal and negative attitude towards post-operative pain management than previously reported findings worldwide. Finally, this study provided significant evidence of the knowledge deficit of nurses concerning pain management in Ethiopia.
It is critical that the hospital must arrange training workshops on post-operative pain management for staff nurses to close the gap. The federal ministry of Health of Ethiopia should enrich the pain content of the nursing curriculum.
The results of this study also provided a framework for the policymakers, government, and nongovernment organizations to develop and implement continuing education programs and inservice training for nursing staff on pain management, which can enhance the quality of patient care. Therefore, it is imperative that pain management should be considered in detail as the fifth fundamental vital signs to reduce patients' suffering from pain.

Limitation of the study
Participants who completed the survey were from one setting and might not entirely reflect the knowledge and attitudes of nurses in broad. This would reduce the possibility of generalizing the implications of the study. Therefore, a larger-scale survey that includes a larger number of nurses and settings would be highly recommended.