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Postoperative Pain Manage
Manageme
agement:
ment: Clinicians’ Knowledge and Practices on Assessment and
Measurement at Moi Teaching and Referral Hospital.
W.P. Kituyi1, K.K. Imbaya1, J.O, Wambani2, T.M. Sisenda3, R.T. Kuremu4
1Lecturer and Anaesthesiologist, 2Associate Professor and Anaesthesiologist
3Lecturer and ENT Surgeon, 4Associate Professor and Paediatric Surgeon
Moi University School of Medicine. P.O. Box 4606, Eldoret – Kenya.
Correspondence to: Dr Kituyi P Werunga Email:
[email protected]Background:
Background: Pain is the cardinal symptom common
common to diverse disease conditions and it is
what drives many patients to seek treatment. It, therefore, commands a central position in
health seeking behavior. In the post-
post-operative period, the main concern about pain is not
only the suffering it causes, but
but also because of its negative effects on the process of
recovery. Its management has, however, remained a major challenge. Numerous myths and
insufficient knowledge of pain assessment, measurement and treatment contribute to the
challenges encountered by health providers in their service to patients. This study was
aimed at determining the knowledge and practices among clinicians who manage post- post-
surgical pain in a hospital setting at The Moi Teaching and Referral Hospital (MTRH) in
Eldoret, Kenya. It was a cross-
cross-sectional survey.
Methods
Methods: The study population consisted of Nurses, Clinical Officers and Doctors working
in the post-
post-operative areas at MTRH. A standardized questionnaire was administered to
236 hospital – based clinicians including medical doctors,
doctors, nurses and clinical officers. The
questionnaire consisted of diverse objective questions set according to internationally
recognized pain assessment instruments.
Results:
Results: Among the 236 health care professionals who were included in the study, 38
(16%) were doctors, 170 (72%) nurses and 28 (12%) clinical officers. On average the
duration of time since they were engaged as healthcare providers was 9.3 years (SD=+
6.7yrs). Almost all (96%) confirmed that they routinely managed post- post-operative pain.
Clinicians
Clinicians who indicated that they had knowledge on how to assess and manage post- post-
operative pain constituted 88%. Among doctors, 54% felt that they had sufficient
knowledge to recognize and manage post-post-operative pain while the proportions of nurses
and clinical officers were 41% and 43% respectively. Fifty seven percent of the participants
indicated that they had inadequate knowledge regarding the tools that may be employed
for pain assessment and measurement. Those who had never had any formal teaching in
relation
relation to pain evaluation and management constituted 21%.
Conclusion: Overall, a significant proportion of clinicians indicated an inadequacy of
knowledge regarding objective evaluation and management of post-
post-operative pain.
Introduction
Pain is the leading symptom common to illness and is what drives the majority of patients
to seek medical treatment for various ailments. Effective management of pain is,
therefore, central in meeting the needs of patients. Knowledge of the evaluation and
treatment of pain constitute the core elements of managing this complex experience1.
Numerous myths, insufficient knowledge coupled with inadequate application of known
principles contribute to its poor management. Pain being an inherently subjective
experience influenced by multiple factors is difficult to assess and manage. Appropriate
assessment tools come in handy particularly in children who cannot vocalize their pain
experiences. It requires anticipatory and proactive interventional measures taken
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accordingly2. Training in the diagnosis and treatment of pain should overcome the major
obstacle of inadequacy in the care of this ubiquitous symptom3.This study was designed
to determine the knowledge and practices among clinicians who manage post-operative
pain at the Moi Teaching and Referral Hospital (MTRH).
Subjects and Methods
The study was commenced after approval by the Institutional Research Committee
(IREC). The post-operative care providers were sampled from surgical and gynecological
wards to get a representative sample. Fischer’s formula was used where a minimum
sample of 200 participants was required. A questionnaire-based cross-sectional study
was performed among 236 post-operative care providers who included doctors, nurses
and clinical officers at the MTRH, the second National Referral Hospital in Kenya. The
study instrument used was a questionnaire designed to collate the demographic data,
knowledge and practices of pain assessment and measurement among clinicians. Data
were then analyzed using the SSPS statistical software considering a p-value <0.05 as
having been significant.
Results
Of the 236 healthcare professionals who were included in this study, 38 (16%) were
doctors, 170 (72%) were nurses and 28 (12%) were clinical officers. On average the
duration since they were engaged as healthcare providers was 9.3 years (SD=+ 6.7yrs).
Two hundred and twenty seven (96%) confirmed that they routinely managed post-
operative pain. A total of 208 (88%) of the respondents, indicated that they had the
knowledge to manage post operative pain; however, only 103 (44%) indicated that they
had knowledge on how to assess and measure post-operative pain. Among the doctors,
21(55%) indicated that they had sufficient knowledge to recognize and manage post-
operative pain while the proportions of nurses and clinical officers were 70 (41%) and
12(43%) respectively.
Table 1. Commonly Employed Pain and Tools Applied
Tool Proportion of Usage
Usage
Numbers Percentage
Visual Analogue Scale 61 26
Categorical Scale 14 6
McGill Scale 5 2
Verbal Description 90 38
Numerical Rating Scale 19 8
Others 19 8
None 28 12
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Of the participants 135 (57%) indicated that they had inadequate knowledge regarding
the tools that may be employed for pain assessment and measurement. Those who had
never had any formal teaching in relation to pain evaluation and management constituted
50 (21%) of all the participants. The duration of service among all the health care
providers in the post-operative care units did not influence the respondents’ knowledge
and confidence in the evaluation and management of pain. (ANOVA (F (1) =0.045,
p=0.832).
Regarding availability of protocols, 59 % of the health care professionals reported that
there were no protocols and guidelines on post-operative pain management at their work
stations. The tools which the participants said were commonly employed by participants
in the present study are shown in the Table.
Discussion
Optimal post-operative pain management is guided by its objective assessment and
measurement4. There are several validated tools that apply in different patient categories
which if implemented appropriately can improve the confidence of the health care
workers in assessing pain4,5. The post-operative orders commonly used are mere
guidelines and hence may not sufficiently address post-operative pain management for
every patient operated on. Those who take care of the patients need to have the
knowledge on post- operative pain management which should be applied appropriately
in the immediate post-surgical period for the patients to benefit.
Despite the majority (81%) of the respondents in our study indicating that they had the
knowledge on how to assess and measure pain, most (73%) of them felt they had
insufficient knowledge on objective pain evaluation using tools that have been tested and
validated for this purpose. A further 21% said they had no knowledge at all on pain
assessment tools. The Verbal descriptive scale had an application frequency of 38% while
the McGill scale had a dismal 2% application. The use of pain assessment tools was
extremely variable among the participating health care providers. Pain assessment tools
used by health care providers elsewhere have produced optimal and satisfactory results
in acute pain management4,5. From this study, it therefore follows that overall post-
operative pain assessment and measurement in our institution is likely to be sub-optimal
from the onset after surgery. This scenario is likely to prevail in the region specifically in
sub Saharan region due to similarities of the institutions in terms of resources and
personnel trained in similar circumstances.
The feeling of knowledge deficiency as reported by the participants in our study can lead
to lack of confidence and to low self –esteem when faced with patient in pain. This can as
a result lead to a poor overall management of post-operative pain. One study showed that
knowledge in the use and implementation of pain evaluation tools increased staff
confidence in assessing pain in the non-verbal sedated patients from 57% before versus
81% after implementation and increased the number of pain assessments documented by
the nursing staff for non-communicative patients in the intensive care unit per day (2.2
before vs. 3.4 after)5,6. Use of protocols and guidelines can greatly improve pain
management7. In our study, approximately 59% of the study population said there were
no protocols/guidelines on post-operative pain management at their work stations;
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hence none were employed in the routine patient care. For a referral institution at a
tertiary level like MTRH, quality management systems based on evidence - based
guidelines and protocols need to be in place and their use monitored for performance
improvements for the clinicians to provide better post-operative care even though
literature is not conclusive on the matter of availability versus adherence and improved
care8,9.
Nurses are multi-tasked in our health institutions performing various functions including
post-operative pain management and the general nursing care of patients. A finding of
concern in the present study is the fact that 41% of them felt that they had the least
knowledge regarding pain management compared to 56% of the doctors and 43% of the
clinical officers. Of all the clinical cadres, nurses spend more time with patients than the
doctors and the clinical officers. Considering the overwhelming workload situation in our
institutions, safety and general care for post operative patients is most likely
compromised. The present study has highlighted the apparent gross deficiencies in the
evaluation, measurement and management of pain among all the cadres of clinicians on
self-report. The health care professionals cannot therefore be expected to approach
patients in pain with confidence if they feel deficient in pain management.
An overwhelming 96% of the respondents in our survey expressed need for training on
pain evaluation tools even though some had said they knew how to assess pain. In a
closely related study done in Malawi, most doctors indeed recognized that post operative
management was important but they were not adequately trained to manage pain using
validated tools consequently post operative pain after caesarian section was not
optimally handled10. Notably, even a long duration of clinical service did not make
experienced health care providers feel sufficiently knowledgeable to assess and measure
pain. Other investigators11 were also unable to confirm the influence of expertise on pain
management. Deep cultural beliefs by health care providers which have been shown to
interfere with approach to pain management12,13 were not investigated in this study but
may need to be looked into in follow up survey to establish other barriers to optimal pain
management in this region.
Conclusion
Overall, a significant proportion of the participants indicated an inadequate knowledge
regarding the objective evaluation and management of post-operative pain. We,
therefore, strongly recommend that institutions endeavor to institute training
programmes on the basic principles of wholesome pain management. Furthermore,
continuous professional development should be strengthened for health care providers
in all our health institutions.
Acknowledgement
To the administration of Moi Teaching and Referral Hospital for permission to carry out
the study. The IREC for approving this study and all the health care professionals who
participated in this survey for their time and effort.
References
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1. Francesca, F., Bander, P., Echtte, D., Guinta, F., Williams, J. EAU: Eur Urol 2003. 44;
383-389
2. Committee on Psychosocial Aspects of Child and Family Health Task Force on Pain
in Infants, Children and Adolescents. The Assessment and Management of Acute
Pain in Infants, Children and Adolescents. Paeds, 2001; 108(3): 793 – 797)
3. Kathryn, A. Padgett. Overcoming Pain Management Obstacles. Physicians News
Digest: 2005: April.
4. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine;
Acute Pain Management: Scientific Evidence, 2nd ed, 2005, updated Dec 2007
Therapeutic Guidelines: Analgesic, Version 5, 2007
5. Jane Topolovec-Vranic. Patient Satisfaction and Documentation of Pain
Assessments and Management After Implementing the Adult Nonverbal Pain Scale
American Journal of Critical Care. 2010;19: 345-354 doi:10.4037/ajcc2010247
Volume 23, Issue 3, Pages 164-170 (August 2010)
6. Topolovec-Vranic, J., Canzian, S., Innis, J., Pollmann-Mudryj, M. A., McFarlan, W.,
Baker, A. J. Patient satisfaction and documentation of pain assessments and
management after implementing the adult nonverbal pain scale. American Journal
of Critical Care. 2010; 19(4):345-54quiz 355.
7. Dahl, J. L., Gordon, D., Ward, S. et al. Institutionalizing pain management: the
Postoperative Pain Management Quality Improvement Project. J Pain 2003; 4:361–
371.
8. Ducharme, J., Tanabe, P., Homel, P., Miner, J. R., Chang, A. K., Lee, J. et al. The
influence of triage systems and triage scores on timeliness of ED analgesic
administration. Am J Emerg Med. 2008;26:867–73.
9. Decosterd, I., Hugli, O., Tamches, E., Blanc, C., Mouhsine, E., Givel, J. C. et al.
Oligoanalgesia in the emergency department: short-term beneficial effects of an
education program on acute pain. Ann Emerg Med. 2007; 50:462–471.
10. Khan, M. F., Omole, O. B., Marincowitz, G. J. Post-operative analgesia following
caesarean deliveries in a rural health district of South Africa. Tropical Doctor. 2009;
39(4):217-21.
11. Hamers, J. P. H., van den Hout MA., Halfens, R. J. G., Abu-Saad, H. H., Heijltjes, A. E. G.
Differences in pain assessment and decisions regarding the administration of
analgesics between novices, intermediates and experts in pediatric nursing. Int J
Nurs Stud.1997; 34:325–334.
12. Rampanjato, R. M., Florence, M., Patrick, N. C., Florence, B. T. Factors influencing
pain management by nurses in the emergency department in Central Africa. Emerg
Med J 2007; 24:475-476.
13. Bates J., Gwyther L., Dinat N. Morphine friend or foe? Malawian Med J 2008:112-
114.
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