Vol. 9(1), pp.

1-6, August 2017

DOI: 10.5897/JCMR2017.0291
Article Number: 8B8F4C665945
ISSN 2141-2235
Journal of Clinical Medicine and
Copyright ©2017 Research
Author(s) retain the copyright of this article
http://www.academicjournals.org/JCMR

Full Length Research Paper

Knowledge, attitudes and perceived barriers to post-

operative pain management: Institution based cross
sectional study
Yosef Tibebu Setegn1*, Eyayalem Melese Goshu2 and Bedilu Girma Weji3
1
Department of Anesthesia, Butajira General Hospital, Butajira, Ethiopia.
2
Department of Anesthesia, College of Medicine and Health Science, Addis Ababa University, Addis Ababa, Ethiopia.
3
Department of Anesthesia, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia.
Received 22 July, 2017: Accepted 10 August, 2017

Post-operative pain is a common problem after surgical procedure. Undertreated and uncontrolled
post-operative pain reduce physical and social performance, impaired quality of life and patient
dissatisfaction, delayed discharge, increased use of health care resources and high cost on their
hospital stay. Even if the problem is vast, researches on the area lack adequate data. This study aimed
to assess knowledge, attitude and perceived barriers to post-operative pain management among
anesthetists in Addis Ababa Governmental Hospitals, Ethiopia 2015. An institution based cross-
sectional study was conducted. A survey method was undertaken to include a total of 150 anesthetists
working in 11 government hospitals found in Addis Ababa, Ethiopia. Pretested structured self-
administered questionnaire was used to collect the data. Data were entered and analyzed through SPSS
version 20. Tables, graphs and frequencies were used to report the descriptive result. In total, 102 (68%)
participants participated in the research. The mean score of correctly answered questions by the
participants was 4.9 SD ±2.3, out of 12 items ranging from a minimum of 1 to a maximum of 11.
Inadequate post-operative pain assessment, absence of pain management guideline and least priority
for post-operative pain control are the major mentioned barriers by the participants. Anesthetist’s pain
management knowledge and attitude level was found to be low. Strengthening educational strategy for
surgical pain management and working on standard guidelines plays major role in alleviating the
problem.

Key words: Attitude, Ethiopia, knowledge, perceived barriers, post-operative pain.

INTRODUCTION

International Association for the Study of Pain (IASP) damage or described in terms of such damage (Brennan
define pain as an unpleasant sensory and emotional et al., 2007).
experience associated with actual or potential tissue The importance of post-operative pain management has

*Corresponding author. E-mail: yoseftibebus@gmail.com.

Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution
License 4.0 International License
2 J. Clin. Med. Res.

been repeatedly demonstrated in the past two decades questionnaire, which is adopted from British journals, the known
Adequate post-operative pain management (POPM) can Pain 50 tool and WHO pain management guidelines, 2008 and
2007 respectively (Brennan et al., 2007). Data were checked,
reduce the patients‟ length of hospitalization and reduce cleaned manually, coded and entered into Epi Info version 5 and
post-operative complications (Suwanraj, 2010). Pain exported to SPSS version 20 for analysis. Percentage and
causes an increase in the sympathetic response of the frequencies calculated tables and graphs were used to report the
body with subsequent rise in heart rate, cardiac work, descriptive result.
difficulty in breathing and oxygen consumption. Prolonged Participants were considered as knowledgeable if their answer to
pain can reduce physical activity and lead to venous the knowledge related questions is greater or equal to 80% and
those with good attitude were participants whose answer to the
stasis and an increased risk of deep vein thrombosis and attitude questions was greater or equal to 80%.
consequent pulmonary embolism (American Society of
Anesthesiologists Task Force on Acute Pain, 2012;
Gallagher et al., 2004). However, many researchers Ethical consideration
reported that unsatisfactory pain management were
Ethical clearance was obtained from Institution Review Board of
practiced in different countries (Taylor et al., 2008; Rejeh
Addis Ababa University and permission letter from Addis Ababa
et al., 2008; Windsor et al., 1996). Health Office and from each government hospital, and finally after
Survey study from Malaysia and Ghana reported that information provision, consent was obtained from each participant.
the reason for poor management of acute pain in
developing countries is absence of institutional training
and national policy for pain management (Jawaid et al., RESULTS AND DISCUSSION
2009). In a study in Helsinki university hospital, proper
management of post-operative pain was challenging to A total of 102 anesthetists with response rate of 68%
establish due to poor communication, insufficient participated in the study.
assessment and the individual differences in the
experience of pain (Kumar, 2007; Madenski, 2014).
In a study in Ethiopia, even though delivery of adequate Socio demographic characteristics
pain control during the post-operative period is the
responsibility and duty of health care providers, mainly Majority of the participants were male (65; 63.7%) and in
anesthetists, they were not assigned in post-operative the age group of 20 to 30, 61 (59.8%) with mean age of
pain management recovery room and wards 32.2 and 73 (71.6%) were degree holders with regards to
(Woldehaimanot et al., 2014). educational level. Forty-four (43.1%) of the participants
Post-operative pain is not merely unpleasant for the had 1 to 5 years‟ experience (Table 1).
patients and his/her relatives, but increases post-
operative morbidity and possibly mortality and the
number of unanticipated readmissions. In addition, it may Knowledge of participants on pain management
cause chronic pain conditions which may be very difficult
to treat. Therefore, in terms of patient safety and In this survey, majority (82; 80.4%) of the respondents
satisfaction, good post-operative pain control is important had knowledge on paracetamol as NSAID (Table 2).
and is part of good clinical practice (Windsor et al., 1996;
McDonnell et al., 2007; Aziato and Adejumo, 2013).
Though the problem is broad, literatures on this area lack Knowledge score of participants
adequate data. Therefore, this study assesses
knowledge, attitudes and perceived barriers to post- The mean score of correctly answered questions by the
operative pain management among anesthetists working participants were 4.9 with standard deviation of ±2.3 out
in Addis Ababa Governmental Hospitals, Ethiopia. of 12 items ranging from a minimum of 1 to a maximum
of 11 (Figure 1).

MATERIALS AND METHODS

Attitude of participants
Institution based cross sectional study was conducted from May to
June 2015 in 11 hospitals in Addis Ababa which is the capital city of Majority (97; 95.1%) of the participants responded
Ethiopia. These hospitals are Tikur Ambessa Specialized Hospital, positively to the question, performing nerve blocks for
St Paul Specialized Hospital, Gandi Specialized Hospital, Army surgical patients is effective in reducing complication and
Specialized Hospital, Alert Specialized Hospital, Zewditu
in early return to activities (Table 3).
Specialized Hospital, Rasdesta Specialized Hospital, Tirunesh
Beijing Specialized Hospital, Minilik Specialized Hospital, Yekatit
Specialized Hospital and Police Specialized Hospital. All
Perceived barriers to pain management
anesthetists working in the 11 government hospitals were included
in the study through preliminary survey and those who were in any
kind of leave were excluded. Data were collected through self- In this study, major barriers to post-operative pain
administer structured and pretested English language prepared management are inadequate post-operative pain
 Setegn et al. 3

Table 1. Socio demographic characteristics of the respondents.

Variables Frequency (N) Percentage (%)

Gender
Female 37 36.3
Male 65 63.7

Age
20-30 61 59.8
31-40 17 16.7
>41 24 23.5

Level of education
Diploma 16 15.7
Degree 73 71.6
Master‟s degree 13 12.7

Anesthetists’ experience
<1 year 11 10.8
1-5 years 44 43.1
5-10 years 23 22.5
>10 years 24 23.5
n=102.

Table 2. Knowledge of respondents on pain management.

Correct Incorrect
S/N Questions on knowledge
N (%) N (%)
1 Any surgical patient who is given opioids has a 25% or more risk of addiction 22(21.6) 80(78.4)
2 NSAIDs are contraindicated to dehydration or hypovolemia 52(51) 50(49)
3 Elderly patients cannot tolerate medication such as opioid for pain 45(44.1) 57(55.9)
There is a limit or „ceiling‟ effect in the dose of pure opioid agonist (e.g.
4 44(43.1) 58(56.9)
morphine) to control pain
5 Patient cultural and ethnic variation has effect on pain severity 69(67.6) 33(32.4)
6 Changes in vital signs are reliable indicators of pain severity 17(16.7) 85(83.3)
7 Opioid induced respiratory suppression is common 27(26.5) 75(73.5)
8 Ilio-hypogastric and ilio-inguanal nerves are purely sensory 24(23.5) 78(76.5)
9 Paracetamol is as effective as NSAIDs at reducing opioid requirement 82(80.4) 20(19.6)
A consistence high score on pain rating scale for minimal to moderate surgery,
10 50(49) 52(51)
which means patient is exaggerating the pain
11 Patient may sleep in spite of severe pain 53(52) 49(48)
12 By far there is a common adverse side effect of opioid therapy 37(36.3) 65(63.7)
n=102.

assessment (90; 88.2%), absence of pain management Ireland and UK (Vickers, 2011; Powell et al., 2009). This
guideline (89; 87.3%) and post-operative pain control is may be due to socio demographic, life style and
not given priority (86; 84.3%) (Table 4). educational background difference. The study also
showed knowledge difference among anesthetists
regarding their educational status. Masters level
DISCUSSION participants had better knowledge than Bsc. and diploma
level anesthetists. This finding is consistent with study
Knowledge score of anesthetists‟ in this study was found conducted in Ireland (McCAFFERY and Robinson, 2002)
to be low as compared to other studies conducted in and different systematic review results (Powell et al.,
4 J. Clin. Med. Res.

Figure 1. Average knowledge score of participants.

2009). On the other hand, most incorrectly answered relatively high as compared to other studies (American
question by anesthetists was changes in vital signs are Society of Anesthesiologists Task Force on Acute Pain,
reliable indicators of pain severity (83.3%). This result is 2012; Madenski, 2014; Woldehaimanot et al., 2014;
comparable to other similar literatures (Aziato and Vickers, 2011; McCAFFERY and Robinson, 2002). This
Adejumo, 2013; Vickers, 2011; McCAFFERY and variance might be due to educational difference among
Robinson, 2002). In addition, half the sample of participants.
respondents (49% of respondents) in this sample wrongly Inadequate post-operative pain assessment and post-
believed that patients‟ cannot sleep in spite of severe operative pain control are not given priority, and absence
pain. This result possibly shows anesthetists‟ inadequate of pain management guideline was most frequently cited
pain assessment skills (McDonnell et al., 2007). barriers by anesthetists. Most of the anesthetists who had
Attitudes of anesthetists in this survey were found to be low score on the knowledge section quoted lack of
low. Significant attitude difference was seen among knowledge as most frequent barrier in the perceived
anesthetists in their educational status and work barriers section of this survey.
experience. Thirty-six (35.3%) of the respondents Previous studies have shown that improving pain
believed that working in collaboration with other assessment procedures requires the caregiver to
professionals do not bring effective post-operative pain acknowledge and have faith in the patient's report (Jho et
control. It was found that those who had diploma and al., 2014).
longer working experience had a positive attitude towards
collaboration and communication with other professionals
than those who have Bsc, Msc and shorter working Conclusion and recommendation
experience in effective pain control. This finding is in line
with other studies (Kumar, 2007; Woldehaimanot et al., Knowledge and attitude level of respondents in this study
2014). About 72% of anesthetists wrongly agreed that was low. Inadequate post-operative pain assessment,
analgesic tolerance and addiction to opioids usually absence of pain management guideline and giving least
occurs following post-operative treatment, even though priority to post-operative pain control are major reasons
opioids have <1% risk of tolerance and addiction mentioned as barrier. Working on the listed barriers with
(Ariyanuchitkul and Petchdee, 2011). The result is improved education and on job training plays major role
 Setegn et al. 5

Table 3. Attitude of respondents to pain management.

Agree Disagree
S/N Attitudes related questions
N (%) N (%)
1 Good communication with surgeon, nurses and patient has positive outcome for effective pain management. 66(64.7) 36(35.3)
2 Post-operative pain management is the responsibility of anesthetists. 80(78.4) 22(21.6)
3 I believe I have taken proper education and training on POPM in my graduating school? 59(57.8) 43(42.2)
4 Service training on POPM can change knowledge, attitude and belief of health professional. 96(94.1) 6(5.9)
5 Performing nerve blocks for surgical patients is effective in reducing complication and in early return to activities. 97(95.1) 5(4.9)
6 There is a need for continuous education and training program on post-operative pain for anesthetists. 95(93.1) 7(6.9)
7 Early return to activity is one of my primary goals when treating a patient with surgical pain. 96(94.1) 6(5.9)
8 The scope of practice, developed by anesthesia association, is important for pain management in prescribing narcotics. 76(74.5) 26(25.5)
9 Continuous professional development (CPD) improves the quality of pain management 94(92.2) 8(7.8)
10 There is active involvement in post-operative pain management in our hospital. 42(41.2) 60(58.8)
11 I think post-operative pain is adequately managed in our hospital. 9(8.8) 93(91.2)
12 I believe that analgesic tolerance and addiction to opioid usually occurs following post-operative treatment 74(72.5) 28(27.5)
n=102.

Table 4. Perceived barriers of pain management (n=102).

Agree Disagree
S/N Questions
N (%) N (%)
Anaesthetist related
1 Inadequate post-operative pain assessment 90(88.2) 11(10.8)
2 Insufficient knowledge of Post-operative pain control 61(59.8) 41(40.2)
3 Time constraints 62(60.8) 40(39.2)
4 Reluctant to prescribe opioids 70(68.6) 32(31.4)
5 Insufficient communication with patient and other health professionals 58(56.9) 44(43.1)
6 Fear of side effect caused by opioids 62(60.8) 40(39.2)

Health care and institution related

7 Strict regulation of opioids 68(66.7) 34(33.3)
8 Inadequate staff 67(65.7) 35(34.3)
9 Limited stocking of different type of opioid 71(69.6) 31(30.4)
10 Post-operative pain control is not given priority 86(84.3) 16(15.7)
11 Need for opioid prescription 65(63.7) 37(36.3)
12 Absence of pain management guideline 89(87.3) 13(12.7)
13 Inadequate analgesic drugs 44(43.1) 58(56.9)
n=102.
6 J. Clin. Med. Res.

in improving the utilization. Kumar N (2007). “WHO Normative Guidelines on Pain Management.”
Geneva: World Health Organization. pp. 3-4.
Madenski AD (2014). “Improving Nurses‟ Pain Management in the Post
Anesthesia Care Unit (PACU).”
CONFLICT OF INTERESTS McCAFFERY MARGO, Eileen SR (2002). “Your Patient Is in Pain-
here‟s How You Respond.” Nursing2016 32(10):36-45.
McDonnell JG, O'donnell B, Curley G, Heffernan A, Power C, Laffey JG
The authors declare that there is no conflict of interests.
(2007). “The Analgesic Efficacy of Transversus Abdominis Plane
Block after Abdominal Surgery: A Prospective Randomized
Controlled Trial.” Anesthesia Analgesia 104(1):193-197.
Abbreviations Powell AE, Davies HT, Bannister J, Macrae WA (2009). “Challenge of
Improving Post-operative Pain Management: Case Studies of Three
Acute Pain Services in the UK National Health Service.” Br. J.
IASP, International Association for the Study of Pain; Anaesthesia 102(6):824-831.
NSAID, non-steroid anti-inflammatory drugs; POPM, Rejeh N, Ahmadi F, Mohammadi E, Anoosheh M, Kazemnejad A
post-operative pain management. (2008). “Barriers To, and Facilitators of Post‐operative Pain
Management in Iranian Nursing: A Qualitative Research Study.” Int.
Nurs. Rev. 55(4):468-475.
Suwanraj M (2010). “Current Practice, Perceived Barriers, and
ACKNOWLEDGEMENTS Perceived Facilitators of Thai Nurses on Using Evidence-Based
Pactice on Pain Assessment and Pain Management in Older Adults.”
The authors express their heartfelt gratitude to Addis The University of Iowa.
Taylor AL, Gostin LO, Pagonis KA (2008). “Ensuring Effective Pain
Ababa University for provision of fund, and the study Treatment: A National and Global Perspective.” JAMA 299(1):89-91.
participants for their time. Vickers N (2011). “Knowledge and Attitudes Regarding Pain among
Surgical Nurses in Three Teaching Hospitals in Ireland.”
Windsor AM, Glynn CJ, Mason DG (1996). “National Provision of Acute
Pain Services.” Anaesthesia 51(3):228-231.
REFERENCES
Woldehaimanot TE, Eshetie TC, Kerie MW (2014). “Post-operative Pain
Management among Surgically Treated Patients in an Ethiopian
American Society of Anesthesiologists Task Force on Acute Pain
Hospital.” PloS One 9(7):e102835.
Management (2012). Practice guidelines for acute pain management
in the perioperative setting: an updated report by the American
Society of Anesthesiologists Task Force on Acute Pain Management.
Anesthesiology 116:248-273.
Ariyanuchitkul T, Petchdee N (2011). Attitude, Knowledge and Practice
of Nurse Anesthetist, Maharat Nakhon Ratchasima Hospital for
Postoperative Pain Assessement and Treatment in Recovery Room.
Maharat Nakhon Ratchasima Hospital Med. Bull. 32(1):S54-S61.
Aziato L, Oluyinka A (2013). “Perspectives of the Surgeons,
Anaesthetists, and Pharmacists on Post-Operative Pain Management
Roles in the Ghanaian Context.” Afr. J. Phys. Health Educ.
Recreation Dance 19(3):678-691.
Brennan F, Carr DB, Cousins M (2007). Pain management: a
fundamental human right. Anesthesia & Analgesia 105(1):205-221.
Gallagher R, Hawley P, Yeomans W (2004). A survey of cancer pain
management knowledge and attitudes of British Columbian
physicians. Pain Res. Manage. 9(4):188-194.
Jawaid MA, Muhammad SH, Shafiq FA, Malik KA (2009). “Acute Post-
operative Pain Management by a Surgical Team in a Tertiary Care
Hospital: Patients Satisfaction.” Middle East J. Anesthesiol.
20(3):405-410.
Jho HJ, Kim Y, Kong KA, Kim DH, Choi JY, Nam EJ, Koh S, Hwang
KO, Baek SK, Park EJ (2014). “Knowledge, Practices, and Perceived
Barriers Regarding Cancer Pain Management among Physicians and
Nurses in Korea: A Nationwide Multicenter Survey.” PloS One
9(8):e105900.