Background
Pain is one of the most common and devastating symptoms experienced by hospitalized patients,
including those who underwent surgical procedures. McCaffery defines pain as “whatever the
experiencing person says it is, existing whenever he or she says it does” (1). The International
Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional
experience associated with, or resembling that associated with, actual or potential tissue damage”
(2). Pain majorly classified into acute pain and chronic pain. Acute pain most of the time rise
from tissue injury, and usually accompanied by physiological responses such as tachycardia,
hypertension, and increased respiratory rate. This type of pain generally lasts less than three
months. Post-operative pain is one form of acute pain resulting from surgical trauma to tissues
and organs, which triggers and stimulates the central and peripheral nervous system sensitization
for that specific trauma.
If post-operative pain is inadequately managed, it can lead to continuous patient suffering,
prolonged recovery and delayed mobilization, increased complications, reduced patient
satisfaction, and higher healthcare costs. It may also progress to even worse complications like
chronic pain syndrome. The physiological consequences include impaired respiratory function,
delayed wound healing, and increased potential for cardiovascular stress. Psychologically,
patients may experience anxiety, depression, sleep disturbances, and a general reduction in
quality of life. Socio-economically, prolonged hospital stays and re-admissions due to pain-
related complications increase the burden on already strained healthcare systems.
The primary goals of post-operative pain management are to improve outcomes and patient
experience. Often this entails balancing analgesia with achieving functional and other recovery
goals, while avoiding preventable complications.
Nurses play a pivotal role in the management of postoperative pain as they are the frontline
providers responsible for continuous patient monitoring, assessment, and implementation of
prescribed pain interventions by acquiring accurate knowledge, positive attitudes, and skills.
However, evidence suggests that nurses’ knowledge, attitudes, and practices (KAP) towards
postoperative pain management can significantly influence the quality of care provided for
surgical patients.
Statement of the Problem
Despite advances in surgery and anesthesia, postoperative pain (POP) remains distressingly
prevalent worldwide. Globally, up to 80% of surgical patients experience POP, and more than
70% report it as moderate to severe (3). Untreated or poorly managed POP can lead to serious
consequences—impaired physical and mental recovery, prolonged hospitalization, readmissions,
increased complications, and significant economic burden (4).
Numerous studies show that the prevalence of pain remains high in post-operative patients (5–7).
Yates et al. reported that 79% of surgical patients experienced a great intensity of pain during the
first 24 hours after surgery (7). Ignatavicius and Workman reported that for patients who
underwent surgery, 20% experienced mild pain, 20% to 40% experienced moderate pain, and
40% to 70% experienced severe pain (8). Apfelbaum et al. found that approximately 80% of
patients described their pain as moderate, severe, or extremely severe (5).
In Africa, the frequency and severity of POP are particularly high. Approximately 47% of
surgical patients suffer from inadequate pain control, compounded by resource scarcity,
inadequate pain assessments, healthcare provider knowledge gaps, limited opioid availability,
and patient misconceptions (9). In Tanzania, for example, 73% of patients reported moderate to
severe POP on the first postoperative day (10).
Within Sub-Saharan Africa, similar challenges persist. In Malawi, musculoskeletal surgical
patients often face limited analgesic access, underuse of pain assessment tools, and inadequate
nurse training (11). At the procedure level, POP intensity varies widely, but studies show that
severe pain is common in the first 24 hours post-surgery (12).
At the Ethiopian national level, POP management remains critically insufficient. A study in a
referral hospital reported moderate to severe POP in 88.2% of patients, with 58.4% inadequately
treated (13). Another study at a university referral hospital found high rates of unmanaged pain
due to inadequate assessment, limited analgesic availability, and underuse of multimodal
approaches (14). Research on traumatic fracture surgeries also revealed persistent high
postoperative pain, reflecting systemic challenges (15). In our country the availability and
amount of Surgical and operational theatre nurse is limited. Due to this reason the available
Clinical and comprehensive nurses take the part in this activity. However due to the broad scope
of their activity in the Hospital the Assessment and management skills of post-operative pain
most usually gain and acquired through experience.
Significance of the Study
This research study will contribute to the limited body of literature on national POP management
in low-resource settings, adding facility-specific insights to global and African trends. The study
results can guide revisions to nursing curricula and continuing professional education programs
to include evidence-based pain management principles, thereby strengthening the role of nurses
in postoperative care by delivering effective POP management that can improve patient comfort,
reduce complications, shorten hospital stays, and lower readmission rates, thus enhancing care
quality and healthcare system efficiency. The research will also address identify systemic
barriers such as lack of formal pain protocols, inadequate drug supply, and absence of ongoing
pain management training. Additionally findings will inform hospital administrators, nurse
educators, and policymakers about existing deficits in knowledge, attitudes, and practices among
non-surgical nurses, providing evidence for targeted training and the development of
standardized POP management protocols.
Literature Review
Introduction to the Literature Review
POP is a subtype of acute pain that usually resolves within three months and is triggered by
surgical tissue injury. This injury initiates nociceptive signaling from the periphery to the central
nervous system, causing peripheral sensitization (increased sensitivity of nociceptors) and central
sensitization (heightened responsiveness of neurons in the spinal cord). Clinically, this manifests
as hyperalgesia (exaggerated pain response) and allodynia (pain from normally non-painful
stimuli).
Effective POP management is crucial because inadequately treated pain can lead to
complications far beyond patient discomfort—progressing to chronic pain syndromes, impairing
physiological recovery, and imposing economic and psychosocial burdens.
Global Burden of Post-operative Pain
Globally, POP prevalence remains alarmingly high. Apfelbaum et al. found that approximately
80% of patients experience moderate to extreme POP, with 86% reporting pain on movement
(5). The United Kingdom’s National Health Service audits have shown that 79% of surgical
patients report moderate to severe pain in the first 24 hours (7). In high-income countries,
although multimodal analgesia is recommended, under-treatment persists due to factors such as
opioid-sparing trends, staff shortages, and inconsistent use of validated pain assessment tools.
Studies also show the complications arise from non-managed post-operative pain including
impaired respiratory function due to splinting, delayed mobilization leading to thromboembolic
risk, delayed wound healing, sleep disturbances, and increased hospital stay (2, 5). There is also
a strong correlation between poorly managed acute pain and the development of persistent post-
surgical pain (PPSP), affecting up to 10–50% of surgical patients depending on the procedure
(5).
Post-operative Pain in the African Context
In Africa, POP burden is exacerbated by structural and systemic limitations: low healthcare
funding, scarcity of trained personnel, inadequate supply chains for analgesics, and lack of
standardized pain management protocols. A review of POP studies in African hospitals found
that, on average, 47–73% of patients experience moderate to severe pain in the first 48 hours
after surgery (16). Barriers included irregular pain assessment, limited opioid access, and cultural
norms discouraging open expression of pain (10). Across the continent, nurses often rely on
patients’ overt distress cues rather than systematic assessment tools, leading to under-recognition
and under-treatment.
Sub - Saharan Africa Perspective
In sub- Saharan countries the management of post-operative pain face so many difficulties due to
wide Nurse-to-patient ratios are frequently 1:20 or higher, limiting the time available for
individualized pain management. Also there are a few hospitals have formal POP guidelines plus
Opioids are available mainly in tertiary hospitals, with morphine often in short supply.
Additionally Pain management receives minimal coverage in nursing curricula, and continuing
professional development opportunities are rare. Although some regional initiatives have
introduced pain care protocols, uptake has been inconsistent. Evidence from Botswana and
Kenya indicates that even where guidelines exist, lack of training and enforcement results in
minimal change in practice.
Ethiopian Context: National Findings
A Prospective longitudinal study across various three tertiary hospitals in Ethiopia shows that
88.2% of patients had moderate to severe POP within the first 24 hours, and 58.4% were
inadequately treated. Barriers included lack of formal pain assessment, insufficient analgesic
supplies, and limited nurse training (16).
A Cross-sectional study was conducted in 2023 in Tikur anbessa Hospital on 219 postoperative
adults. Results shows that 82.2% experienced acute POP; 34.2% reported moderate-to-severe
intensity. Associated factors included absence of intraoperative analgesics and longer surgery
durations (15).
A Survey of 203 nurses in Jimma Medical Center revealed 88.8% had poor knowledge and
attitude, and only 23.5% had good POP practice. Training and reading pain-related materials
were significant predictors of better KAP (17).
A research conducted on Addis Ababa Federal Hospitals found 51.5% poor knowledge and
48.5% poor practice despite favorable attitudes in 58.5% of respondents. Lack of protocols and
minimal institutional support hindered practice (18).
A research conducted on Arsi Zone Hospitals in 2018 shows that 54.9% of nurses had good
knowledge, but over half had unfavorable attitudes (52.1%) and low practice levels. Age
correlated significantly with practice differences, with younger nurses performing better (19).
These findings highlight that while knowledge gaps are important, systemic and organizational
barriers also play a major role. In all these studies, non-surgical nurses who often monitor
surgical patients postoperatively were rarely studied separately, leaving a significant evidence
gap.
Role of Nurses in Post-operative Pain Management
Nurses are at the frontline of POP care, especially in the immediate postoperative ward setting.
Their responsibilities include regular pain assessment, administration of analgesics, monitoring
for adverse effects, and implementing non-pharmacological strategies. The KAP model is
particularly relevant
Knowledge — Understanding of pain physiology, assessment tools, pharmacological and
non-pharmacological options.
Attitude — Beliefs about pain expression, opioid safety, and patient credibility.
Practice — Actual clinical behaviors, which can be hindered by workload or lack of
resources.
International evidence suggests that even when nurses have high knowledge scores, attitudes and
practice may lag due to institutional constraints (5, 17).
Pain Assessment Practices
Systematic pain assessment is the foundation of effective management. Common validated tools
include the Visual Analogue Scale (VAS), Numeric Rating Scale (NRS), and Brief Pain
Inventory (BPI) (20, 21). While these are widely used in high-income countries, Ethiopian
studies report inconsistent use—ranging from 24% in Wolaita Zone to 56% in Addis Ababa
hospitals (18, 22). Reasons include lack of training, absence of institutional policy mandating
their use, and reliance on subjective observation.
Pain Management Strategies
Multimodal analgesia is the golden standard, combining opioids, non-opioids (e.g., NSAIDs,
acetaminophen), and adjuvants. However, lack of morphine availability and fears of opioid
dependence leads to under-dosing in Ethiopian hospitals (16, 17).
Non-pharmacological POP management methods such as relaxation techniques, distraction, and
application of heat/cold are rarely implemented. In Benishangul Gumuz, only 47% of nurses
demonstrated favorable attitudes towards non-drug interventions, and just 51.2% had adequate
knowledge (23).
Barriers to Effective POP Management can be viewed from various levels. System level barriers
include lack of national POP guidelines, poor drug supply chain, inadequate staffing.
Misconceptions about opioids, limited training and low confidence in managing severe pain are
one of the barriers observed in provider’s level. Patient’s Cultural reluctance to report pain, fear
of addiction, low health literacy also have effect on the outcomes
All Ethiopian studies reviewed emphasized that without organizational support—training,
protocols, and adequate staffing—even well-intentioned nurses struggle to deliver optimal care
(17–19, 22, 23).
REFERENCES
1. McCaffery M. Nursing practice theories related to cognition, bodily pain, and man-
environment interactions. Los Angeles: UCLA Students’ Store; 1979.
2. International Association for the Study of Pain. IASP Terminology [Internet]. 2020 [cited
2025 Aug 10]. Available from: https://www.iasp-pain.org/resources/terminology/
3. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction,
and perceptions of post-surgical pain: results from a US national survey. Curr Med Res
Opin. 2014;30(1):149-60.
4. Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery.
Lancet. 2003;362(9399):1921-8.
5. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a
national survey suggest postoperative pain continues to be undermanaged. Anesth Analg.
2003;97(2):534-40.
6. Moss E, Taverner T, Norton C, Lesser P, Cole P. A survey of postoperative pain
management in United Kingdom. Anaesthesia. 2005;60(10):1073-5.
7. Yates P, Dewar A, Edwards H, Fentiman B, Najman J, Nash R, et al. The prevalence and
perception of pain amongst hospital in-patients. J Clin Nurs. 1998;7(6):521-30.
8. Ignatavicius DD, Workman ML. Medical-surgical nursing: critical thinking for
collaborative care. 4th ed. Philadelphia: W.B. Saunders; 2002.
9. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al.
Management of postoperative pain: a Clinical Practice Guideline from the American Pain
Society, the American Society of Regional Anesthesia and Pain Medicine, and the
American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive
Committee, and Administrative Council. J Pain. 2016;17(2):131-57.
10. Mwaka G, Thikra S, Mung’ayi V. The prevalence of postoperative pain in the first 48
hours following day surgery at a tertiary hospital in Nairobi. Afr Health Sci.
2013;13(3):768-76.
11. Chokotho L, Mulwafu W, Jacobsen KH, Pandit H, Lavy C. The burden of
musculoskeletal disease in Malawi: a cross-sectional survey. Int J Surg. 2017;42:28-33.
12. Gerbershagen HJ, Aduckathil S, van Wijck AJM, Peelen LM, Kalkman CJ, Meissner W.
Pain intensity on the first day after surgery: a prospective cohort study comparing 179
surgical procedures. Anesthesiology. 2013;118(4):934-44.
13. Woldehaimanot TE, Eshetie TC, Kerie MW. Postoperative pain management among
surgical patients in a referral hospital in Ethiopia. J Pain Res. 2016;9:815-22.
14. Fentie DY, Nigussie WD, Tamiru AT, Bayisa BM. Assessment of postoperative pain
management and associated factors among adult surgical patients at Ambo University
Referral Hospital, Ethiopia. PLOS One. 2020;15(11):e0242481.
15. Abebe Y, Woldeamanuel Y, Lelisho ME, Degefa G. Magnitude and determinants of
postoperative pain among patients undergoing surgery in Ethiopia: a prospective cross-
sectional study. J Orthop Surg Res. 2023;18:186.
16. Eshete MT, Baeumler PI, Siebeck M, Tesfaye M, Haile-Mariam T, Gutema B, et al.
Quality of postoperative pain management in Ethiopia: a prospective longitudinal study.
PLoS One. 2019;14(5):e0215563.
17. Negewo AN, Germossa GN, Mathewos B, Ayane GB. Postoperative pain management:
knowledge, attitude, and practice among nurses at a comprehensive specialized hospital
in Ethiopia. Clin Med Res. 2020;9(5):120-9.
18. Asmare H. Knowledge, attitude and practice towards postoperative pain management
among nurses working at four federal hospitals in Addis Ababa, Ethiopia [master’s
thesis]. Addis Ababa: Addis Ababa University; 2020.
19. Girma B. Knowledge, attitude and practice of nurses regarding postoperative pain
management in Arsi Zone hospitals, Southeast Ethiopia [master’s thesis]. Addis Ababa:
Addis Ababa University; 2018.
20. Pain scale [Internet]. Wikipedia; 2025 [cited 2025 Aug 10]. Available from:
https://en.wikipedia.org/wiki/Pain_scale
21. Brief Pain Inventory [Internet]. Wikipedia; 2025 [cited 2025 Aug 10]. Available from:
https://en.wikipedia.org/wiki/Brief_Pain_Inventory
22. Taye M, Daba W, Mulugeta H, Getahun F. Pain assessment practice and associated
factors among nurses in Wolaita Zone, Southern Ethiopia: a cross-sectional study. BMC
Nurs. 2022;21:140.
23. Regasa A, Assefa M, Simegnew D. Knowledge and attitude towards non-
pharmacological pain management among nurses in Benishangul Gumuz regional state,
Ethiopia. J Pain Res. 2020;13:2919-27.
24.
