KNOWLEDGE OF NURSES ON ACUTE PAIN ASSESSMENT AND DIAGNOSIS AMONG POSTOPERATIVE PATIENTS

pain management in numerous studies indicate that post-operative pain is not in most patients. target Ninety- were descriptive and statistics. showed that a very low percentage of the (18.3%)

Pain is one of the commonest reasons why individuals visit various hospitals for treatment. It gives people capability to be aware of tissue trauma. Despite enormous technological advances and substantial research in the area of pain management in recent years, numerous studies indicate that post-operative pain is not relieved in most patients. The target population was nurses involved in the care of post-operative patients. Ninety-three nurses that consented in surgical wards in the study setting filled the questionnaire while seventeen out of them were involved in in-depth interview and they were analyzed using descriptive and inferential statistics. Results showed that a very low percentage of the respondents (18.3%) had adequate knowledge of pain and its assessment.
In conclusion, it was demonstrated that there was no significant association between nurses" educational qualification and knowledge of acute pain. Likewise, there was no significant association between nurses" years of experience and knowledge of acute pain as well. It is therefore of high importance that nurses update their knowledge especially on assessment and diagnosis of acute pain this is one of the major reasons while many individuals are hospitalized. It is also necessary to be able to bridge the gap between theory and practice.

…………………………………………………………………………………………………….... Introduction:-
Pain is a diverse set of perpetual events that are characterized by their unpleasant or distressing nature (NANDA, 2006). Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (International Association for the Study of pain, 2015). It is not a discrete sensory experience that is switched on by a particular or identifiable set of pain pathway to elicit an invariant sensation. Although, from our everyday experience, we tend to associate pain only with an intense or noxious peripheral stimuli in most patients, pain arises either in the apparent absence of any peripheral input (spontaneous pain) or in ISSN: 2320-5407 Int. J. Adv. Res. 6(4), 1271-1277 1272 response to low intensity or innocuous stimuli that are usually not associated with pain. Pain is a subjective experience, and no objective tests exist to measure it (American Pain Society, 2006). Acute pain has strong cognitive and emotional components, though it is still poorly understood (Woolf, 2001; Abiodun, Olaogun, Adereti & Ayeni, 2016). It is a highly subjective state in which a variety of unpleasant situations and a wide range of distressing factors may be experienced by the sufferer (Herdman, 2012).
Knowledge of these features may assist in diagnostic accuracy. Advances in knowledge and use of the nursing process have driven the construction of standardized terminologies (for the elements of nursing practice diagnosis, intervention and outcomes) to enable the classification and organization of these elements into coherent units of cross referenced information. These classification systems facilitate the communication and encoding of information for entry into computer databases and provide other major benefits to clinical practice, teaching and research in nursing Anecdotal observations have it that there are many potentially successful approaches available for pain management yet there is still a shortage of knowledge about the strategies used by health professionals especially how reliable the strategies are. The fact that patients often undergo a deal of suffering from pain and lack of adequate relief may be considered as an indicator for shortage of knowledge (Abiodun, Olaogun, Adereti & Ayeni, 2016).
Despite advances in technology and medications, unrelieved post-operative pain continues to be problematic for surgical patients and the claimed vast amount of current knowledge still puts uncontrolled post-operative pain percentage in patients at approximately 50% (Craig, 2014). Clinical studies from different parts of the world reveal that the incidence of post-operative pain reported is still high with about 75% reporting moderate pain and additional 15% severe pain. A national study was done in United State of America among surgical patients, it was reported that 80% had moderate to severe pain with more patients experiencing pain after discharge than before discharge (International Association for the Study of Pain, 2000). Establishment of the nursing diagnosis of acute pain in post-operative patients requires nurses to conduct a careful assessment by observing and noting the defining characteristics during assessment. Valid and reliable assessment of pain is essential for both clinical trials and effective pain management. The nature of pain makes objective measurement impossible. Acute pain can be reliably assessed, both at rest (important for comfort) and during movement (important for function and risk of postoperative complication) (Breivik et al, 2008) by identifying its indicators. In developing countries like Nigeria where there are so many challenges in the management of pain. A study was done in a teaching hospital, it was revealed that analgesia was not prescribed in 45% of postoperative cases and that even when post-operative analgesia were provided, they were inadequate in the majority of patients (American Pain Society, 2006). Pain assessment, accurate diagnosis and management are therefore clinical problems that health workers have to deal with. Kolcaba"s Theory of Comfort served as the conceptual framework for this study. Comfort Theory is a nursing theory developed in the 1990s by Katharine Kolcaba (Kolcaba, 1992;Craig, 2014). In Comfort Theory, human needs are addressed as existing in three characteristics: relief, ease, and transcendence. (Craig, 2014) The study"s objectives aimed at evaluating the knowledge of nurses on pain assessment and diagnosis.

Methods:-
The study utilized explorative descriptive design (mixed method) and was conducted in a tertiary hospital setting (Federal Medical Centre, Owo) which is located in Owo Local Government Area in Ondo-State, Nigeria. Owo is located in Ondo North Senatorial district and belongs to Owo/Ose Federal Constituency. It is a tertiary health institution that was established in November, 1994. The Centre is a major referral health facility in the state. There are 19 wards in all out of which 7 are surgical wards. The Centre is 303 bedded out of which 114 beds are in surgical wards. There are 371 Nurses in the Centre at large while 97 of them were in the surgical wards as at the time of this study.
The scope of the study spanned over clinically assessing and identifying acute pain in post-operative patients by nurses and measuring their knowledge level. Nurses in the following wards participated in the study; male surgical, female surgical, obstetrics, gynaecology, male orthopaedic, female orthopaedic and burns unit. Five research assistants and the principal researcher administered the questionnaires which was the major research tool used. Data collection took about two and a half months.
The target population for the study was nurses who work in the male surgical, female surgical, male orthopaedic, female orthopaedic, obstetrics, gyneacological and burns wards in Federal Medical Centre in Owo. A census of the 1273 all the nurses in the male and female surgical wards, male and female orthopeadic wards, obstetrics and gyneacology wards and burns unit was done and the total was 97. Hence, all the nurses who consented in the wards (93) participated in the study. In-depth interview was done for 17 out of the 93 nurses. The interview session was held with only 17 because the last few participants responded almost the same way (Saturation point) hence, the interview session was stopped. Two different samples were obtained for the study. Purposive sampling technique was used. This consists of a sample of all nurses who work in surgical wards. Two instruments were used for the study: 1. Questionnaire:- The questionnaire had two sections; section A has 9 items on sociodemographic data while section B has 10 items on knowledge of acute pain and its assessment. It took about 25-30 minutes to administer each questionnaire.

Indepth interview for nurses:-
This is a selfdeveloped instrument by the principal researcher. It has two sections. It was modified by the researcher"s supervisor and other experts in pain management. Section A had the sociodemographic/professional characteristics. Section B had four open ended questions on pain, question 5 was an open-ended item seeking for defining characteristics of pain that the nurses know while item 6 is seeking for the defining characteristics that the nurses observe in post-operative patients on their wards. Items 7-11 were openended questions on pain assessment, diagnosis, how pain is managed and the influence of culture and education on pain perception. The interview sessions were done one on one and they took place at pre-agreed places and times. Each interview session took about 40 minutes. The sessions were audio-recorded and written down verbatim before analysis.
The socio-demographic characteristics were analyzed using descriptive statistics such as frequency tables, mean, mode, median and standard deviation. Responses from the other sections of the questionnaires were also presented using descriptive statistics i.e. frequency distribution, mean, mode, median, variance , standard deviation, Cronbach"s alpha reliability test and Chi -square were used to describe relationships between variables. SPSS version 17 package was used in testing the various hypotheses generated to guide the study. Responses from the interview sessions were analyzed using typical verbatim reports.    The scores range from 10 to 47 with mean of 31.2 and a standard deviation of ± 5.59:- Table IV shows the frequency of responses to each of the 10 items. Majority (87.1%) of the respondents submitted that pain is subjective in nature, this was corroborated by this statement in the in-depth interview: "Acute pain is the pain that a patient experience secondary to surgery…and it is subjective (Participant 1, BNSC)". Majority (79.6%) also submitted that the second item; most post-operative patients experience severe pain is true. A little below half (41.9%) of the respondents submitted that the pain experienced by most post-operative patients is neither mild nor severe but moderate is true while more than half (58.1%) submitted that surgical incisions make post-operative patients to experience more pain after surgery than before is true, this was also corroborated by this statement in the in-depth interview: "Incisions…make patients experience more pain after surgery (Participant 10, RN, RM)". Majority (90.3%) of the respondents submitted that most nurses hardly recognize or diagnose correctly postoperative pain in patients is false, this was supported by this response during the in-depth interview: "I diagnose pain in my patients immediately through their verbal reports and signs shown (Participant 12, RN, RM)". Attending to post-operative patients promptly when they report pain is very important was marked as true by 83.9% of the respondents, this was also corroborated by this statement in the in-depth interview: "I reassure patients, inform managing teams and give analgesics when they report pain, (Participant 3, RN,RM)". Most of the respondents (93.5%) submitted that using a pain scale is important in pain assessment is true, it was corroborated ed by this response during the in-depth interview: "I use a scale of 0-10 in assessing pain (Participant 1, BNSC)". The next item; NANDA-I approach helps to manage post-operative pain very well was marked true by (83.9%) of the respondents, this was also corroborated by this in the in-depth interview: "I use NANDA-I approach … (Participant 5, RN, RM)". Availability of NANDA -I textbooks in the hospital will help to manage post-operative pain was marked as true by majority (89.2%) of the respondents. Cultural and educational background affect individuals" reaction and perception to pain was also marked true by majority of the respondents (89.2%), this was also corroborated in the in-depth interview: "Yes, some people shout when they have pain while some don"t because of their culture, highly educated people normally complain of pain while illiterates do not disturb (Participant 11, RN, RM)".  (2014) as well that were done in two secondary health facilities in Cross -River State and the Niamey National Hospital respectively both found out that nurses assessment methods were inappropriate, this was also confirmed by the in-depth interview sessions as only three of the participants each reported that they assess for pain by "asking the patients how they really feel" , "Use the NANDA-I approach and Nursing diagnosis". Only one participant was using pain scale. Also about half of the participants reported that they assess for pain before treating patients. The use of NANDA-I approach in pain management was also not popular as only three said it was in use on their wards.

Implications for Practice and Research:-
There is need for nurses to update their knowledge as they practice so as to bridge the gap between their educational qualification, years of experience and their knowledge in clinical practice. This is otherwise saying that the gaps between theory and practice should be closed so that patients who are direct recipients of care can have regular relief from their pains.
More research should be done in different settings and geographical locations on the subject matter among nurses so that there will be all-round improvement as research has a lot of influence on practice.

Conclusion:-
The study demonstrated that there was no significant association between nurses" educational qualification and identification of the defining characteristics of acute pain. Likewise, there was no significant association between nurses" years of experience and identification of the defining characteristics. It is therefore of high importance that nurses, whatever their status is need to update their knowledge as they practice so as to bridge the gap between their educational qualification, years of experience and their knowledge in clinical practice in order to maintain their relevance in care of patients.