NURSES ATTITUDE TOWARDS THE MANAGEMENT OF PAIN IN

POST-OPERATIVE PATIENTS IN IMO STATE UNIVERSITY

TEACHING HOSPITAL ORLU.

BY

ONYEKWUO CHINONYE FESTA

PG/MSC/11/61030

M.Sc DISSERTATION

PRESENTED TO
THE DEPARTMENT OF NURSING
FACULTY OF HEALTH SCIENCES AND TECHNOLOGY
UNIVERSITY OF NIGERIA
ENUGU CAMPUS, ENUGU.

SUPERVIOR: DR. (MRS) I. L. OKORONKWO

JANUARY, 2016.

i
 TITLE PAGE

NURSES ATTITUDE TOWARDS THE MANAGEMENT OF PAIN IN

POST-OPERATIVE PATIENTS IN IMO STATE UNIVERSITY
TEACHING HOSPITAL ORLU.

BY

ONYEKWUO CHINONYE FESTA

PG/MSC/11/61030

MSC DISSERTATION

PRESENTED TO THE
DEPARTMENT OF NURSING SCIENCE
FACULTY OF HEALTH SCIENCES AND TECHONOLOGY,
UNIVERSITY OF NIGERIA, ENUGU CAMPUS

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR AWARD OF

MASTER OF SCIENCE (M.Sc) DEGREE IN NURSING
(MEDICAL SURGICAL NURSING).

SUPERVIOR: DR. (MRS) I. L. OKORONKWO

JANUARY, 2016.

ii
 CERTIFICATION

This is to certify that this project was originally carried out by Onyekwuo

Chinonye F., Registration Number MSC/PG/11/61030 in the Department of

Nursing Sciences, Faculty of Health Sciences and Technology, University of

Nigeria, Enugu Campus.

____________________ ________________
Dr. Okoronkwo I. Date
(Project Supervisor)

____________________ ____________

Dr. Nwaneri A.C. Date

(Head of Department Nursing Sciences)

____________________ ____________

External Examiner Date

iii
 DEDICATION

This dissertation is dedicated to my beloved husband, Mr. Onyekwuo Ambrose.

iv
 ACKNOWLEDGEMENT

I am immensely indebted to God Almighty, who made it possible for me to start

and accomplish this work.

My deep appreciation goes to my Supervisor, Dr (Mrs) Okoronkwo Ijeoma for

her patience, motherly role, advice and for spending her time to read this work

and make necessary corrections. I equally recognize and acknowledge the good

roles of the lecturers in Nursing Department.

I am grateful to my beloved friend, Mrs Emesonwu A. who helped in numerous

ways. My appreciation also goes to my beloved husband, Ambrose Onyekwuo

for his love, support, understanding and encouragement. My children, Ifechukwu,

Obinna, Tochukwu, Ugochi and Kelechukwu for their patience while pursing my

academic aspiration.

Lastly, I thank my typist Mrs. Joy Arukwe who typed this work and my Analyst,

Mr. Ibekamma C. May God bless you all – Amen.

v
 ABSTRACT

The purpose of this study is to investigate nurses’ attitude towards the

management of pain in post -operative patients in Imo State University Teaching
Hospital Orlu. It was a cross-sectional descriptive study involving one hundred
and ten (110) nurses working in the surgical wards of the hospital. The
instrument for data collection was a pre-tested questionnaire. Data were analyzed
using descriptive and inferential statistics. Findings revealed that majority of the
respondents 78(74.3%) had negative attitude towards the use of pharmacological
measures in the management of pain. While more than half of the respondents
97(92.4%) had positive attitude towards the use of non-pharmacological
management of pain in post-operative patients. Majority of the respondents that
had negative attitude towards pain management in post-operative had less
number of years of clinical experience (1-10years). No statistical relationship was
found between nurses’ level of education and their attitude towards management
of pain in post-operative patients, (P > 0.05). This study concluded that there is
negative attitude towards pain management in post-operative patients among
nurses in IMSUTH and therefore recommends that nurse managers and hospital
administrators should put up educational strategies to correct misconceptions
about pain management to the nurses and also encouraged to promote the use of
both pharmacological and non-pharmacological management of pain in post-
operative patients in IMSUTH.

vi
 TABLE OF CONTENTS

Title Page i
Certification ii
Dedication iii
Acknowledgement iv
Abstract v
Table of Contents vi
List of Tables vii
List of Figures viii

CHAPTER ONE: INTRODUCTION

Background of the Study 1
Statement of the Problem 5
Purpose of the Study 6
Research Questions 7
Significance of the Study 7
Scope of the Study 8
Operational Definition of Terms 9

CHAPTER TWO: LITERATURE REVIEW

Conceptual Review 10
Theoretical Review 26
Empirical Review 33
Summary of Literature Review 38

CHAPTER THREE: RESEARCH METHODS

Research Design 40
Area of Study 40
Target Population 41
Study Respondents 41

vii
Inclusion Criteria 41
Instrument for Data Collection 41
Validity of Instrument 42
Reliability of the Instrument 42
Ethical Considerations 42
Procedure for Data Collection 43
Method of Data Analysis 43

CHAPTER FOUR: DATA PRESENTATION AND ANALYSIS

Presentation of Results and Interpretation of Data 45
Social Demographic Data 45
Summary of Findings 57

CHAPTER FIVE: DISCUSSION OF FINDINGS

Discussion of Major Findings 58
Implications for Nurses 62
Limitations of the Study 62
Suggestions for Further Study 63
Summary 64
Conclusion 65
Recommendations 66
REFERENCES 67
APPENDICES 73

viii
 LIST OF TABLES

Table 1 : Social Demographic Data 44

Table 2: Attitude of towards management of pain in post-operative
Patients 47
Table 3: Mean response on Attitude towards the Management of pain
in Post-operative Patients 48
Table4: Attitude of Nurses towards the use of pharmacological pain
management in post-operative patients 49
Table 5: Mean responses on attitude towards the use of pharmacological
Measure in the management of pain 50
Table 6: Self-reported capability of nurses of using non-pharmacological
management of pain in Post-Operative Patient 51
Table 7: Mean responses on Attitude towards the use of non-
Pharmacological management of pain in post-operative patients 52
Table 8: Cross tabulation between educational level and nurses’ attitude
towards the management of pain in post-operative patients 53
Table 9: Chi-Square Result: (Cross tabulation between educational level
and nurses’ attitude towards the management of pain in post-
operative patients 54
Table 10: Cross tabulation between length of clinical experience and nurses’
attitude towards the management of pain in post-operative
patients 55

Table 11: Chi-square Tests Results (Cross tabulation between length of

clinical experience level and nurses’ attitude towards the
management of pain in post-operative patients 56

ix
 LIST OF FIGURES

Fig. 1: Factors influencing the blending of the nurse/patient relationship 28

Fig. 2: Diagrammatic Illustration of Peplau’s Model Showing Nurse’s

Attitude and Management Pain in Post-Operative Patient 32

x
 CHAPTER ONE

INTRODUCTION

Background to the Study

Pain is an unpleasant sensory and emotional experience which is primarily associated

with tissue damage or described in terms of such damage or both (Caffery & Ferrell,

2011). It is the most common symptom of any disease and the prompting factor for a

health care consumer’s visit for consultation. The experience of pain negatively

influences patient’s daily living (Caffery & Paseros, 2008). The relief of pain has been

one of the primary reasons for development of health care. Despite the growing

awareness of pain management, patients still suffer from unnecessary pains in many

hospitals with the resultant negative effect on physical, emotional and spiritual health

and quality of life (Lui, & Fong, 2008).

Pain management is considered an important part of care. It is referred to as the “fifth

vital sign to emphasize its significance and increase the awareness among health

professionals of effective pain management (American Pain Society, 2013). This

suggests that the assessment of pain should be as automatic as taking a patient blood

pressure and pulse.

Barett (2007) opined that pain is the way the peripheral nervous system warns the

central nervous system of injury or potential injury to the body. The message is

transmitted through nerve cell called nociceptors by neurotransmitters. The body also

releases prostaglandins that may enhance the pain message. Stedman (2006) described

1
pain as a variable unpleasant sensation associated with actual or potential tissue damage

and mediated by specific nerve fibers to the brain where its conscious appreciation

maybe modified by various factors.

Attitudes are the way a person views something and tends to behave towards it, often in

an evaluative way. Pain management is an important aspect of patient care and nurses

play a significant role in the acute care setting in providing pain assessment and

treatment. In this regard, nurses who possess strong foundation in pain management

and who can provide individual care to patients with the proper attitude can make an

important impact in pain management (Courtenay & Carey, 2010). Misconceptions and

biases can affect pain management. These may involve attitudes of the nurse or the

client as well as knowledge deficits. However, pain is a multidimensional phenomenon

and it is the role of nurses to identify the factors that may influence the patient’s way of

perception and expression of pain (Maryland Board of Nursing, 2011).

Mann and Carr (2009) opined that pain management encompasses various types of pain

experiences throughout an individual’s life cycle from birth to the end of life. Pain

experiences may include acute and chronic pain, pain from a chronic deteriorating

condition, or pain as one of many symptoms of the patient receiving palliative care.

Pain is not exclusively physiological but also include spiritual, emotional and

psychosocial dimensions. The goal of pain management throughout the life cycle is to

address the dimensions of pain, and to provide maximum pain relief with minimal side

effects (Mann & Carr, 2009). Birth and Willis (2011), indicated that adequate

assessment in conjunction with opiod titration based on patient response can provide

2
maximum pain relief without adversely affecting respiratory status. Therefore, it is

wrong to under-utilize or withhold opiods from patient who is experiencing pain based

on fear of causing respiratory depression.

Coll, Mead and Ameren (2011) asserted that inadequate pain relief in post operative

care may result in immobility, prolonged recovery and many patients also develop

increased cardiovascular, respiratory and gastro-intestinal complications as well as

chronic pain conditions. Apart from its humanitarian utility, effective relief of post

operative pain is a critical element of a patient’s post operative recovery.

Failure to manage pain effectively in the immediate post operative period can produce

undesirable long term physical and psychological consequences that can disrupt an

individual’s quality of life (Parvizi, 2009). Post operative pain constitutes a health care

challenge requiring knowledge on how to prescribe and administer drugs, assess and

reassess post operative patient and a broad understanding of cultural and ethical

responses to pain and pain management (Classidy, 2011). Mackintosh (2012) suggested

that treatments of post operative pain using the World Health Organization analgesic

ladder, should be from top down, that is starting with strong opiod analgesic such as

morphine and working down to mild analgesic (non - opiods) such as parecetamol or

aspirin. The nurse should be fully aware of the use of pharmacological and non-

pharmacological measures in pain management. The nurse should have the knowledge

on the use of pharmacological measures, such as opiods, narcotics, analgesics and

morphine and also the use of non-pharmacological approaches such as acupuncture,

massage and breathing measures among others in pain management. In addition

3
knowledge on the existing standards of pain management is considered to be vital.

Nurses should learn to distinguish between physical and psychological reliance,

withdrawal and pseudo addiction as a result of patient using or having used certain

drugs (Maryland Board of Nursing, 2011). It is considered that these therapies will help

the standard pharmacological treatment in pain management, while medical drugs are

being used for treating the somatic (physiological and emotional) dimensions of the

pain. Eidelson (2010) opined that non-pharmacological therapies aim to treat the

affective, cognitive, behavioural and socio-cultural dimensions of the pain.

Non-pharmacological methods used in pain management can be classified in different

ways. In general, they are classified as physical, cognitive, behavioural and other

complementary methods or as invasive or non-invasive methods. Meditation, rhythmic

respiration, biofeedback, therapeutic touching, transcutancous electrical nerve

stimulation (TENS), musical therapy, acupressure and cold-hot treatment are non-

invasive methods (Eidelson, 2010). Bjordal, Johnson and Junggreen (2011) noted that

there are many benefits to using non-pharmacological methods in relieving pain,

therefore, the barriers keeping patients, nurses and physicians from using them need to

be explored. Nurses attitude and use of non-pharmacological pain management

therapies need to be assessed, and any deficits identified need to be rectified so that

patients could experience satisfaction in pain management.

4
Statement of Problem
Pain treatment is directed toward relieving pain with minimal adverse treatment effects,

allowing the patient a good quality of life and level of function and a relatively painless

death. Though, 80-90% of patient with pain can be eliminated or well controlled,

nearly half of all patients with pain including those in developed countries receive less

than optimal care (Induru & Lagman, 2011).

Notwithstanding the availability of effective analgesic approaches, many patients

continue to experience pain after surgery (Bostrom, 2012). This makes them prone to

some post-surgical complications like tissue damage, trauma, necrosis and others and its

is also a key factor to their disturbed body comfort. Judging from the negative impacts

of pain on health, with its unpleasant sensation, it is necessary to treat pain.

Bostrom (2012) asserted that negative and mistaken beliefs about pain and its treatment

are common in the health care system. It has been observed that many health care

professionals do not have adequate knowledge, attitude and skills to manage pain

effectively. Nurses attitudes towards pain influence the way they perceive and interact

with clients in pain. Without adequate assessment skills or knowledge of pain and

analgesic therapy, nurses may not be able to understand their client’s pain and

confidently participate with other health care providers in its treatment.

Following surgical intervention, patients are placed on analgesic agents. In an effort to

obtain adequate pain relief, the patient may respond with demanding behaviour,

escalating demands for more or different medications, and repeated requests before the

5
prescribed interval between doses has elapsed. The nurses are usually faced with

dilemma to administer more analgesic or not because of the implications of such

actions. McCaffery and Ferell, (2011) asserted that the use of evidence based

information alone by nurses is inadequate to effect change on post-operative pain

management. This is because a variety of other nurse characteristics and conduct affect

the pain management process in different ways. They include, educational background

of the nurse, misconception and lack of skill about pain management among physicians

and nurses.

Similar observations were made by the researcher in surgical ward during her clinical

experience in IMSUTH. Based on the above, the researcher decided to ascertain the

nurses’ attitude to and management of pain in post-operative patients in Imo State

University Teaching Hospital Orlu.

Purpose of the Study

The purpose of this study was to assess nurses’ attitude to and management of pain in

post operative patients in surgical wards of Imo State University Teaching Hospital,

Orlu.

The specific objectives were to;

1) Determine the nurses attitude towards management of pain in post operative

patients in Imo State University Teaching Hospital, Orlu.

2. Assess the nurses attitude in the use of pharmacological management of pain in

post operative patient in Imo State University Teaching Hospital, Orlu.

6
3. Ascertain the nurses attitude in the use of non-pharmacological management of

pain in post operative patients in Imo State University Teaching Hospital, Orlu.

4. Determine influence of socio-demographic characteristics on nurse’s attitude

towards management of pain in post operative patients.

Researcher Questions

1. What are the attitudes of nurses in surgical wards towards management of pain in

post operative patients in Imo State University Teaching Hospital, Orlu?

2. To what extent do nurses use pharmacological measures in management of pain

in post operative patients in Imo State University Teaching Hospital, Orlu?

3. To what extent do nurses utilize the non-pharmacological measures in

management of pain in post operative patient in Imo State University Teaching

Hospital, Orlu?

4. How do socio-demographic characteristics influence nurse’s attitude towards

management of pain in post operative patients?

Hypotheses
Ho1: Educational level of nurses has no significant influence on nurse’s attitude towards

the management of pain in post operative patient.

Ho2: Nurses years of experience have no significant influence on nurse’s attitude

towards management of pain in post operative patient.

7
Significance of the Study

Findings from this study will form the bases for implementing and enhancing nurses

understanding of pain and positive attitude towards pain which will lead to effective

management of post-operative pain.

To the institution, it will help them to formulate policies, that will assist nurses in

effective assessment and management of pain. Such knowledge is important in

improving nursing care that aims in delivering high quality of nursing practice.

Findings of this study will provide evidence based data that will enhance nursing

practice. Also, this study will help in health educating the patients on the side effects of

opoid use, as they pose a threat to patient suffering from pain. This will help to decrease

their escalating demands for more. Also, the knowledge of both pharmacological and

non-pharmacological management of post-operative pain will enhance nurses positive

attitude and quality care.

Scope of the Study

The scope of the study was delimited only to nurses working in surgical wards of Imo

State University Teaching Hospital, it was also confined to nurses attitude to and

management of pain in post-operative patient, and also nurses attitude to the use of

pharmacological and non-pharmacological measures in the management of post

operative pain.

8
Operational Definition of Terms

Nurses Attitude to Post-Operative Pain Management: The nurse’s attitude entails

the way they think, behavior act towards the patients’ experience of pain and report of

pain.

Pharmacological Management of Post-Operative Pain: They are those conventional

methods in form of drugs employed in the management of post of operative pain.

Non-pharmacological Management of Post-Operative Pain: It involves all non-

pharmacological measures advocated in the management of post-operative pain like

deep breathing exercise, positioning and restriction of movement.

Post-Operative Patient: These are patients under the immediate care and management

of the nurses after surgery.

9
 CHAPTER TWO

LITERATURE REVIEW

This chapter dealt with the review of literature related to the study. The relevant

literature includes concept of pain, types of pain, pain management, pharmacological

management of pain and non-pharmacological management of pain, post-operative

pain, nurses’ attitude about patient’s pain, theoretical review, empirical review and

summary of literature review.

Concept of Pain

Bostrom (2012) opined that pain is an unpleasant emotional and sensory experience that

is associated with potential and actual tissue damage. Mackintosh (2010) asserted that

pain is first of all a subjective experience that is unique to every patient. Every person

experience pain in their own unique way and it is important to remember that the

experience of pain will differ considerably between patients. This may be one of the

most important aspects of pain management and must be considered by everyone who is

working with patients in pain. People have different ways and different abilities to cope

with pain and they will respond differently to the pain treatment given (Mackintosh,

2010). Pain is an unpleasant emotional situation which originate from a certain area,

which is dependant or non-dependant on tissue damage and which is related to the past

experience of the person in question (IASP, 2010). Carr and Goudes (2008) described

pain as the normal physiological response to an adverse chemical, thermal, or

10
mechanical stimulus associated with surgery, trauma or acute illness, and it is thus

characterized as a sensory response.

Burke, Mohn-Brown, and Eby (2011) described pain as a subjective response to

physical and psychologic stressors. All people feel pain at some point during their lives.

Although, pain is unwelcome, it often serves as a warning of potentially health-

threatening conditions. Burke et al, (2011) further noted that pain is whatever the person

experiencing it says it is, and existing whenever the person says it does. They also

asserted that the client is the only person who can accurately describe his or her own

pain.

The quantification of pain intensity and the accompanying quality of response varies

from individuals in regards to their perception and it is affected by social and cultural

background, ethnicity, past experience, age and environmental factors, consequently

interpreting pain solely on action or behavioural outlook can be misleading (Ignativicus

& Workman, 2010).

Pain may arise from different etiologies. It can be due to the direct effects of the surgery

or caused by treatment of the diseases. Surgery, radiation, and chemotherapy may all

result in pain. The patient may also have chronic underlying disease that directly causes

or contributes to pain (Clecland, 2008). Byrne and Waxman (2009) asserted that pain

was the only symptom of lumbosacral plexopathy in 24% of patients in series, and in

15% of these patients diagnosis resulted in the discovering of a primary pelvic tumour.

In addition, to the obvious difficulties of experiencing persistent pain, secondary

11
consequences of relieved pain in the patients include decreased functional activity and

depressed appetite, which may negatively impact the course of the disease of self

(Foley, 2009).

Types of Pain

Pain can be acute or chronic

Acute pain: has an identifiable cause and it occurs soon after injury to tissues in the

body such as bone, skin or muscle. It is protective and motivates a person to take

action. Its onset maybe sudden or slow and its intensity may vary from mild to severe. It

subsides as healing takes place. It is characterized by sympathetic nervous system

responses like increased pulse rate, increased respiratory rate, elevated blood pressure,

diaphoresis, client appears restless and anxious. Clients report pain and exhibit

behaviour indicative of pain such a crying, rubbing the area of holding it (Berman et al

2008).

Chronic pain: It is constant or intermittent pain that persists beyond the expected

healing time and that can seldom be attributed to a specific cause or injury. It may have

a poorly defined onset, and it is often difficult to treat because the cause or origin

maybe unclear (Smeltzer & Bare 2010). It is non-protective in that it serves no useful

purpose. It is characterized by parasympathic nervous system responses: .e.g. normal

vital signs. Patient appears depressed and withdrawn: may not often complain of pain

unless asked and pain behavours may often be absent (Berman et al 2008).

12
Etiology of Pain

It can be physiological or neuropathic. Physiological pain is experienced when an intact

nervous system sends signals that tissues are damaged. It is neuropathic when there is

damaged or malfunctioning nerve (i.e. phantom pain ) (Mccaffery & Pesaro, 2009).

Neuroscience of pain/pathophysiology of pain

The physiology/experience of pain involves a complex sequence of biochemical and

electrical events or processes. The term nociception is used to describe the various

physiologic processes that bring about pain perception. Hence, pain receptors are

synonymously referred to as nociceptors and are differently distributed in different

organs of the body. The process of pain stimulation include transduction, transmission,

perception and modulation.

Transduction: In this first phase the noxious stimuli interacts with the tissue, causing

the release of some alogenic biochemical mediators like prostaglandins, bradykin,

substance P, histamine and serotonin into the site of the interaction. These excite the

nociceptors to generate pain impulses. Some pain medications (e.g. Ibuprofen and

piroxicam) act by blocking transduction (that is by inhibiting the production of the

excitatory chemical mediators or by decreasing ionic movements across the membrane

(ad one by local anesthetic agents).

Transmission: The second phase of transmission of pain includes three segments.

During the first segment, the pain impulse travels from the peripheral nerve fibres to the

spinal cord. Substance P serves as a neurotransmitter, enhancing the movement of

impulses across the nerve synapse from the primary afferent neuron to the second-order

13
neuron in the dorsal horn of the spinal cord. Two types of nociceptor fibres cause this

transmission to the dorsal horn of the spinal cord. Unmyelinated C fibres, which

transmit dull, aching pain, and thin A – delta fibres, which transmit sharp, localized

pain. In the dorsal horn, the pain signal is modified by modulating factors (e.g.

excitatory amino acid or endorphins) before the amplified or dampened signal travels

via spinothalamic tracts. The second segment of transmission from the spinal cord, and

ascension, via spinothalamic tracts, to the brain stem and thalamus. The third segment

involves transmission of signals between the thalamus to the somatic sensory cortex

where pain perception occurs. (Berman et al, 2008).

Modulation: This is often described as the “descending system” it occurs when

neurons in the thalamus and brain stem send signals back down to the dorsal horn of the

spinal cord (Paice 2012). These descending fibres release substance such as endogenous

opioids, serotonin, and nor epinephrine, which can inhibit (dampen) the ascending

noxious (painful) impulses in the dorsal horn. In contrast, excitatory amino acids (e.g.

glutamate, N-methyl D-aspartate NMDA), and the up regulation of excitatory glial cells

facilitate (amplify) these while the effects of the inhibitory neurotransmitters tend to be

short-lived as they are reabsorbed into the nerves. Tricyclic antidepressants block the

reuptake of norepinepheri and serotonin or NMDA antagonists (e.g. Ketamin) maybe

used to help diminish the signals of pain.

Pain Management

Foley (2009) opined that numerous approaches can be used to manage pain in patients.

These encompass multiple modalities of therapy, including pharmacologic, anesthetic,

14
physical, behavioural/psychological and neurosurgical approaches. In the mid 1990s, a

comprehensive approach to the assessment of pain in patient was formulated by the

Agency for Health Care Policy and Research (AHCPR). The guidelines emphasized the

need to evaluate the extent of disease and the appropriate anti tumour therapies to treat

the pain whenever possible (Poley, 2009).

Barrett (2009) described pain management as a basic right of people who are seriously

ill. Nurses are legally and ethically responsible for managing pain and relieving

suffering. When caring for patient in pain, consider the nurse/patient relationship,

patient advocacy, patient empowerment, compassion and respect. Caring for patients in

pain requires recognition that pain can and should be relieved. Effective communication

among the patient family and professional caregivers is essential to achieve adequate

pain management. Effective pain management improves quality of life, reduces

physical discomfort, promotes earlier mobilization and return to previous activity

levels, results in fewer hospital and clinic visits, and decrease hospital lengths of stay

resulting in lower health care cost (Barrett, 2009). These approaches are selected n the

basis of the requirements and goals of particular patients. Appropriate analgesic

medications are used as prescribed. They are not considered a last resort to be used

only when other pain relief measures fail. Any intervention is most successful if it is

initiated before pain sensitization occurs, and the greatest success is usually achieved if

several interventions are applied simultaneously. Non-pharmacological intervention are

15
often used together with analgesic to treat pain for all types of pain, but their success is

highly individualize (Burke, Mohn-Brown & Eby, 2011).

Smeltzer, Bare, Hinkly and Cheever (2010) noted that pain management is considered

such an important part of care that it is referred to as “the fifth vital sign” to emphasize

its significance and to increase the awareness among health care professionals of the

importance of effective pain management. Moreso, identifying pain as the fifth vital

sign suggests that the assessment of pain should be as automatic as taking a patient’s

blood pressure and pulse (Smeltzer et al, 2010).

Post - Operative Pain

Smeltzer, Bare, Hinkle and Cheever (2010) and Mackintosh (2010) described post-

operative as a period which extends from the time the patient leaves the operating room

(OR) until the last follow-up visit with the surgeon. This maybe as short as a day or

two or as long as several months. During the post-operative period, nursing care focuses

on rest-period, reestablishing the patient’s physiologic equilibrium, alleviating pain,

preventing complications, and teaching the patient self care. Careful assessment and

immediate intervention assists the patient in returning to optimal function quickly,

safely, and as comfortably as possible. On - going care in the community through home

care, clinic visits, office visits, or telephone follow-up facilitates an uncomplicated

recovery (Smeltzer et al, 2010).

16
International Association for the Study of Pain (IASP) (2010) opined that post-operative

pain is an unpleasant sensation and sense of hurt perceived by the individual following

an operation or surgery. However, it further noted that post operative pain as a complex

phenomenon, encompassing physical, cultural and social and environmental factor that

interconnect and affect how pain is perceived, managed and evaluated (IASP, 2010).

Similarly, Mackintosh (2010) viewed post-operative pain is an unpleasant sensation

ranging from mild discomfort to agonized distress following an operation or surgery.

Post – operative pain is an expected phenomenon and the commonest reason for

delayed hospital discharged.

World Health Organization (2010) opined that post operative care is the time from

completion of surgery until recovery and follow-up clinics. Pain after surgery, as well

as after acute injury or disease, moreso post operative pain usually originates from the

surgical incision, the chest tube, mechanical ventilation, endotracheal intubation or

suction although the most distressing and painful procedure for adult post operative

patients is turning and mobilization.

Pharmacological Management of Pain

Mackintosh (2010) suggests that treatment of post operative pain using the World

Health Organization analgesic ladder, should be from top-down that is starting with

strong opiod analgesic such as morphine working down to mild analgesic (non-opoids)

such as paracetamol or aspirin. Parvizi (2012) found that the multimodalities approach

involving changes in administration of opiods, addition of anti-inflammatory drugs such

17
as methyl predisolone other types of corticosteroids, ketorolac, narcotic, pre-operatively

coupled with post operative management of nausea and vomiting, results in better

patient satisfaction and better pain relief. However, a combination of ropivacine a local

anesthesia and fetanyl (an opioid) can effectively relieve post operative pain with

minimal side effects (Parvizi, 2012).

Smeltzer et al, (2010) noted that pharmacologic management of pain is accomplished in

collaboration with physicians, patients and often families. A physician or nurse

prescribes specific medications for pain or may insert an IV line for administration of

analgesic medications. However, close collaboration and effective communication

among health care provider are necessary. In the home setting, the family often

manages the patient’s pain and diseases. The effectiveness of pharmacologic

interventions, and the home care nurse evaluate the adequacy of pain relief strategies

and the ability of the family to manage the pain (Smeltzer, 2010). The goal of

administrating opiods is to relieve pain and improve quality of life; therefore, the route,

dose, and frequency of administration are determined on an individual basis. However,

analgesic medication is the most powerful tool for pain relief that is available, but it is

not the only one (Adams & Arminio, 2011). Costa and Coleman (2012) asserted that

pharmacologic interventions are most effective when a multimodal or balanced

analgesia approach is used. Balanced analgesia refers to the use of more than one form

of analgesia concurrently to obtain more pain relief with fewer side effects.

18
Patient controlled analgesia is used to manage post-operative pain as well as persistent

pain. Patient controlled analgesia allows patients to control the administration of their

own medication within predetermined safety limits. This approach can be used with oral

analgesic agents as well as with cotninous infusion of opioid analgesic agent by

intravenous, subcutaneous, or epidural routes (Pasero & McCaffery, 2009).

Pharmacologic measures are the major means used to relieve pain. Therefore, analgesia

is used with clients who are predisposed to respiratory complications, including those

undergoing thoracic surgery, those with preexisting respiratory disease, and those who

are obese (Gordon, Pellino & Higgins, 2013). Pharmacologic pain management

involves the use of opioids (narcotics), nonopoioids/nonsteriodal anti-inflammatory

drugs (NSAIDS), and conanalgesic drugs. The principles of modern analgesic use are

built on a foundation established by the World Health Organization (WHO), three step

approach to treating pain. This approach focuses on aligning the proper analgesic with

the intensity of pain. This approach has evolved into what is currently termed “rational

polypharmacy”, which demands that health professionals be aware of all ingredients of

medications that alleviate pain and use combinations to reduce the need for high doses

of any one medication, and to maximize pain control with a minimum of side effects or

toxicity (Berman, Erb, Kozier & Snyder, 2009).

Non-Pharmacological Management of Pain

According to Bjordal, Johnson and Ljunggreen (2011), non-pharmacological methods

used in pain management can be classified in different ways. In general they are

classified as physical, cognitive, behavioural and other complementary methods or as

19
invasive or non-invasive methods. Medication, progressive relaxation, respiration,

biofeedback, therapeutic touching, transcutanoues electrical nerve stimulation (TENS),

hypnosis, musical therapy, acupressure and cold-hot treatments are non-invasive

methods.

On the other hand, Demir and Khorshid (2010) state that the most famous and common

method among the invasive methods is acupuncture. It is considered that these methods

control the gates that are vehicles for pain to be transmitted to the brain and affect pain

transmission or the release of natural opioids of the body such as endorphin. However,

they further noted that non-pharmacological methods used in pain management have

been examined in three groups such as peripheral therapies (physical agents/skin

stimulation methods), cognitive-behavioural therapies and other therapies. Some of

these methods require special training (Demir & Khorshid, 2010). Eidelson (2009)

opined that massage is a manipulation applied on the soft tissue with various techniques

(such as friction, percussion and vibration) for recovering and supporting health. It is

thought that the massage relieves the mind and muscles and thus increase the pain

threshold. Peripheral receptors on the body are stimulated with massage and stimulants

reach the brain by means of spinal cord. Massage plays a role in reducing the pain, and

it is established that massage made during labour decreases pain and anxiety; it also

improves the general well being and progression of birth process and less reaction is

given to the pain (Eidelson, 2009).

20
Cognitive - behavioural therapies are a part of multimodal approach in pain

management. These attempts affect not only the pain level but also helps the patients to

establish a management feeling of less stress while dealing with pain and develop

management behaviors and improved self-esteem. Cognitive behavioural therapies can

generally be applied by all members of the pain team (Lui, & Fong, 2008). Getting the

attention away from the pain reduces its severity. The aim in using the technique

(Distraction) is to increase the tolerance for pain and decrease the sensitivity to pain.

This method includes listening to music, watching television, reading books and

dreaming.

Exercise includes active-passive movements, bed movements and ambulation. Exercise

increases the movement and provides continuity thus increasing the blood flow,

preventing spasm and contractures of the muscles and relieving the pain (Eidelson,

2009). He further noted that restriction of movement/resting are applied for patients

who need certain bed rest and those in traction. However, it should not be used alone

for pain management. It can be used for fractures and back surgeries. Restriction of

movement can also decrease oedema development (Deng & Cassileth, 2012).

Biofeedback is another approach used for treatment in the cases of pain, migraine pain,

spinal cord injuries and movement disorders. It is aimed to control physiological

reactions such as muscle tension, body temperature, heart rate, brain wave activity and

other vital parameters. Biofeedback also help train patient in terms of mental and

physical exercises, visualization and deep breaths (Eiddson, 2009). Acupressure is one

21
of the traditional Chinese Medicine approaches used for pain relief, diseases and

injuries. Acupressure is a therapy that is conducted by applying physical pressure on

various points on body surface by means of energy circulation and balance in cases of

pain symptoms. This therapy is similar to the acupuncture and it is conducted by

applying pressure on selected points of the body fingers, hands, palms, wrists and knees

in order to provide internal flow of energy. Acupressure technique is a noninvasive,

safe and effective application. It is suggested that acupressure reduces backache,

headache, osteoarthritis, musculoskeletal and neck pains, pre-operative and post-

operative pains, nausea, vomiting and sleeping problems (YU & Petrini, 2012).

Nurses Attitude towards Pain in Post Operative Patients

The nurse’s attitude entails the way they think, behave or act towards the patients’

experience of pain and report of pain. Nurses’ belief of pain affects their attitude hence

their perception of patients’ pain. The belief may stem from the nurses cultural

background. Beliefs about pain and how to respond to it differ from one cultural to the

other. A nurse who recognizes cultural differences will have a greater understanding of

the patients’ pain and will be more effective in relieving it (Berman et al, 2008). The

authors also noted that nurses’ religion will equally affect their attitude to patients’ pain

or respond appropriately to patients’ report of pain. For instance, a nurse that belong to

a religion that believe that suffering or pain is a way of showing faith in God may not

accurately perceive or assess patients’ pain. This will lead to poor management of

patients’ pain.

22
Nurses who have little personal experience with pain may not appreciate the magnitude

of painful conditions associated with diseases and medical and surgical interventions.

They may expect clients with chronic pain to react similarly to those with acute pain.

They may assume that reactions to pain fall within a certain norm on the basis of their

own cultural values. The more a client’s response varies from these expected norms, the

more likely nurses attitude toward the client will be positively or negatively biased

(Ignativicus & Workman, 2010). Mackintosh (2010) noted that nurses play an

important role on how clients view their pain. When the nurse is helpful and caring, the

client is less anxious about future pain. However, when the patient has unrelieved pain

or a non-supportive nurse, the patient fears how future pain will be managed. The

patient’s anxiety, in turn, increases pain.

McCaffery and Ferrell (2011) asserted that the use of evidence based information alone

by nurses is inadequate to effect change on pain management. This is because a variety

of other nurse characteristics and conduct affect the pain management process in

different ways. They include; educational requirements of the nursing profession as

well as the years of working experience, knowledge based on certain situations, values

and opinions possessed by the nurses themselves. These consists of patient’s condition

and complications associated with it, appearance of the surroundings, employee assets

as well as relationship developed by health professionals, patients and their relative as

they interact. All the effects related to pain management stated may cause

misconceptions that will eventually affect the nurses ability to make informed decisions

on patient care (McCaffery & Ferrell, 2011).

23
Luzzani (2012) reported that the barriers of the health care staff were found to be

inadequate knowledge and skills on pain management including assessment,

monitoring, and pharmacological treatment of pain especially frequently used opiods.

Moreso, nurses have inadequate skills and even inappropriate knowledge regarding the

use of placebo in pain management. Most nurses have indicated the reason for their

inadequate knowledge and attitude on the little emphasis placed on pain management in

the nursing curriculum (Luzzani, 2012).

British Pain Society (2010) noted that the nurse’s primary responsibility is towards

people who need care. Nurses should provide nursing care with respect for the human

rights and concern about people’s values, customs and beliefs. The process of nursing is

to identify, diagnose and treat patients using nursing process, assessment, nursing

diagnose, planning, implementation and evaluation. The role of the nurse is to assess

the patient’s state of health by taking health history and proper examination. Despite

increased education about pain, there are several reasons why many nurses may under

utilize medication for patients in pain, especially opioids such as morphine. Firstly,

cultural and societal attitudes exist regarding opioid use. Secondly, fear of regulatory

scrutiny may lead to under-prescribing of opioids. A nurse or physician may be

reprimanded by the governing state board for prescribing what the board considers an

inappropriate amount or type of pain medication. Thirdly, there is still a lack of attitude

and knowledge about the effects of analgesics. Even with knowledge and skills about

correct prescribing practices, nurses and other health care providers may fail to assess

and treat the patient’s pain properly (Eidelson, 2009).

24
Myths and Misconceptions about Patient’s Pain

Myths and misconceptions can affect nurse’s attitude to pain assessment. Berman et al,

(2008) identified the following misconceptions:

That patients’ experience severe pain only when they have had major surgery.

Nurses and other health professionals are the authorities on patients’ pain assessment.

Administering analgesics regularly for pain will lead to addiction.

The amount of tissue damage is directly related to the amount of pain.

Visible physiologic or behavioural signs accompany pain and can be used to validate its

existence.

They further stated that health care professionals should know that:

Patients can experience intense pain even after minor surgery.

Patients are unlikely to become addicted to an analgesic provided to treat pain.

Pain is a subjective experience, and the intensity and duration of pain vary among

individuals. The person who experiences pain is the only authority on the existence of

pain and its nature.

Finally, that even with severe pain, periods of physiologic and behavioural adaptation

can occur.

Ethnic and Cultural Values

Beliefs about pain and how to respond to it differ from one culture to the other;

therefore nurses from different ethnic/cultural may perceive pain differently. Nurses

who recognize cultural difference will have a greater understanding of the patients’ pain

25
and will be more accurate in assessing pain and behavioural responses to pain, as well

as more effective in relieving the pains (Smeltzer et al, 2004).

Expectations

Nurses expect patient to be objective about pain and to be able to provide a detailed

description of pain (Berman et al, 2008). Nurses’ cultural expectations and values may

include avoiding exaggerated expressions of pain, such as excessive crying and

moaning, seeking immediate relief from pain, (Smeltzer et al, 2004).

Past Experiences

Nurses’ past experience will equally affect their perception of pain. This may either be

positive or negative. Nurses with wealth of experiences may respond more to patients’

pain or vice versa.

Theoretical Review
The Theory Underlining the study is Peplau’s Theory of Interpersonal Relationship. In

her interpersonal relationship theory, Dr. Peplau emphasized the nurse-client

relationship as the foundation of nursing practice. Peplau went on to form an

interpersonal model emphasizing the need for a partnership between nurse and client as

opposed to the client passively receiving treatment (and the nurse passively acting out

doctor’s order).

The essence of Peplau’s theory is the creation of a shared experience. Nurses, she

thought, could facilitate this through observation, description, formulation,

interpretation, validation and intervention. For example, as the nurse listens to her

26
client, she develops a general impression of the clients situation. The nurse then

validates her inferences by checking with the client for accuracy. The result may be

experimental learning, improved coping strategies, and personal growth for both parties.

(Wayne, 2014). Peplau’s theory of interpersonal relationship discussed the theory in

three phases which are orientation phase, working phase and termination phase

(George, 2003).

Orientation Phase: Commences at the nurses’ first contact with the patient. Both of

them meet as two strangers. The patient has a felt need and has come to seek the

professional assistance of the nurse. This phase is affected by both the patients’ and

nurses’ attitude towards giving and receiving. Also by several other factors like belief,

age, religion, educational background, past experience, preconceived ideas and

expectations. The effective handling of this stage successfully ushers them into the

working phase of the relationship.

Working Phase: In this phase both of them, the nurse and the patient must clarify each

other’s perception and expectation. In a situation, where the nurses’ perception of

patients’ pain is positive, the patient begins to have a feeling of belonging and a

capacity for dealing with the problem. This change decreases the patients’ feeling of

helplessness and hopelessness thereby creating an optimistic attitude. This leads the

patient unto exploitation stage in which the patient takes advantage of all the services

available. Goerge (2003) noted that during this stage, some patients might even make

more demands than they did when they were seriously ill. In this study, it implies that

27
the patient may complain of more pain than when he was seriously sick. This is because

he now feels that he is an integral part of the helping environment. He further stated that

the nurse must convey an attitude of acceptance, concern, and trust in order to maintain

the therapeutic relationship. The nurse must also provide a non – judgment atmosphere

and a therapeutic emotional climate. Communication tools like listening, accepting,

teaching and willingness to offer services, solidity the relationship. Thus, in this phase

the nurse aids the patient in using services to help solve the problem (pain).

Termination Phase: The patients’ need has already been met by the collaborative

efforts of both of them. The relationship needs to be terminated. Sometimes they may

find it difficult. The depending needs in the therapeutic relationship often continue

psychologically after the physiological needs have been met. As in other phases,

anxiety and tension increase in both the nurse and the patient if there is unsuccessful

completion of the phase. In successful termination the patient drifts away from

identifying with the helping person, the nurse.

Values, culture, race

Values, culture,
Educational background Nurse/ Race
Patient
Educational
NURSE Relationship
Background
Belief, sex PATIENT
Beliefs, sex
Past experience Past experience
Expectations

Fig. 1: Factors influencing the blending of the nurse/patient relationship

28
Source: George, (2003), Nursing Theories. The base for professional nursing practice.

Application of Peplau’s Interpersonal Theory in Management of Pain

Hildegard Peplau interpersonal relation theory has proved of great use of later nurse

theorists and clinicians in developing more sophisticated and therapeutic nursing

interventions. The need for a partnership between nurses and client is very substantial in

nursing practice. This definitely helps nurses and health care providers develop more

therapeutic interventions in the clinical setting (Wayne, 2014). The assumptions of

Peplau’s Interpersonal Relations Theory are:

(i) Nurse and patient can interact

(ii) Peplau emphasized that both the patient and nurse mature as the result of the
therapeutic interaction.
(iii) Communication and interviewing skills remain fundamental nursing tools. And

lastly.

(iv) Nurses must clearly understand themselves to promote their client’s growth and

to avoid limiting client’s choices to those that nurses value, can be applied in pain

management.

The theory explains that the purpose of nursing is to help others identify their felt

difficulties and that nurses should apply principles of human relations to the problems

that arise at all levels of experience. Since pain is a felt need, it entails that a nurse’s

duty is not just to care but the profession also incorporates every activity that may affect

the client’s health.

29
The knowledge of the seven roles of nursing, as identified by Peplau will guarantee

patient’s to acquire the best care possible in managing pain, and will ultimately speed

along treatment and recovery. The seven roles of the nurse in the therapeutic

relationship identified by Peplau include:

Stranger: Offering the client the same acceptance and courtesy that the nurses would to

any stranger.

Resource Person: Providing specific answers to questions within a larger context.

Teacher: Helping the client to learn formally or informally.

Leader: Offering direction to the client or group.

Surrogate: Serving as a substitute for another such as a parent or a sibling.

Counsellor: Promoting experiences leading to health for the client such as expression

of feelings.

Technical Expert: Providing physical care for patient and operates equipment.
The nurses through the orientation phase, offer the client the same acceptance and

courtesy that she would to any stranger. She provides the client specific answers to

questions relating to the pain the client is undergoing. The nurse as education may help

the client to learn formally or informally as regards to how best to manage the patient’s

pain. She may teach the patient how to relief pain using cold compress or through

massage. With the role of a leader, the nurse offers direction to the client on how to use

prescribed pain-relieving drugs. She equally may promote the experiences of the patient

by providing positive expression of feelings as regards the type of pain the patient is

experiencing. The nurses through technical expertise, provides physical care for the

30
patient undergoing pain. She may provide non-pharmacological techniques that may be

of help in pain management.

The nurse therefore, through the utilization of Peplau’s interpersonal theory will

develop the best attitude needed in managing patient’s pain. She can achieve this by

being guided creating on a good nurse/client relation, use of non-pharmacological

techniques and appropriate pharmacological medications.

31
 The nurse offers the same acceptance
and courtesy to her client as she
would a stranger.

Provide the client specific answers

Orientation Phase question relating her pains as the
client’s teacher, resource person and
her Counsellor.

The nurse as a Counsellor clarifies the

client’s on his expectations. In the same
vein, assesses the client’s feelings and
perceptions about his condition.

With her technical expertise, the nurse

Working Phase accepts the patients’ feeling and creates a
therapeutic emotional climate.

The nurse as a leader offers direction to

her client on how to use the prescribed
pain-relieving drugs, educate him on
physical care and non-pharmacological
techniques in her management and then
plan for her client’s discharge.
Termination Phase

Discharge planning.

Fig. 2: Diagrammatic Illustration of Peplau’s Model showing Nurse’s Attitude

and Management Pain in Post - Operative Patient.

32
Empirical Review

Many studies have been carried out on management of pain to measure its

effectiveness. It has been a focus of many studies in developed and developing

countries. Internationally, in Canada, Manias, Bucknall and Botti (2012) carried out a

cross sectional descriptive study on nurses strategies for management of pain in Canada.

The study involved 316 post operative cases, randomly selected from 28 hospitals. The

instrument for data collection was a 23 item structured validated questionnaire. Results

showed that analgesia was administered to 37.9% (120 of the patients) while pain

management was discussed with 5.8% (50) patients. Non-pharmacological strategies,

including walking, (1.9%), warm bath 1.3%, and applying heat compress 0.6% are

rarely used by nurses.

Similarly, a study conducted in Inoun Anatolian Hospital by Karayurt, Ozemen and

Centinkaya (2010) in Turkey investigated knowledge and attitude of nurses towards

post-operative pain management. A descriptive cross sectional study was utilized. The

study sample included 246 nurses. Questionnaire was used in collecting data. Data

collected were based on socio-demographic characteristics respondents. Results

obtained revealed that the nurses average correct answer rate for the entire knowledge

and attitudes scale was 39.65% indicating poor attitude towards pain management.

Among the 40 pain knowledge questions assessed, the mean number correctly answered

questions was 15.86% with a range of 3-37%. Several items received a very low

percentage of correct answers. The 10 items with the lowest rate of correct answers

were related especially to pharmacological information (dosage, routs of administration,

33
drug interaction, mechanism of action, side effects etc). The attitude scores were further

analyzed by nurses’ characteristics. Results revealed that nurses with an educational

level of master’s degree or higher and those with baccalaureate training had a

statistically significantly adequate attitude score than nurses with an associated degree

(p = 0.001). The differences between nurses according to the unit they worked in was

the result of the higher scores of nurses working at surgical units than those working in

medical units (P = 0.006).

Horbury, Henderson and Bromley (2011) conducted a survey on validating influence of

patient behaviour on clinical nurses pain management in Eastern Region of Neptal. This

was done because of the effects of opiods. The objective of the study was to evaluate if

patients verbal report of pain is a reliable indicator for post-operative pain management.

The survey was a population based study and non-probability sampling technique and

questionnaire was used as an instrument for data collection. Nearly (44.9%) of the

respondents were reluctant to accept the patients self report of pain and administration

of opiods in the absence of objective signs of pains. Results showed that there was poor

patient’s pain management and exaggerated concerns over the risk of pain relievers. It

was concluded that the patient’s verbal report of pain is a more reliable indicator of pain

management than physical signs or pain behaviours (e.g. facial grimace).

Similarly, Akptelbaum, Chen, Mehta and Gan (2008), conducted a cross - sectional

descriptive study with the aim to assess the knowledge and attitude of nurses towards

management of pain in post operative patients in a cohort of Indian nurses working in

34
surgical wards. Study sample involved a cohort of 203 nurses. Questionnaire was used

in collecting data. Result revealed the negative attitude of nurses towards the

management of post operative pain. The study highlighted the need for educational

programs to create awareness regarding effective pain management knowledge and

attitude scores upon correlation revealed a significant correlation between knowledge

and attitude.

Aptebaum, Chen, Mehta and Gan (2008) conducted a survey on nurses attitude towards

post-operative patients in Ghana. A sample of 92 nurses from the selected hospital

whose age ranged from 20-60years was used for the study. Data was collected using a

self report questionnaire and analyzed using descriptive statistics. The study revealed

that approximately 80% of patient’s experienced pain post-operatively, 60% had

moderate to severe or extreme pain with more patients experiencing pain after

discharge. About 25% of these patient's had post medication adverse effects. However,

90% of the patient express satisfaction with pharmacological interventions especially

opiods; while about two-thirds of these patient reported less pain with diversional

therapy.

Olowayeye, Arogun Date, Bessey and Onajole (2012) conducted a study on 85 nurses

caring for patients with cancer in Lagos State University Teaching Hospital using a

cross - sectional survey and questionnaire was used as an instrument for data collection.

Undesirable attitude towards pain management for patients in pain were demonstrated.

More than 22% of the nurses indicated that they would reduce a patient’s reported pain

35
when charting it, 89% believe that they should have more control over the timing of a

patients pain medication than the patient or family, and 84% believe that steady state

analgesic achieved through round the clock was undesirable. About 56% of the nurses

exhibited misconceptions about addiction and 51% indicated that their estimation of

pain were more valid than the patients.

Unpublished work was conducted by Ogwa (2012) in Nigeria on nurses’ perception of

patients’ pain assessment in routine care, with the aim to ascertain nurses ability on the

use of assessment scale use for the management of pain. It was a cross sectional

survey. The sample size was four hundred and fifty (450) nurses working in two tertiary

institutions in Ebonyi State. The instrument for data collection was a self reported

questionnaire. Findings revealed that nurses from the two hospitals were aware of the

basic components of pain assessment with mean scores of (3.58). They agreed to the

assertion that they assess and manage pain routinely when other vital signs are checked,

during initial health assessment, when patients complain of pain, before and after giving

pain relieving drugs. However, nurses perceived barrier to pain management was

burden of having so many patients to care for (3.17). They had fear of patients getting

addicted to pain relieving drug (3.80). Majority of the nurses use mainly patient’s verbal

report of pain (87%). She concluded that despite the awareness of nurses on what they

ought to do in pain assessment and management, they do not carry it out especially

when they have so many patients to care for. There was no significant statistical

difference in perception of pain management and assessment between the nurses of the

36
two hospitals (P<0.05) and also between the nurses demographic variables within

groups (P<0.05).

Also in Nigeria, an unpublished work was conducted by Anusionwu (2013) on nurses’

perception, attitude and use of non-pharmacological measures in the management of

pain in St. Mary’s Joint Hospital Amaigbo, Nwangele in Imo State. It was a cross

sectional survey. The sample size was fifty (50) nurses working in the hospital.

Questionnaire was used as an instrument for data collection. Findings revealed, majority

of the respondents (48%) have adequate knowledge about non-pharmacological

measures in pain management. The study also demonstrated that nurses do use non-

pharmacological therapies on a regular basis with their patients in the hospital. The

study concluded that nurses have positive attitude towards the use non-pharmacological

measures in the management of pain among post - operative patients.

A similar unpublished study, was conducted by Opara, (2012) on nurses’ perception

and management of pain among post operative patient at Federal Medical Centre

Owerri in Imo State. A sample of 42 nurses from the selected surgical wards was used

for the study. Data was collected using a self reported questionnaire and analyzed using

descriptive statistics. Result revealed that approximately (38%) of the nurses had

insufficient knowledge and poor attitude regarding post-operative pain management.

They concluded that nurses have poor knowledge and negative attitudes toward the

approach and treatment of post - operative pain.

37
Summary of Literature Review

Pain has been defined as an unpleasant emotional and sensory experience that is

associated with potential and acute tissue damage. Pain can be acute or chronic,

depending on its onset. Pain can be managed by non-pharmacological techniques and

pharmacological medications. Nurses attitude towards pain management influence the

way they perceive and interact with clients in pain.

The reviewed literature also discussed some studies that investigated nurses’ attitude

towards post operative pain management. Majority of the studies Aptebaum, et al,

(2008), Opara (2012) and Olowayeye et al, (2012) revealed inadequacies regarding pain

management despite countless training courses, application strategies and

multidisciplinary pain team. The reasons for the inadequacies in pain management and

barriers of the healthcare staff were found to be inadequate knowledge on pain

management including, assessment, monitoring and pharmacological treatment of pain

especially frequently used opiods.

The major theory on which this study was based is Peplau’s theory of interpersonal

relationship. The theory was considered suitable for the study because nurses

incorporate them during assessment, planning and implementing care in the

management of pain, nurses are being guided based on the attitude developed.

Most empirical studies reviewed showed that pain is a major health problem all over the

world. In Nigeria, despite the growing awareness on pain management, patients still

suffer from unnecessary pain in many hospitals with the resultant negative effects on

physical, emotional and spiritual health and quality of life. The conclusion of this

38
report is that except nurses, put up positive attitude and adequate knowledge towards

pain management, patient’s pain rate will continue to increase at an alarming rate

globally.

Most of the studies carried out on pain assessment were on cancer patients. Few studies

have been done in post-operative patients. Based on the fact that post – operative

patients experience pain following the wearing off of anesthesia, the researcher is

prompted to investigate nurse’s attitude to and management of pain in post-operative

patients in order to fill this gap.

39
 CHAPTER THREE

RESEARCH METHODS

This chapter discussed the research design, area of the study, study population, sample

size, sampling procedure and instrument for data collection, method of data collection

and data analysis. It also describes the inclusion criteria, validity and reliability of

instrument, ethical consideration, procedure of data collection and method of data

analysis.

Research Design
This is a cross - sectional descriptive survey study of nurses’ attitude to and

management of pain in post operative patient in Imo State University Teaching Hospital

Orlu. The design was successfully used by (Lui & Fong, 2008) in their studies on

knowledge and attitudes of nurses towards pain management.

Area of Study

The study was carried out in Imo State University Teaching Hospital, Orlu. Orlu is in

Imo State, one of the 36 states of Nigeria. Imo State University Teaching Hospital Orlu,

is located at about 39 kilometers south of Owerri, which is an off shoot of the State

University established in 1981. This hospital is a tertiary health care facility that was

established in 2004 and it is located at Umudike Umuna in Orlu Local Government

Area of Imo State. It is bounded in the North by Eziachi and in the West by Umutanze

while in the East is Ihioma all in Orlu Senatorial Zone. The hospital comprises the

following wards male and female surgical wards, male and female orthopaedics wards,

40
peadiatrics surgical and medical wards, obstetrics and gynaecological wards, urology,

accident and emergency unit, community medicine etc.

Target Population

All the nurses working in surgical wards in Imo State University Teaching Hospital

Orlu constituted the target population. The available population at the time of study was

110. (Source: Administrative records of the Hospital, 2015).

Study Respondents
The total available population of 110 was used because of the small size.

Inclusion Criteria
Nurses included for the study were those that are:

- Employed and working presently during the study period

- Only nurses in surgical ward and

- Willingness to participate.

Instrument for Data Collection

The questionnaire was drawn strictly on extensive literature search on pain management

and the stated objectives. The questionnaire was divided into two sections; Section ‘A’

and Section ‘B’. Section ‘A’ consisted of six questions on socio-demographic

characteristics of the respondents. Section ‘B’, a 4 point likert scale was used for

questions 7 to 12. These questions were based on nurses’ attitude to and management of

pain in post operative patients. The likert scale was rated as Strongly Agreed, Disagreed

41
and Strongly Disagreed. Each questions has closed and opened ended questions that

allowed the respondents to give responses that described their disposition on the issue.

(See appendix I). The questionnaire consisted of a total of 23 items.

Validity of Instrument

The face validity of the instrument was carried out by giving the questionnaire to the

research supervisor and four other experts - two from measurement and evaluation for

content validity and two nurses in surgical unit. The necessary suggestions were

effected by the researcher in the final refinement of the instrument, thus increasing the

items from 18 to 23.

Reliability of the Instrument

A pilot study was conducted on 10% of sample size among nurses of FMC, Owerri who

are not part of the study population using test- retest method. The data obtained were

analyzed using Pearson product moment correlation coefficient (r) to get the coefficient

of reliability (r). A score of 0.79 (79%) was obtained which indicates that the tool is

reliable.

Ethical Consideration

Ethical approval was obtained from Health Research Ethics Committee of Imo State

University Teaching Hospital Orlu.

Informed consent was obtained from the respondents. They were assured of

confidentiality and anonymity.

42
Procedure for Data Collection

With the ethical approved and letter of introduction from the Head of Department

Nursing Sciences an administrative permit was obtained from the Chief Medical

Director and the ward heads before data collection. Four (4) research assistants were

instructed on the purpose of the study and on how to administer the instrument after

obtaining consent from the respondent who were willing to participate in the study.

The researcher and the assistants administer the copies of questionnaire to nurses during

morning and afternoon shifts who met inclusion criteria. Data collection lasted for a

period of seven days.

Method of Data Analysis

Data generated from this research instrument were analyzed using descriptive and

inferential statistics. Descriptive statistic like percentages, mean and standard deviation

was used. The 4 point - likert scale was used to analyze the attitudinal questions. The

four scales were positively worded and interpreted in order of 4, 3, 2, 1. . The mean

responses were calculated thus:

Strongly Agreed - 4

Agreed - 3

Disagreed - 2

Strongly Disagreed - 1
10

43
The mean value of 2.5 was used as mean decision point. A mean score of 2.5 and above

was thus accepted as positive while less than 2.5 was accepted as negative response for

the items.

Chi square was used for determining the relationship between socio-demographic data

and nurse’s attitude towards pain management at significant level of 0.05

44
 CHAPTER FOUR
PRESENTATION OF RESULTS AND INTERPRETATION OF DATA
This chapter presents data obtained from the analysis. Out of the 110 questionnaire
administered 105 was retrieved giving a return rate of 90.
Table 1: Socio-Demographic Data

Frequency Percentage
Age Category
18-22 1 1.0
23-27 4 3.8
28-32 4 3.8
33-37 12 11.4
38-42 21 20.0
43-47 6 5.7
48-52 1 1.0
63-67 1 1.0
Total 50 47.6
No response 55 52.4
Total 105 100

Marital status 78 74.3

Married 21 20.0
Single 2 1.9
Divorced/separated 4 3.8
Widowed 105 100
Total

What is your Highest professional qualification?

Registered nurse only 3 2.9
Registered Midwife only 4 3.8
Registered Nurse/Midwife 48 45.7
50 47.6
105 100
Highest Academic Attainment
First Degree
Higher Degree 48 45.5
No response 9 8.6
Total 48 45.5
105 100

Working Area
Anaesthestic Nursing 14 13.3
Perioperative Nursing 3 2.9
Orthopaedic Nursing 2 1.9
Public Health Nursing 8 7.7
Accident and Emergency 1 1.0
Psychiatric Nursing 2 1.9
Total 30 28.6

Religion 100
Christianity 105 0.0
Islam 0 0.0
Atheist 0 0.0
Traditional 0
Mean Length of clinical experience (in year) = 10.48
Std. Dev= 6.64
Age Mean = 37.7, Stad. Dev = 7.17

45
Table 1 above shows the socio-demographic data of the respondents. From the table,

most 96(91.4%) of the respondents were females and were majorly 78(74,3%) married.

In response to the question of highest professional qualification, 3(2.9%) of the

respondents were Registered Nurse, 1(1.0%) was Registered Midwife, 48(45.7%) were

BNSc holders, 48(45.55%) had Registered Nurse/Midwife and any other Diploma in

nursing, 50(47.6%) had Master’s degree while 9(8.6%) and 48(45.5%) did not respond

to the question.

Also in table 1, out of the 30 respondents that have specialized in one area or the other,

14(13.3%) of the respondents had their specialty area as Anaesthesia, 3(2.9%) were Pre-

operative nurses, 2(1.9%) were Orthopedic nurses, 8(7.7%) were Public health nurses,

1(1.0%) did Accident and Emergency nursing, while 2(1.9%) did Psychiatric nursing.

All the respondents were Christians. The mean length of clinical experience was

10.4years.

46
 Presentation of Results according to study objectives
Objective 1: Determine the nurses’ attitude towards the management of pain in post-operative patients
in IMSUTH, Orlu.
Table 2: Attitude of Nurses towards management of pain in post-operative patients
Items SA(%) A(%) D(%) SD(%) Mean St. Dev
A. I am capable of assessing 63(52.9) 39(32.8) 3(2.5) 0(0.0) 3.571 .55222
post-operative pain
B. Patients who can be 2(1.7) 7(5.9) 40(33.6) 56(47.1) 1.569 .70516
distracted from post-operative
pain usually do not have severe
pain
C. Do you feel that cultural 21(17.6) 33(27.7) 34(28.6) 17(14.3) 2.552 .99015
factors influence your attitude
towards pain management?
D. Nurses’ use of vital signs 29(24.4) 43(36.1) 26(21.8) 7(5.9) 2.104 .88713
are always indicators of the
intensity of a patient's pain
E. Patients are best assessors 57(47.9) 35(29.4) 13(10.9) 0(0.0) 3.419 .70412
of their pain
F. Patient's verbal report is 14(11.8) 30(25.2) 48(40.3) 13(10.9) 2.428 .87549
highly subjective and therefore
should not be relied on always
G. Patients over report their 29(24.4) 52(43.7) 20(16.8) 4(3.4) 1.990 .79051
level of pain to gain attention
H. Validation of patient's pain 11(9.2) 26(21.8) 52(43.7) 16(13.4) 2.304 .85624
can effectively be done with
patient's verbal report of pain
only
I. Nurses are best assessors of 45(42.9) 32(30.5) 18(17.1) 10(9.5) 1.993 .88775
pain.
Overall mean 2.436, Std.
0.8054.

47
Table 3: Mean response on Attitude towards the management of pain in post-
operative patients.
Decision rule: mean< 2.5 – Negative
Mean ≥ 2.5 – Positive

Mean attitude towards pain management

Frequency Percent

Valid Negative 75 71.4

Positive 30 28.6

Total 105 100.0

Table 3 above shows the respondents’ attitude towards management of pain in post-

operative patients. As shown in table 2 above, out of the items which were used to

determine the respondents’’ attitude towards pain management in post-operative

patients, six(6)(1.569, 2.104, 2.428, 1.990, 2.304, 1.993) were negative evidenced by

mean score of below 2.5. Mean score below 2.5 suggests that respondents disagree with

the sentences. On the other hand, three items had mean score above 2.5 (3.571, 2.552,

and 3.419) and this suggests that respondents agree with sentences with the

corresponding scores.

Summarily, from Table 3 above, 75(71.4%) respondents had negative attitude towards

the management of pain in post-operative patients while 30(28.6%) had positive attitude

having an overall mean score of 2.436

48
Objective 2: Assess the nurses attitude in the use of Pharmacological Management
of Pain in Post – operative Patient in IMSUTH, Orlu.
Table 4: Attitude of Nurses towards the use of pharmacological pain management in
post-operative patients.

Items SA(%) A(%) D(%) SD(%) Mean St. Dev

Patients will be addicted to pain 43(41.0) 41(39.0) 15(14.3) 6(5.7) 1.847 .87465
relief if nurses should rely on
their verbal report of pain
Are you for any reason afraid to 20(19.0) 55(52.4) 27(25.7) 3(2.9) 2.123 .74285
administer morphine or other
opioid compounds to patients?
I give drugs when patients 6(5.7) 33(31.4) 54(51.4) 12(11.4) 2.314 .75082
complain of pain
Analgesics for immediate post- 49(46.7) 38(36.2) 13(12.4) 5(4.8) 1.596 .85238
operative pain should initially
be given round the clock on a
fixed schedule
Under utilization of prescribed 30(28.6) 57(54.3) 7(6.7) 11(10.5 3.009 .88247
medication and fear of causing
respiratory depression may
cause poor management of
post-operative pain
Combining analgesics that 39(37.1) 47(44.8) 15(14.3) 4(3.8) 3.1524 .80600
work by different mechanisms
(e.g combining an opioid with
NSAID) may result in better
pain control with fewer side
effects than using a single
analgesic agent
Overall mean 2.340, Std.
0.8181

49
Table 4 above shows the respondents’ attitude towards the use of pharmacological pain

management in post-operative patients. Out of the six items which were used to

determine this attitude, four of them had scores below 2.5(1.847, 2.123, 2.314, and

1.596) which suggests that they did not agree with the sentences while two items had

mean score more than 2.5 which suggests that respondents agreed with the sentences.

Table 5: Mean response on attitude towards the use of pharmacological

measures in the management of pain
Decision rule: mean< 2.5 – Negative
Mean ≥2.5 –Positive

Frequency Percent

Valid Negative 78 74.3

Positive 27 25.7

Total 105 100.0

Table 5 shows that out of 105 respondents, 78(74.3%) had negative attitude towards the

use of pharmacological measures in the management of pain while 27(25.7%) with an

overall mean of 2.340

50
Objective 3: Ascertain the nurses’ attitude in the use of Non-pharmacological
management of pain in post-operative patients in IMSUTH, Orlu.

Table 6: self-reported capability of nurses of using non-pharmacological management

of pain in post-operative patients
Items SA(%) A(%) D(%) SD(%) Mean Std. Dev
Deep breathing 50(47.6) 46(43.8) 7(6.7) 2(1.9) 3.371 0.69693
exercise
Positioning and 51(48.6) 48(45.7) 5(4.8) 1(1.0) 3.419 0.63217
restriction of
movement
Diversional therapy 60(57.1) 40(38.1) 5(4.8) 0(0.0) 3.523 0.589903
e.g. listening to music,
watching television,
and reading news paper
Exercise and relaxation 41(39.0) 61(58.1) 3(2.9) 0(0.0) 3.3619 0.53930
Therapeutic massage 46(43.8) 55(52.4) 4(3.8) 0(0.0) 3.4000 0.56501
Overall mean 3.414 Std.
0.6026.

Table 6 above shows the attitude of nurses towards the use of non-pharmacological

management of pain in post-operative patients. For deep breathing exercises, 50(47.6%)

strongly agreed to the use of it, 46(43.8%) agreed, 7(6.7%) disagreed, while 2(1.9%)

strongly disagreed with a mean response of 3.371 and a standard deviation of 0.69693.

51(48.6%) strongly agreed to the use of Positioning and restriction of movement,

48(45.7%) agreed, 5(4.8%) disagreed while 1(1.0%) strongly disagreed with a mean

response of 3.419 a standard deviation of 0.63217. 60((57.1%) strongly agreed to the

use of diversional therapy e.g. listening to music, watching television, and reading

51
newspaper, 40(38.1%) agreed, 5(4.8%) disagreed, 0(0.0%) strongly disagreed with a

mean response of 3.523 a standard deviation of 0.589903. 41(39.0%) strongly agreed to

the use of Exercise and relaxation for pain management, 61(58.1%) agreed, 3(3.9%)

disagreed. No respondent strongly disagree with it. The mean response was 3.3619 and

the standard deviation was 0.53930. 46(43.8%) strongly agree to the use of therapeutic

massage, 55(52.5%) agreed, 4(3.8%) disagreed, and none strongly disagreed with a

mean response of 3.4000 and a standard deviation 0.565.

Decision rule: mean< 2.5 – Negative

Mean ≥2.5 –Positive

Table 7: Mean response on Attitude towards the use of non-pharmacological

management of pain in post-operative patients

Frequency Percent Valid Percent Cumulative Percent

Valid Negative 8 7.6 7.6 7.6

Positive 97 92.4 92.4 100.0

Total 105 100.0 100.0

Summarily, Table 7 shows the respondents’ attitude towards the use of non-

pharmacological management of pain in post-operative patients categorized into

positive and negative attitude. 8(7.6%) had negative attitude while 97(92.4%) had

positive attitude.

52
Objective 4: Determine the influence of socio-demographic characteristics on nurses

attitude towards the management of pain in post-operative patients in IMSUTH, Orlu

In achieving this objective, the research hypothesis one and two were tested using Chi-

square on respondents’ socio-demographic data (educational background and length of

clinical experience)

Hypothesis One: Educational level of nurses have no significant influence on nurses

attitudes towards management of pain in post-operative patient.

Table 8: Cross tabulation between educational level and nurses’ attitude towards the
management of pain in post-operative patients.

Attitude towards the

management of pain in post of
operative patient.

Negative Positive Total

What is your Highest Registered nurse only 2 2 3

professional qualification? Registered Midwife only 1 0 1

Registered Nurse/Midwife 35 7 48

Orthopeadic Nursing 1 0 1
Anaesthetic Nursing 16 8 22

Registered Nurse/Midwife
and any other Diploma in 20 10 27
nursing

Total 75 27 102

53
Table 9: Chi-Square Tests Result (Cross Tabulation between educational level and

nurses’ attitude towards the management of pain in post-operative patients

Value df Asymp. Sig. (2-sided)

Pearson Chi-Square 5.054a 5 .409

Likelihood Ratio 5.496 5 .358

Linear-by-Linear Association 1.359 1 .244

N of Valid Cases 102

a. 7 cells (58.3%) have expected count less than 5. The minimum expected count is .19.

In comparing the attitude of nurses towards post-operative pain management on their

professional qualifications. No statistical significant difference was found between

attitude of nurses towards pharmacological management of pain and their level of

education, χ2(5) =5.1, p > 0.05. Therefore, H0 is accepted.

54
Hypothesis two: Nurses years of experience have no significant influence on nurses

attitude towards the management of pain in post-operative patients.

Table 10: Cross Tabulation between length of clinical experience and nurses’

attitude towards the management of pain in post-operative patients.

Attitude towards the management of

pain in post-operative patients

Negative Positive Total

Length of clinical experienced 1-5years 16 7 24

6-10 years 30 8 39

11-15years 18 9 24

16-20 years 1 0 1

21years and above 6 4 11

Total 71 28 99

55
Table 11: Chi-Square Tests Results (Cross Tabulation between length of

clinical experience and nurses’ attitude towards the management of pain in

post-operative patients.

Value df Asymp. Sig. (2-sided)

a
Pearson Chi-Square 4.334 4 .363

Likelihood Ratio 4.488 4 .344

Linear-by-Linear Association .283 1 .594

N of Valid Cases 99

a. 3 cells (30.0%) have expected count less than 5. The minimum expected count is .21.

In testing the attitude of nurses towards post-operative pain management according to

their years of clinical experience. No statistical significant difference was found

between attitude of nurses towards pharmacological management of pain and their years

of experience, χ2(4) =4.3, p > 0.05. Therefore, H0 is accepted.

56
Summary of Findings

· Majority of the respondents, 75(71.4%) had negative attitude towards the

management of pain in post-operative patients.

· Majority of the respondents 78(74.3%)had negative attitude towards the use of

pharmacological measures in the management of pain.

· Majority of the respondents 97(92.4%) had positive attitude towards the use of

non-pharmacological management of pain in post-operative patients

· These was no statistical significance between educational level and attitude of

nurses towards the management of pain in post-operative patients.

· There was no statistical significance between length of clinical experience and

attitude of nurses towards the management of pain in post-operative patients.

57
 CHAPTER FIVE

DISCUSSION OF FINDINGS

This chapter dealt with the discussion of major findings, implications of the study,

limitations of the study, suggestions for further studies, summary, conclusion and

recommendations.

The major findings are discussed as they relate to the objectives of the study and

research hypotheses.

Discussion

Research Question 1: What are the attitude of nurses in surgical wards towards

the management of pain in post - operative patients?.

The findings of this study revealed that nurses have negative attitude towards the

management of pain in post-operative patients. This supports the works of Bostrom

(2012) conducted in India on nurses knowledge and attitude towards the management of

pain. The study asserted that negative and mistaken beliefs about pain and its treatment

are attributed to the fact that nurses do not have adequate knowledge, attitude and skills,

to manage pain effectively. This could be the reason why the nurses in this study have

negative attitude towards the management of pain in post-operative patients as revealed

in objective 1.

However, the findings is also in agreement with the findings of Horbury Hdenderson

and Bromly (2011) in Turkey validating the fact that nurses had negative attitude

towards pain management. The reason in this study may be misconception, poor

58
educational background and lack of skill about effective post-operative pain

management among nurses in Imo State University Teaching Hospital, Orlu.

Research Question 2: To what extent do nurses use pharmacological measures in

the management of pain in post-operative patients in IMSUTH, Orlu?

The results of the findings revealed that nurses have negative attitude towards the use of

pharmacological management of pain in post-operative patients. This can be attributed

to the tight regulatory restrictions that have been placed on the use of opioids in the

country and this created unnecessary fear on its use. Aptebaum, Chen, Mehta and Gan

(2008) in their study pointed out nurses underestimate post-operative pain experienced

by patients and this could be a factor contributing to the negative attitude in this case.

This result is not far from the findings of Olowayeye, Arogun, Bessey and Onajole

(2012) from a study conducted in Lagos State University Teaching Hospital where

undesirable attitude towards pain management for patients in pain were demonstrated.

More than 22% of the nurses indicated that they would reduce a patient’s reported pain

when charting it, 89% believe that they should have more control over the timing of a

patients pain medication than the patient or family, and 84% believe that steady state

analgesic achieved through round the clock was undesirable. About 56% of the nurses

exhibited misconceptions about addiction and 51% indicated that their estimation of

pain were more valid than that of the patients.

59
Research Question 3: To what extent do nurses utilize non-pharmacological

measures in the management of pain in post-operative patients in IMSUTH, Orlu?

The findings of this study revealed that nurses have positive attitude towards the use of

non-pharmacological management of pain in post-operative patients. The findings is in

disagreement with the findings of Manians, Bucknell and Both (2012) conducted in

Canada on nurses strategies for management of pain. In their study, non-

pharmacological strategies, including walking, warm bath and applying heat compress

were rarely used by the nurses. This could be attributed to the fact that nurses in this

present study viewed non-pharmacological method as a better alternative to

pharmacological method. Non-pharmacological methods have less or none of the side

effects compared to pharmacological methods. This also could be the reason why the

nurses in this study have negative attitude toward the use of pharmacological

management of pain in post-operative patients as was revealed in objective 2 above.

However, the findings of this study concurred with the findings of Anusionwu (2013) in

Imo State on nurses’ perception, attitude and use of non-pharmacological measures in

the management of pain. The reason for this may be that both study were carried out in

Imo State. The nurses in Amaigbo and those in the present may have had the same

orientation in the use non-pharmacological methods, thus, they have the same view

towards pain management.

60
Research Question 4: determine the influence of socio-demographic characteristics

on nurses’ attitude towards the management of pain in post-operative patients in

IMSUTH, Orlu?

Hypothesis One: Educational level of nurses have no significant influence on nurses

attitude towards the management of pain in post-operative patients.

The result revealed no statistical significance difference was found between attitude of

nurses’ towards management of paint in post-operative patients and their level of

education.

This is in agreement with the work of Ogwa (2012) who observed that there was no

statistical difference between the nurses’ perception of pain assessment and their

demographic characteristics P < 0.05. It may be, perhaps nurses in both study have the

same orientation.

Hypothesis Two: Nurses years of experience have no significant influence on nurses

attitude towards management of pain in post-operative patients.

Data analyzed showed that there is a no statistical significance influence between nurses

attitude towards pain management in post-operative patient and their years of clinical

experience. This was further proved by the Pearson Chi-square value X 2 (5) = 5.1 and

P-value >0.05. Hence relationship between years of clinical experience and nurses

attitude towards the management of pain in post-operative patient was established.

61
Implications for nurses:

The findings of this study has shown that the attitude towards pain management in post-

operative patients negative and this has implication for nurse as formal caregivers who

are usually in touch with the patients. There is need for training on pain management,

particularly on the use of opioids to correct misconceptions and myths that have

contributed to the low attitude score among nurses. It has been empirically shown that

people do not get addicted to opioids or get some of the dreaded side effects when used

appropriately and this should be communicated to the nurses through organized

teaching. The positive attitude towards use of non-pharmacological management of pain

should be encouraged so that nurses will employ them as needed for varying situations.

Limitations of the study

The limitation encountered was time constraint and this consequently reduced the extent

of literature reviewed and the discussion of findings. There was also the challenge of

retrieving the instruments from the nurses who are most times busy.

62
Suggestions for further study

1. A study should be carried out on the knowledge of pharmacological management

of pain

2. A similar study should be carried out to explore the reasons for the negative

attitude among nurses towards pain management.

3. There should be a correlational study on the influence of ethnicity on attitude

towards pain management among health workers.

4. It would help if researchers will replicate this study at a larger scale.

63
Summary

This study was carried out to assess Nurses’ attitude to management of pain in post-

operative patients in Imo State University Teaching Hospital. The specific objectives of

this study were to: Determine the nurses’ attitude towards the management of pain in

post-operative patients in IMSUTH Orlu.

Assess the nurses’ attitude in the use of pharmacological management of pain in post-

operative patients; Ascertain the nurses’ attitude in the use of non-pharmacological

management of pain in post-operative patients; Determine if educational level of nurses

influence their attitude towards pain management in post-operative patients; and Assess

if years of experience influence nurses’ attitude towards pain management in post-

operative patients.

Extensive literature was reviewed to enhance the theoretical background of the study.

The subjects of the study were nurses and the data was collected using a self-

constructed questionnaire. Descriptive and inferential methods of analysis were used in

the analysis of the data obtained. The major findings of this study are: The mean age of

the respondents is 37.7 ≈38years; Majority of the respondents were Nurse/Midwife. The

mean of years of clinical experience is 10.48years. Majority of the respondents,

75(71.4%) had negative attitude towards the management of pain in post-operative pain.

Majority of the respondents 84(80%) had negative attitude towards the use of

pharmacological measures in the management of pain. Majority of the respondents

97(92.4%) had positive attitude towards the use of non-pharmacological management of

64
pain in post-operative patients. No statistical relationship was found between Nurses’

attitude towards management of pain in post-operative patients and nurses’ r(103) =

0.005, p > 0.05;A positive relationship was found between Attitude of nurses towards

the management of pain in post-operative patients and years of clinical experience,

r(103) = 0.21, p = 0.037< 0.05; Majority of the respondents that had negative attitude

towards pain management in post-operative patients had less no of years of clinical

experience (1-10years).

Conclusion

From the findings of this study, it can be concluded that:

· There is negative attitude towards pain management in post-operative patients

among nurses in IMSUTH

· There is negative attitude towards the use of pharmacological measures in the

management of pain among nurses in IMSUTH

· There is positive attitude towards non-pharmacological management of pain

among nurses in IMSUTH

· No statistical significance influence exists between the nurses’ level of education

and their attitude towards pain management in post-operative patients.

· There is no statistical significance influence exist between a nurses’ attitude

towards pain management in post-operative patients and their years of clinical

experience

65
Recommendations

Based on the findings of this study, the researcher made the following

recommendations:

1. For the sake of a positive change in attitude the hospital management should put

up educational strategies to correct misconceptions about pain management to the

nurses and also relay to them the current trend in pain management and empirical

evidence showing the effectiveness of opioids

2. The use of non-pharmacological management of pain should be promoted among

nurses.

3. The government should make opioids readily available for use in pain

management

66
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 APPENDIX I: INSTRUMENT

Department of Nursing Science,

Faculty of Health Sciences and
Technology,
University of Nigeria,
Enugu Campus.

Dear Respondent,

I am Onyekwuo Chinonye Festa, a prost graduate Student of Nursing Sciences,

University of Nigeria, Enugu Campus. I am carrying out a study on Nurses’ Attitude to
and Management of Pain in Post-Operative patient in Imo State University Teaching
Hospital, Orlu.

I hereby solicit your cooperation in responding to items in the questionnaire as

accurately as possible. The information obtained will be strictly used for clinical
purposes only and will thus be treated with high level of confidentiality.

Thanks for your anticipated co-operation.

Yours Sincerely,

Onyekwuo, Chinonye Festa.

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 QUESTIONNAIRE

Instruction: Please tick (√) in the most appropriate box, if your response is not listed,
write them down in the space provided.

SECTION A:
SOCIO-DEMOGRAPHIC CHARACTERISTIC OF RESPONDENTS

1. What is your age? (in years) last birthday?

2. Gender: (a) Male (b) Female
3. Marital Status: (b) Married (b) Single (c) Divorced/Separated
(d) Widowed

4. What is your highest professional qualification?

(a) Registered nurse only

(b) Registered midwife only

(c) Registered nurse/registered midwife only

(d) Registered nurse/registered midwife and

Any other diploma in nursing

(e) Highest Academic Attainment: First Degree Higher Degree

(f) Specialty area Specify …………………

Other specify ……………………..

5. Religion: (a) Christianity (b) Muslim (c) Atheist

(d) Traditionalist

6. Length of clinical experience (in year)

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 SECTION B:
NURSES ATTITUDE TOWARDS PAIN MANAGEMENT

7. What are the attitude of nurses towards Strongly Agreed Disagreed Strongly
Disagreed
the management of post-op pain? Agreed

a. I am capable of assessing post- operative

pain?
b. Patients who can be distracted from post -
operative pain usually do not have severe
pain.
c. Do you feel that cultural factors influence
your attitude towards pain management?
d. Do you encourage patients to endure as much
pains as possible before using an opiod.
e. Patients may sleep inspite of severe pain.
f. Patients should be individually assessed to
determine cultural influences.
g. Patients over-report their level of pain to gain
attention.
h. Validation of patients’ pain can effectively be
done with patients verbal report of pain only.
i. Nurses are the best assessors of pain
8. Nurses attitude towards the use of
pharmacological measure in the
management of pain.
a. Patients will be addicted to pain relief if
nurses should rely on their verbal report of
pain.
b. Are you for any reason afraid to administer
morphine or other opiod compounds to
patients?

75
c. I give drugs when patient’s complain of pain
d. Analgesic for immediate post-operative pain
should initially be given round the clock on a
fixed schedule.
e. Under utilization of prescribed medication
and fear of causing respiratory depression
may cause poor management of post-
operative pain.
f. Combining analgesics that work by different
mechanisms (e.g. combining an opiod with
NSAID) may result in better pain control
with fever side effects than using a single
analgesic agent.
9. Are you capable of using the following
Non- pharmacological techniques in post-
operative in pain management?
a. Deep breathing exercise
b. Positioning and restriction of movement
c. Diversional therapy e.g. listening to music,
watching television and reading news paper
d. Exercise and relaxation
e. Therapeutic massage
g. Cognitive behavioural therapy.

10. What are other non-pharmacological techniques you could use to manage post-
operative pain that is not listed above? ___________________________
11. Do you have any barrier towards the use of the non-pharmacological measures?
____________________
12. If Yes, please mention them? ___________________________________
Department of Nursing Science,

76