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Nurses’ Perception of Pain Assessment of Hospitalized Patients

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ABSTRACT

 The study investigated nurses’ perception of patients’ pain assessment in routine care. It was a crosssectional descriptive research design. Four hundred and fifty (450) nurses working in the two tertiary institutions in Ebonyi State were used. Two instruments were used for data collection. The researcher developed questionnaire and in depth interview guide to validate further the qualitative responses. Reliability of the quantitative instrument was established using test-retest technique. Spearman’s product moment correlation yielded a co-efficient of 0.86. The qualitative instrument was also testretested using four unit heads from UNTH Enugu. Their opinions did not vary between test periods (two weeks), the instrument was therefore considered reliable. Quantitative data were analyzed using descriptive (mean and percentages) and inferential statistics (T-test and ANOVA) for testing at 0.05 level of significance. Content analysis of qualitative data was done using thematic approach. Nurses from the two hospitals were aware of the basic components of pain assessment with mean scores of (3.58, 3.00, 4.28 and 3.86). They agreed to assertion that they assess pain routinely when other vital signs are checked, during initial health assessment, when patients complain of pain, before and after giving pain relieving drugs (3.99, 4.17, 4.11 and 4.13) respectively. However, nurses’ perceived barrier to pain assessment was burden of having so many patients to care for (3.17). They are quite aware that patients are the best assessors of their pain (3.88). However, they had fear of patients getting addicted to pain relieving drugs (3.80). Majority of the nurses use mainly patients’ verbal report of pain (87%) and simple descriptive pain intensity scale (57%) as their pain assessment tools. They rarely document patients pain data on patients’ case note (44%) where other health professionals can easily access and use it for clinical decision in pain management. The quantitative and qualitative findings are in agreement except on assessing pain routinely. Nurses’ acceptance that they assess pain routinely with other vital signs was not validated by the qualitative study. This revealed that despite the awareness of nurses on what they ought to do in pain assessment, they do not do it especially when they have so many patients to care for. There was no significant statistical difference in perception of pain assessment between the nurses of the two hospitals (P<0.05), and also between the nurses’ demographic variables within groups (P<0.05). The study concluded that the nurses’ response to patients’ report was affected by their fear of patients getting addicted to pain relieving drugs. It was recommended that an intensive training for nurses on pain assessment with emphasis on pharmacological and practical aspect of pain assessment should be organized by nurse managers to bridge the identified gap.

CHAPTER ONE

INTRODUCTION

 

Background to the study

The nurses’ perception of hospitalized patients’ pain assessment stands absolutely essential in determining the actual pain diagnosis/management and improved quality of life. Although, physicians order the types and doses of analgesics, nurses are in the best position to influence patients’ pain as they administer the medication and determine its effect. Nurses’ perception of pain assessment determines how they assess, manage pain and teach patients about pain control. Also, nurses advocate for patients when ordered medications are not effective and can have a real impact on patients’ pain management outcome.

Perception is an awareness and understanding of an impression that has been presented to the senses.  The characteristics of perception are that it is universal, or experienced by all, subjective or personal and selective for each person. This means that any given situation will be experienced in a unique manner by each individual involved (George 2003). Perception is focused on activity in the present that is based on the available information; which could be based on knowledge, facts or belief/opinion, hence the subjectivity of perception. Therefore nurses’ perception of patients’ pain will indeed determine appropriate pain assessment/management strategies for quality nursing care of patients.

Gregory (2000), pointed out that when pain assessment is appropriately done, it leads to proper pain management, quick recovery, shorter hospital stay, fewer admissions and improved quality of life. Pain assessment is a continuous process of collecting data, making judgment, or forming an opinion about a patient’s pain. It comprises relevant pain history, physical examination and observation of behavioural and physiologic responses, additional investigations of biological structures, functions and documentation of pain data.

Pain is also a systematic process. As a systematic process, pain assessment may be complex, time consuming and frustrating to the assessor, but it remains a viable strategy for essential quality nursing care. Its complexity is as a result of the subjective nature of pain. McCaffery and Ferrel (2000) pointed out that “pain is what the patient says it is, and exists whenever the patient says it does”. A patient’s report concerning his/her pain should always be the primary source of information that the healthcare providers use to assess and control pain successfully. (Gabor B,Racz &Carl E.Noe 2012). Feeling of pain cuts across every race, age and status but individuals express it in different ways. Similarly, caregivers’ view/opinion on patients’ pain expressions may vary and this could adversely affect pain management. This informed this study of nurses’ perception of pain assessment of hospitalized patients.

In the past, pain was viewed primarily as a sensory experience produced by a nociceptive or neural response associated with tissue injury. To this effect, pain assessment does not need any formal training (Gregory 2000). Later it was discovered that pain also affects every other aspect of the individual experiencing it, the family and the entire community. It is known to be pervasive and poorly treated in hospital settings (Smeltzer & Bare 2004). Studies show that pain is one of the most common reasons people seek treatment (McFachin, 2002). However, it is ironic that although pain is one of the most treatable symptoms, it is often cited as one of the failures of modern medicine (Mayer, Torma, Byolk & Norris 2001). This is because the ability of one individual to perceive and interpret accurately what another feels is complex.

In the United States of America (USA), three quarter of surgical patients report inadequate relief of acute pain, four in ten people with moderate to severe chronic pain have inadequate relief, more than twenty six million people aged 20-64 years live with frequent or persistent back pain, one in six suffers from arthritic pain, only 30% of cancer patients have adequate pain relief (Philips 2000, Richard & Hubbert 2007). Richard and Hubbert (2007) found that 20% of people visiting emergency departments had moderate to severe pains. They further stated that despite enormous technological advances and substantial research in the area of pain management in recent years, numerous studies indicate that pain is not relieved in most patients. In Nigeria, Ogan & Enyiodah (2006) pointed out that even severe pain from episiotomy or perineal injury is often poorly treated.

The reasons for this failure have been the focus of several researchers. Inadequate pain assessment has been the greatest barrier to pain management (Clark 2005, Mac Donald et al, 2002). However, Laughlin & Tabler (2000) identified inadequate knowledge of pain assessment as one of the greatest barriers to optimal pain management. Kennedy (2000) in what he called “triple whammy” effect explained the reasons for the failure as follows: patients’ underreport of pain, nurses’ under-administration and physicians’ under-prescribing of analgesics (McCaffery & Psaro, 1999). Gordon & Love (2004) also, identified the following reasons for the failure in pain management:

-Practitioners’ perception of patients’ self report of pain, underestimation of patients’ pain in different circumstances, nurses neglect to reassess patients’ pain after interventions, poor and inconsistent documentation of pain assessment and reassessment of pains that leads to underdosing for pains with analgesics and the resulting inadequate pain management, unfounded cultural and religious biases.

In 1995, the American Pain Society (APS), according to Mayer et al (2001) challenged all healthcare systems to make pain assessment the fifth vital sign. The essence of linking pain assessment as a routine vital assessment performed by nurses and its documentation is to ensure proper pain management (Berman, Synder, Kozier & Erb 2008). It will also help to ensure that pain is monitored on a regular basis compared with inconsistent ways of monitoring clients’ pain presently (Smeltzer & Bare 2004). The APS noted, “If pain were assessed with the same zeal as other vital signs, there would be a better chance of it being treated properly”. Sequel to this challenge some other efforts have been made by so many organizations in different countries to make pain assessment the fifth vital sign.

Joint Commission on Accreditation of Healthcare Organization, JCAHO, (2005) made pain assessment mandatory and incorporated it into its standards. One of the JCAHO standards states that “pain is assessed in all times when other vital signs are done; patients have the right to appropriate assessment and management of pain. They further stated that since assessment and documentation of other vital signs are mainly done by nurses, likewise  patients’ pain assessment and documentation should equally be done by nurses” (Asterin 2003). The United State Congress has equally designated the year 2000 – 2010 as the decade of pain control and research. All these effort attest to the importance of nurses’ perception of pain assessment of hospitalized patients. Olaitan (2009), in a study on cancer pain management in developing countries pointed out that there was paucity of published data on pain assessment and pain management from developing countries. Richards & Hubbert (2007) observed that although nurses are the healthcare professionals that spend the most time with patients in pain, yet there is lack of research that has sought to understand the perception of nurses on pain assessment irrespective of the dire need.

 

Statement of problem

Generally, studies show that patients’ self-reports (expression) of pain have been regarded as the golden standard of pain assessment for effective management, (Gregory 2000, Melzack & Katz 1994, Smeltzer & Bare 2004). Efforts have been made to implement this into practice. Despite massive multifaceted educational efforts, implementation of JCAHO standards, implementation of pain education programmes, policies and procedure and identification of pain management as a right for all, the recognition of nurses’ perception of pain assessment as one of the core aspects of quality nursing care in developing countries is doubtful. McCaffery et al (2000) pointed out that practitioners were not incorporating the guidelines into their practice. Peter and Watson (2002) stated that nurses appear to distrust patients’ self report of pain which suggests that they may have their own bench mark /perception of what is acceptable, when and how patients should express pain. This failure of accepting patients’ verbal report will grossly affect patients’ pain assessment and management and quality of life. Hence the need to study nurses’ perception of pain assessment of hospitalized patients in tertiary institutions in Ebonyi state.

 

Purpose of the study

The study investigated nurses’ perception of pain assessment of hospitalized   patients’ in the two tertiary Institutions in Ebonyi State.

 

Objectives of the study include to:

  1. Ascertain nurses’ perception on what they do during pain assessment in tertiary institutions in Ebonyi State.
  2. Elicit nurses’ perception on patients’ report of pain.
  3. Ascertain their opinion on preferred tools for pain assessment by nurses.

 

Research questions

The following research questions were answered by the study:

  1. What do nurses’ say they do during pain assessment of hospitalized patients in tertiary institutions in Ebonyi State?
  2. What are nurses’ opinions on patients’ reports of pain?
  3. What are the nurses’ opinions on their preferred tools for pain assessment?

 

Hypotheses

Two hypotheses were tested by the study. They include:

 

Ho1: There is no statistical significant difference in the perception of pain assessment between the nurses of the two hospitals, P>0.05.

Ho2: There is no significant statistical difference in the perception of pain assessment of the nurses and their socio-demographic characteristic, P> 0.05.

 

Significance of the study

Findings from the nurses’ perception of pain assessment

Will show areas of misconceptions, biases and ignorance in nurses’ perception of pain assessment of hospitalized patients. The discovery of the deficiencies would help to determine where emphasis will be needed in planning programmes to integrate pain assessment into routine patients’ care in Ebonyi State for quality nursing care services. Will help nursing schools in improving nursing curriculum with regard to practical aspect of patient’s pain assessment. It will also serve as a source of information to all those concerned with teaching of pain assessment to incorporate pain as the fifth vital signs .The findings may also be useful in spurring further investigations into the differences in perceptions of nurses and patients on pain assessment and other related topics

 

Scope of the study

The study covered nurses’ perception of pain assessment of hospitalized patients in tertiary institutions in Ebonyi State; the preferred tools for pain assessment; their opinions on patients’ report of pain; the difference in their perception of pain assessment between nurses at EBSUTH/ FMC, within hospitals, the difference in perception of nurses’ pain assessment of patients and their socio demographic variables. Nurses for this study, included those currently working in clinics and wards of the two tertiary institutions where patients with pain are treated. The only two tertiary institutions in Ebonyi state are EBSUTH and FMC .They are within the state capital.

 

Operational definition of terms

  1. Nurses’ perception of pain assessment: In this study implies nurses’ opinions, views and judgment about what they do during pain assessment and their preferred tools for pain assessment. It was measured with the researcher’s self generated statements. The mean value for 1,2,3,4 and 5 is 3.0 was considered as mean decision point, any item that scored 3.0 or above was accepted as being significant and it indicated positive perception. While any item with the mean score below 3.0 was regarded as having been rejected by the respondents and it indicated negative perception.
  2. Pain assessment: Comprises of relevant pain history, physical examination (observation of behavioural) and physiologic responses and documentation. This can be facilitated by using pain assessment tools. In this study, pain assessment refers to: Nurses’ practices in assessing patients’ pain and the preferred unidimensional tools, Interpretations or judgment of patients’ pain report and documentation of patients’ pain data
  3. Patients: In this study means hospitalized persons in the two tertiary Institutions in Ebonyi State that experience any form of pain irrespective of the pain intensity
  4. Tertiary institutions: Refers to Ebonyi State University Teaching Hospital and

Federal Medical Centre, Abakaliki.

 

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