This is a study discusses the utilization of the non-pharmacological techniques as methods of alleviating patients pain and also if barriers exist towards the use of these methods. The study was conducted using a standard instrument used in different settings, which makes it useful for making comparisons. As it was conducted in the major hospitals, it gives an informative picture of the degree of utilization of these methods in the country.
Utilization of Non-pharmacological methods of postoperative pain management
Generally, the results revealed that these methods are utilized by the nurses at a low percentage level. A recent study conducted among the Eritrean nurses revealed a deficit in the knowledge and attitude among Eritrean nurses regarding pain management in which the study further explained that such a deficit was from the lack of attention given to pain assessment and management course in the schools these nurses underwent. The study also reported that this was due the obvious lack adequate sessions to pain assessment and management in the nursing curriculums(21).Another study also reported the existence of a generally neglected pain management in the Eritrean settings (22).Moreover, the common complaint that has been existing in any of the national hospitals, which is the limited number of nurses, is also among the main factors to limit the application of all these techniques.
Of the cognitive behavioral methods only breathing and relaxation techniques were found to be used with higher percentages, while the rest of the techniques were utilized less often. In support of this, in a study done by Faigeles et al, (2013), it was stated that the most frequently used non-pharmacological interventions during acute pain included; calming voice, providing information, and deep breathing. The study further stated that these techniques are easy to implement and did not require equipment or specific training(23). Moreover, one study from Westminister was conducted on non-pharmacologic pain management for postoperative coronary artery bypass graft surgery patients and it reported that deep breathing followed by distraction are used commonly by the patients as pain relieving methods as suggested by the nurses(24). The majority of the patients said it helped decrease both the perception and sensation of pain more than pain medication alone. The preparatory information involves items which are done during the preoperative period before the patient undergoes surgery and in this current study, they are found to be less often utilized by the nurses. This is a similar report with a previously conducted research(17), in which less frequent provision of adequate sensory information, paying enough attention to the ways of giving information, and the use of materials to help with informing was reported. In both researches such a result could be attributed to the fact that the provision of preparatory information was mainly done by surgeons/anesthetists and was not routine nursing practice in the participating wards.
The physical methods of non-pharmacological pain management, alleviating pain by repositioning patients, was responded by most of the nurses (84.4%) as used ‘nearly always/always’. This could be due to the fact that the approach is more routine and acceptable in nursing practice, and less time-consuming and more easily administered than the other strategies. Whereas, massaging and thermal regulation with heat and cold application were used rarely as pain relieving methods. This can be argued that the lack of heating and cooling devices, lack of training and cultural influences could be the affecting barriers. Similar studies done also reported positioning as the most commonly used physical method during postoperative pain, whereas, thermal regulation and massage were used sometimes (15, 17, 20). Similarly in the study done by Faigeles et al., (2013), it was claimed that less usage of thermal regulation. Furthermore, Kooten (1999) stated repositioning was the most frequently used, whereas cold packs were used rarely for postoperative pain management. Moreover, another study done in Finland regarding postoperative pain management after hip surgery, was congruent with this study in which repositioning was the most commonly used non-pharmacological method of pain management (25). Meanwhile, in a study done by Gelinas and his collogues, it was found out nurses practice simple massaging as a pain relieve method on critical ill patients(26).
Nurses in the surgical wards commonly practice the emotional support strategies, such as comfort and reassurance (92.2%), therapeutic touch (39%) and presence (45.5%) as ‘always’ to soothe patients’ postoperative pain. However, presence of the nurses was less frequently utilized compared with the Finnish (77%) and Singapore (49%) nurses on relieving postoperative pain (17, 20). This discrepancy could be explained by the less time surgical nurses spent with patients or nurses lacked understanding of the actual meaning of presence. The results of Bonnie Faigeles, (2013) on the other side were incongruent with this study, reporting that nurses provide pain relief by frequently holding hands and gentle touch during acute pain. In this current study, helping patients during their daily activities was stated as ‘nearly always/always’ by (67.5%) of the nurses. Moreover, creating a comfortable environment for patients was claimed by most of the nurses (45.5%) as being used ‘nearly always/always’ mainly by offering a good environmental condition such as reduce noises, promoting conducive room temperature, bringing patients own belongings to the hospital and providing rest to the patients. Furthermore, in the research done by He et al., (2010), it was reported that nurses’ practice on helping patients with daily activities and creating a comfortable environment were practiced more often.
Over all, nurses age, educational status and experience in healthcare made a significant difference in the utilization of non-pharmacological methods. The utilization of these methods were seen to increase with an increase of the age of the nurses. A significant difference was observed in the utilization of the cognitive behavioral methods among the different educational levels. Nurses with higher level of education scored higher level of usage or practice. Moreover, the utilization of these methods was observed to increase with an increase in work experience. It can be summarized that with an increase in age, experience and educational level of nurses, the practice of non-pharmacological methods increases as well. These findings corresponded with Pölkki et al., (2001), which states older nurses as well as nurses with a higher level of education and designation, and longer working experience used non-pharmacological methods more frequently. Moreover, the study done in china by He et al., (2005) argued that nurses in the highest staff position and with the longest experience in health care are more often involved in non-clinical work, such as dealing with documentation and administration.Preparatory information was explored using several questions, including cognitive and sensory information and ways of giving the information. Statistically significant difference were also found among nurses providing preparatory information across their educational level (p=0.015), place of work (p<0.001), experience in health care (p=0.002), availability of pain assessment tools (p<0.001) and prior experience of hospitalization (p=0.004). Furthermore, the findings of the current study was congruent to the research done by Pölkki et al.,(2001) in which the nurses' age, educational levels and nursing experience showed statistically significant associations with the preparatory information.
Perceived barriers that hinder the utilization of non-pharmacological methods
Nurses perceive a variety of barriers when attempting to provide non-pharmacological methods for postoperative pain management(16). In this current study, the perceived barriers for utilization of non-pharmacological methods were categorized as healthcare system-related, nurse-related, patient- related barriers in which all had significant effect (p<0.001).Among the health related barriers, heavy workload(87.7%), lack of time (84.4%) and limited of resources (82.5%) were the most commonly perceived barriers.
A reduced nurse patient ratio limiting the time for implementation of the non-pharmacological methods has been a common compliant explained by these nurses, which could be an enhancing factor for these barriers. This study was consistent with the study done by Elcigil A. et al., (2011) on nurses’ perceived barriers in the assessment and management of pain, reporting heavy work load and lack of time as common perceived barriers (27). A study done by Batiha, (2014) identified that policies and rules of the hospital, lack of proper pain assessment tool, nursing shortages, interruptions of activities relating to pain and lack of alternative non-pharmacologic therapy were found to be healthcare related barriers(28). A similarly study done in Poland, found out that limitations such as lack of rules, procedures and guidelines by the administration interfered with pain management (16). Moreover, a study done in China found out that the most common factors limiting Chinese nurses’ use of non-pharmacological methods were nurse patient ratio and heavy workload leading to less attention on post-surgical pain which was consistent with the current study findings (15).
Among the nurse related barriers, lack of knowledge which conspicuously stood at 50% was stated as the most common barrier. This was associated with less experience and specialization on non-pharmacological methods for postoperative pain management. The study found out that nurse’s poor positive opinion on the efficiency of non-pharmacological method played a role in their utilization. Consistent with this study, the research done on pain management barriers in critical care units by Batiha, (2014) stated that the barriers related to nurses included,time limitations, limited communication, inadequate staff knowledge of pain management. Likewise, a study from South Korea indicated that time constraints and insufficient knowledge regarding pain management of both physicians and nurses were the most commonly encountered barriers(29). Furthermore, a research from Iran indicated that limited nurse-patient relationship, and disturbance of pain management interventions, inadequate time for health teaching, inadequate time to deliver non-pharmacological pain relief measures were among the identified nurses related barriers (30). Inconsistent results were reported by He GE et al., (2005) in which only 12% of nurse’s believe in inefficacy of non-pharmacological methods. In can be argued that the more positive trust on the pharmacological methods and lack of observed evidence on the efficiency of non-pharmacological methods by the nurses may be the affecting factors of such nurse related barriers.
On patient related barriers for non-pharmacological methods, patient uncooperativeness (57.1%) and language barriers (64.9%) were recorded as a hindrance to non-pharmacological pain management in this study. This could be due to patients’ belief that medications are more effective and takes less time to act than non-pharmacological methods. In line with this finding, a study done by Becker, (2017) indicated that patient’s uncooperativeness secondary to stress and pain during postoperative period. Consistent to the present findings, a research done in china showed patients uncooperativeness as one of the three most mentioned limiting factors for implementation of non-pharmacological methods(15).