Knowledge and associated factors towards post-operative pain management among nurses working at referral hospitals, Ethiopia

Introduction: Post-Operative Pain (POP) is a common patient problem subsequently surgical procedure. Uncontrolled POP reduces physical, social and overall recovery of the patient. Effective pain management requires faultless knowledge. Objective: To determine Knowledge and its associated factors towards POP management among nurses working in referral hospitals, northwest Ethiopia. Methods: Data were collected from Nurses from March 08 to April 23, 2019. Nurses who are working in the surgical track were included in the study. The data were analyzed by SPSS version 20 Software. Result: The nurses’ level of good knowlegde towards POP management was 43.46%. The multivariable logistic regression analysis showed; master of science degree (AOR=3.125, 95%CI (2.53-10.11)], bachelor of science degree [(AOR=2.10,95%CI (1.86, 9.05), having 5 to10 years working experience [(AOR= 2.661, 95%CI (1.278, 5.540), having 10 to 15 years of working experience [(AOR= 2.581 95%CI (1.758, 11.938)], having 15 to 20 years working experience [AOR=4.62,95%CI (1.28, 6.68), having >20 years of working experience [AOR=7.27,95%CI (1.44, 11.95), receiving training [AOR=1.59, 95%CI (1.06, 2.39) were factors signifi caantly associated with the level of knowledge regarding POP management. Conclusion: This study indicated that the good level of knowledge towards POP management was poor. Educational level, working experience and receiving training were factors signifi cantly associated with nurses’ level of Knowledge towards POP management. Finally, we recommend that the training program for nurses concerning to the POP management guidelines and treatment protocols should be designed to improve their knowledge. Further, health education program for nurses may be necessary to take place. Research Article Knowledge and associated factors towards post-operative pain management among nurses working at referral hospitals, Ethiopia Desalegn Tariku Jaleta1, Techane Sisay Tuji2* and Addisu Dabi Wake2 1School of Nursing, Surgical Department, College of medicine and Health Sciences, University of Gondar, Gondar, Ethiopia 2Nursing Department, College of Health Sciences, Arsi University, Asella, Ethiopia Received: 22 March, 2021 Accepted: 30 March, 2021 Published: 31 March, 2021 *Corresponding author: Techane Sisay Tuji, Nursing Department, College of Health Sciences, Arsi University, Asella, Ethiopia, Email:


Introduction
POP is an acute pain present in a patient meanwhile a prior surgical procedure or a combination of disease and sources associated with procedure [1]. Pain is offensive sensory and emotional impact which linked to actual or potential tissue damage [2]. POP is a critical community health issues both economically developed and developing countries [3]. Un improved pain post surgery is extremely predominant and have signifi cantly infl uences the morbidity and mortality of the subjects [4]. Unremitting pain can lead to a short and long lasting harmful consequences for subjects [5].
The data showed abundant challenges with POP management worldwide [6]. In United States of America, eighty percent of patients' suffered of moderate to severe POP from the estimated 23.9 million surgical procedures performed [7]. But, the burdens are more greater in developing countries Citation: Jaleta [6]. Developing countries remain to face this impacts with establishing and maintaining effective programs for the enhancement of POP [8,9]. In Africa, the issue of pain has been visited principally in relative to AIDS and cancer. However a pain from surgical procedures own a far superior effect on the subjects [10,11]. The prevalence of moderate to severe POP was 88.2% in Ethiopia, of which only 41.6% of them suffi ciently treated [12]. Another study done in Ethiopia showed the prevalence of moderate to severe POP was 28.6% [13].
The management POP leads to a healthcare test, which needs a knowledge of how to assess and reassess POP, prescribe and administer drugs [14]. Assessment is a continuing process to maintain continuousness through time being done during activity and at rest. So that nurses require to develop knowledge about the harmful impacts of unrelieved pain [15,16]. Nurses should be conscious of a vital role of assessing, treating, and evaluating POP [17]. As the duty of nurses, they should identify and report pain. They are the principal caregivers and they spend most of their time with the patients [18]. The evidence has indicated that management of POP by nurses still leftovers enormous issue. For this poor POP management, it was reported that inadequate education and lack of training for nurses were parts the problems [19]. Furthermore, insuffi cient knowledge regarding POP management can meaningfully contribute to this problem [20]. However, there has been augmented attention for enhancing POP management as a consequence of several new guidelines and progresses of techniques in managing POP [21]. Therefore, this study will be aimed to assess knowledge and factors associated towards POP management among nurses who working at study areas. The fi ndings of this study will fi ll the gaps that are identifi ed and may notify the concerned bodies to set specifi c strategies to improve the knowledge of nurses on POP management.

Objectives
General objectives: To assess the level of knowledge and associated factor towards POP management among nurses working in referral hospitals in Northwest Ethiopia.

Study area and Period
The Study was conducted in Amhara regional state referral hospitals, Northwest Ethiopia from March 08 to April 23, 2019.
Currently, it has 11 administrative zones and 67 governmental hospitals and 5 referral hospitals. Whereas, each hospital serves for more than 5 million people in the catchment area [22].

Study design
Hospital based cross sectional study was conducted.

Source population
All staff nurses working in the referral hospitals in Northwest Ethiopia.

Study population
All nurses working in orthopedic, surgical, recovery, OR, and trauma wards.

Eligibility criteria
Inclusion criteria: Nurses working in the surgical wards Exclusion criteria: Nurses who were severely ill, on maternity leave, and off duty.

Sample size determination
The fi nal sample size for this study was 437. This is because a survey was was conducted. During this, all nurses who were working in the surgical ward were included.

Sampling technique and procedure
All 5 referral hospitals were selected with a purposive sampling method. Then, all staff nurses working in the postoperative care were included in to a survey.

Operational defi nition
Good knowledge: When nurses scored mean and above the mean value [23].
Poor knowledge: When nurses scored below the mean value.
Trained: This is when nurses who have got a minimum one training on pain assessment and management [24]. on the average daily number of patients seen, type of care, the average time of assistance for each patient, according to dependence and type of care delivered [25].
Communication in Nursing Practice: a transaction and message creation during nursing care [26].

Data collection instrument
Self-administered questionnaire was used to collect the data from nurses. The questionnaire contains two parts which include nurses' socio-demographic status, knowledge of POP assessment and management, The questionnaires was adapted after an intense review of the related literatures [23,27,28]. It was prepared in English.

Data collection procedure
Data were collected by 7 diploma nurses and supervised by 3 MSc nurses. The principal investigator took the responsibility of coordinating the nurses and discussing the objectives of the study. Afterwards, a questionnaire was distributed and orientation and clarifi cation for any diffi culty was provided accordingly for those who were willing to take part in the study.

Data quality control
The quality of data was assured by using pre-test of the questionnaire on 5% of the sample size prior to data collection period. A one day training was given for data collectors and supervisors concerning the data collection instrument and the procedure. The reliability analysis the questionnaire was checked and a Cronbach's alpha value was 0.842. Moreover, the supervisors and principal investigator were offered a feedback for the data collectors on the spot. Finally, the collected data were checked daily.

Data processing and analysis
The collected data were entered into Epi info version 7 and then it was exported to SPSS version 20.0. Descriptive statics such as frequency, percentage, means, and standard deviation was used to describe the data. Bivariable and multivariable logistic regression analysis was done to fi nd associated between dependent and independent variables. The Hosmer-Lemeshow's goodness-of-fi t test was used to check the model fi tness while the result was p-value=0.432. Finally, p< 0.05 was considered as a statistically signifi cant.

Sociodemographic characteristics of study participants
Four hundred fi ve (405) nurses were enrolled in the study with a response rate of 92.6%. The mean age of the participants was (SD 31 ± 5.381) with the age range between 22 to 46 years. 208(51.4%) of them were male. 278 (71.1%) were orthodox followers and 326(80.5%) were degree holders, and 157(38.8%) had 5-10 year work experience (Table 1).

Nurses' item score of knowledge towards POP management
Among the study participants, almost eight in every ten (82.7%) of them acquainted with pharmacological analgesic such as pethidine and Pentazocine are used to relieve pain in surgical patients, 334(82.5%) knew that Observation is one of the technique used in surgical pain Assessment. Furthermore, (66.25%) of the nurses have identifi ed that respiratory depression can occur in patients receiving opioids and (73.6%) knew that the side effects of narcotics should be observed at least 20 minutes after administering medication ( Table 2).

Level of knowledge towards POP management
The level of good knowlegde towards POP management was 43.46% ( Figure 1).   (Table 3).

The level of Knowledge towards POP management
The level of good knowledge about POP management was 43.5% (95% CI (39.3%, 48.4%). The fi nding of this study was in line with a study conducted in Bangladesh (40%), Jordan (39.5%), Kenya (41%) and Ghana (48%) [29][30][31][32]. The possible explanation might be due to the educational background of the study participates. For instance; study conducted in Jordan majority of nurses had a bachelor's degree which makes similir with this study participates. In fact, as educational level of the participants increased, there level of understanding would be improved.
However, the result of this study was lower than study conducted in Uganda (71.8%), Ireland (65.7%), Nigeria (60%) and southeast Ethiopia (54.86%) [5,23,33,34]. The possible explanation could be due to the sociodemographic characteristics of the participants. In addition the variation might be due to pain management training and the absence of pain management protocol. For instance; in a study conducted in Uganda (69%) of the nurses was received training related to pain management as compared to 52.0% of a participant in the current study. This fi nding was argue with a study conducted in Nigeria [34].

Factors associated with knowledge towards POP management
The possible explanation could be due that the duration of  working experience has a positive impacts on the knowledge of nurses towards POP management. This is due the fact that the nurses are expected to receive an updated POP management guidelines or different supportive learning materials, and also training concerning to POP management in the long run of the service duration. Besides, the nurses would read different books, and they have chance of learning from their staff.
The odds of having good knowledge among nurses who received training was nearly two times [AOR=1.59, 95%CI(1.06,2.39) higher than its counterpart. This fi nding was supported by study conducted in Iran [13], and Ethiopia [35]. This could be due to the reason that, it is a fact that receiving training can update the knowledge of nurses regarding POP management by offering the essential and signifi cant information to them. Whereas, in turn, this could have the impact of motivating the nurses to read and do in collaboration with their staffs for the effective management.

Conclusion
This study indicated that the good level of knowledge towards POP management was poor. The multivariable logistic regression analysis showed; educational level, working experience and receiving training were signifi cantly associated with nurses' level of Knowledge towards POP management.
This study has investigated the problem and this could be the foundations for the healthcare providers, and hospitals to create the plan and fi nd out the strategies to abate this critical issue. Finally, we recommend that the training program for nurses concerning to the POP management guidelines and treatment protocols should be designed to improve their knowledge. Further, health education program for nurses may be necessary to take place.

Authors' contributions
All the authors analyzed, critically revised, edited the manuscript, and fi nally all authors have reviewed and approved the last version of the manuscript.

Funding
The study was funded by University of Gondar.

Ethics approval and consent to participate
The study was approved by school of nursing research ethical review committee on behalf of University of Gondar.
Then, offi cial letter was submitted to Amhara referral hospitals and permission was gained. All the study participants were informed about the signifi cance and objectivs of the study.
Also, they were insured about the confi dentiality of information obtained and there names were not asked. Finally, verbal consents were attained from each study participants.