Abstract

Introduction:

Pain is an unpleasant sensory and emotional experience associated with actual or potential damage. Recently, in developing countries including Ethiopia, there is insufficient data regarding the knowledge and practice of neonatal pain management among nurses. Hence, the current study identified the nurses’ knowledge, practice, and factors associated with neonatal pain management at west Oromia public hospitals.

Objective

This study aimed to assess knowledge, practice, and factors associated with neonatal pain management among nurses at west Oromia public hospitals, Ethiopia 2022.

Methods

An Institutional-based cross-sectional study design was used to conduct the study from all thirty-five public hospitals in west Oromia, from May 1 to 30/2022. A simple random sampling technique was used to select the study participant. The data was entered into Epi-data version 4.6 and exported to SPSS version 26 for analysis. Descriptive statistic was presented in text, tables, and charts. Bivariable and multivariable logistic regression was computed considering the p-value < 0.05 to identify statistically significant factors.

Result

This study was conducted with 203 staff nurses’ working in the neonatal intensive care unit with a response rate of 98.5%. 127(62.6%) of the nurses had adequate knowledge regarding neonatal pain management. As a practice, 33(16.3%) of the participant had a good practice. There was a significant association between nurses’ knowledge status and getting training on neonatal pain management at university/college (AOR, 2.31; CI 1.29, 4.27). The knowledge level (AOR, 3.3 CI: 1.14, 9.32), having a pain management policy in place (AOR, 5.44, CI: 1.92, 15.37), and receiving training on neonatal pain management at university/college (AOR, 2.55 CI: 1.09, 5.97) were significantly associated with the practice of nurses.

Conclusion and Recommendation:

The finding revealed that nurses had inadequate knowledge and practice in neonatal pain management. Though the level of nurses’ knowledge of neonatal pain management is mediocre and the level of nurses’ practice in neonatal pain management is unpredictably low. Therefore, providing training on neonatal pain management at university/college, providing on-job training, and endorsing pain management policy have a paramount role in improving nurses’ knowledge and practice on neonatal pain management.

Introduction

As the international association for the study of pain (IASP) defines it, pain is “an unpleasant sensory and emotional experience associated with actual or potential injuries leads to long and short-term complications ^(1, 2). Many procedures as part of routine care and surgeries cause pain and require prompt assessment with frequent management⁽³⁾. The effects of newborn pain can be severe, potentially leading to physiological, behavioral, and cognitive abnormalities ^(4-6). Thus, the nurses ‘knowledge and practice play a vital role in the assessment and management of neonatal pain in the area of neonatal intensive care unit^(7). 

The American Academy of Pediatrics reveals that there is a high prevalence of knowledge and practice gaps in health care professionals' ability to properly assess and manage pain in neonates⁽⁵⁾. From evidences, around 65.6% of the nurses’ do not know the name of the pain assessment scale which may be related to a lack of training of neonatal pain assessment and management⁽⁸⁾. This was supported by the study in which nurses had a low level of knowledge and poor practice in managing the pain of hospitalized children ⁽⁹⁾. Similarly neonatal nurses do not use any pain assessment tools and majority of them had inadequate knowledge and poor practice towards neonatal pain management ^(7, 10-12).

Even though the availability of clinical-based guidelines regarding the effectiveness of non-pharmacological methods of pain relief, in hospitalized neonates still the majority of the methods are under-utilized by nurses’^(13). Inadequate knowledge could hurt the practice of nurses on neonatal pain management and it may happen due to lack of training on neonatal assessment and management ^(14, 15). Barriers to effective pain management includes lack of education regard to neonatal pain assessment and management, lack of pain management policy, lack of standard guidelines, and absence of analgesics in the neonatal intensive care unit ^(16-19). 

Poor pain management may increase the morbidity and mortality, while persistent and sever pain may change the nervous system, behavioral changes and prolong the pain in newborn infants^(20).  Broadly, in a developing country, there is insufficient data of nurses’ knowledge and practice regarding neonatal pain management. Consequently, its assessment and management is the fundamental basis for improving the quality of care in neonates experiencing pain ^(21).

Despite various aspects of pain management have been investigated throughout the world, it’s difficult to find adequate evidence and little is known about nurses’ knowledge and practice regarding neonatal pain management in Ethiopia, particularly in the Oromia region. To my knowledge, no study assessed nursing staff's knowledge and practice on neonatal pain management and factors associated with neonatal intensive care units at public hospitals in West Oromia. Hence, this study aimed to address this gap and provide baseline information on the nursing staff's current knowledge and practice in the area.

Methods and Materials

Study setting

This study was conducted in West Oromia public hospitals, Ethiopia. The study includes all thirty-five (35) public hospitals in the Oromia regional state of West Oromia, named East Wollega Zone, West Wollega zone, Kellem Wollega Zone, Horo Guduru Wollega zone, West Shoa Zone, Jima Zone, Buno Bedelle zone and Illuababor Zone. The total numbers of a nurse working in those hospitals are one thousand nine hundred thirty-one (1931) and two hundred ninety (290) currently working in the Neonatal Intensive care unit (NICUs). The study aimed to assess knowledge, practice and factors associated with neonatal pain management among nurses.

Study design, period and population

An institutional-based cross-sectional study design was conducted from May 1 to 30/2022. The source population for this study was all employed nurses working in neonatal intensive care units at west Oromia public hospitals. The study populations were all nurses working in the neonatal intensive care unit in each hospital and present during the time of data collection period.

Eligibility criteria

All employed nurses and at least who had six month work experience in the neonatal intensive care unit during the study period were included. Nurses who were on annual leave, maternity leave and who had less than six month work experience were excluded.

Sample size determination and procedure

The sample size of this study was calculated by Epi Info statcalc using the prevalence of the previous study conducted in Addis Ababa city of the selected public hospitals. Initially, the sample size was calculated for both knowledge (68.70%) and practice (32.17%) from the prevalence of the previous study. Meanwhile, the prevalence of practice provides a large sample size it was used to calculate the sample size for this study. 290 source populations of neonatal intensive care units were considered in the western cluster of public hospitals in the Oromia region. The prevalence of the previous study (32.17%) was used and a 95% confidence level with a 4% margin of error was assumed to calculate the sample size. Hence, the sample size calculated by Epi info was 187. By adding a 10% non-response rate the final sample size was 206 neonatal intensive care unit nurses.

The number of study units from each hospital was determined using the proportional to site allocation formula from all thirty-five hospitals: nf x ni

                                                                                   N

Where: nf =final sample size

             ni =number of nurses working in the neonatal intensive care unit at each hospital

             N= total number of nurses working in the NICU western cluster of a public hospital in the Oromia region.             

A simple random sampling technique was used to select sampled nurses from each hospital. Each study unit in the population who were present during data collection was represented by a slip of paper after obtaining the lists of nurses’ from the matron nurses. 

Operational definitions

Adequate knowledge: Those nurses who scored equal to or greater than 80% of the knowledge questions correctly.

Inadequate knowledge: Those nurses who scored below 80% on the knowledge item.

Good practice: Those nurses who scored equal to or greater than 80% of practice questions correctly.

Poor practice: Those nurses who scored below the 80% for practice-related questions correctly.

Data collection tool, procedures and quality control measures

Data collection tool and procedures 

Data were collected using a structured and pre-tested self-administered questionnaire among the nurses working in the neonatal intensive care unit of west Oromia public hospitals. The pretest was done on 5% of a total sample size of nurses. The questionnaire was adapted from a valid and reliable instrument used in previous research done on a similar topic. On the pretest, Cronbach alpha of knowledge and practice resulted in acceptable reliability of assessment tools ( 0.787 and 0.771) respectively. The questionnaire consisted of four parts. 

The first part contains information regarding the nurse’s profile such as age, sex, religion, training, years of experience, and professional qualification, and consists of 8 questions; the second part is regarding nurses’ knowledge (20 questions) composed of affirmative and negative sentences by using the Likert Scale and answered as follows: I disagree (1), I partially disagree(2), I don’t know(3), I agree(4), and I strongly agree(5) that graded as 1-5 and transformed, reversed, computed and recoded to 2-point rating scale as disagree(0) and Agree (1).

The third part was regarding nurses’ practice (15 questions) of affirmative sentences, the answers were as follows; never (1), rarely (2), sometimes (3), most of the time (4), and always (5) and this was transformed, computed and recoded to 2-point rating scale as Never (0) and Always (1): The fourth part was regarding about institutional related factors (seven questions) and answered using Yes or No. Thirty-five BSc nurses working in the west Oromia public health facility for data collection and five BSc nurses and three Health officers from the respective zone for supervisor were recruited and participated in the data collection after taking training by the principal investigator.  

Data quality control

Structured, validated and reliable adapted questionnaires were used to collect the data from each study participant. For consistency and clarity, a pretest on 5% (10 nurses) of the total sample size was calculated working in Adama referral hospitals. The training was given to data collectors and supervisors half a day ahead of the actual data collection and the filled questionnaire was checked for its clarity and understandability. 

Data processing and analysis

The collected data were checked for completeness and consistency. Then, it was coded and entered into Epi data version 4.6 and exported to IBM SPSS version 26 for further analysis. Finally, the data was processed descriptively and analytically. Descriptive analysis was used to process the frequency of the socio-demographic characteristics of nurses and the questions related to the knowledge and practice of nurses on neonatal pain management. To identify the predictive variables a bivariate analysis was conducted and factors with a p-value <0.25 at a 95% CI were said to be significant. Then, after the identified factors were entered into multivariate analysis to control the confounding factors and those factors with a p-value <0.05 at a 95% CI were declared as a predictor of the outcome variables. The model fitness was checked using Hosmer-Lemeshow goodness of fit test. The model was at good fitness with the (p-value 0.761 for knowledge and 0.781 for practice). The findings of the study are presented using texts, tables, and figures.

Results

Socio-Demographic Characteristics of the Study

A total of 203 Nurses participated in the study with a response rate of 98.5%. The median ages of the participant were 29 with ± 3 Interquartile ranges. Among the participants 102 (50.2%) of them were male and 50 (24.6%) were unmarried. In addition, 111 (54.7%) of them were comprehensive nurses followed by 60 (29.6%) neonatal BSc nurses, and 165(83.1%) had NICU experience of 2 years or above. Regarding their training on neonatal pain management 113 (55.7%) of them have not received it during their studies, but only 65 (32.0%) of participants were get training on neonatal pain management while working in NICU.

Nurses' knowledge of neonatal pain management

127(62.6%) of the study participant with a CI: 55.7- 69.9 had Adequate knowledge regarding neonatal pain management, while 76(37.4%) with a CI: 31.1-45.3 had inadequate knowledge of neonatal pain management (Figure1).

Among the total respondents, 165(81.3%) of them agreed that pre-term newborns experience pain. Similarly, the majority of 171(84.2) respondents agreed that full-term newborns feel pain. The number of participants who agreed that the vital sign of neonates can be affected by pain was 185(91.1%). There were also more than half 66.0% of respondents who reported they knew that light and noise affect newborns' reactions to pain. Among the participants, 165(66.5%) respondents stated that nurses’ have sufficient knowledge to assess pain in the neonate (Table1).

Pain is considered one of the vital signs in newborns as stated by respondents 163(80.3%), and the majority of them 171(84.2%) reported that its assessment must be systematized. There were also among respondents 155(76.4%) knew pain assessment should be part of prescriptions. Regarding newborns requiring painkillers due to the maturity of the nervous system and nurses' knowledge adequacy to assess pain, less than half of the participants 60(29.6%) and 68(33.5%) disagreed respectively.

Factors associated with knowledge of nurses on neonatal pain management 

The bivariate logistic regression was used to determine the predictor variables for neonatal pain management. Among those predictors, receiving training on neonatal pain management while in NICU, level of education, getting training on neonatal pain management at university/college, in-service training on neonatal pain management, and shortage of nurses in each work shift were associated with knowledge of nurse’  towards neonatal pain management in bivariate logistic regression analysis(P<0.25). Those variables that have an association with an outcome variable were included in the multivariate logistic models. Consequently, getting training on neonatal pain management at university or college was significantly associated with the knowledge of nurses towards neonatal pain management after potentially confounding variables were controlled (p=0.008). 

Those nurses’ who received training on neonatal pain management at university or college were 2.31 times more likely to have adequate knowledge when compared to those nurses who didn’t receive training on neonatal pain management at university/college(AOR=2.31: CI 1.24-4.27) (Table 2).

Nurses practice in neonatal pain management

This study revealed that 33(16.3%) of the study participants with the CI: 11.8-23.1 had good practice regarding neonatal pain management (Figure 2).

More than half of respondents 123(60.6%) always assess newborns through crying followed by 103(50.7%) through facial expression. Almost greater than half of 107(52.7%) respondents use a pain scale to assess neonatal pain whereas 96(47.3%) didn’t use It. similarly, the assessed newborn pain was recorded on medical charts by half of the respondents 102(50.2%).

Regarding neonatal pain management, 68(33.5%) always uses nonnutritive suckling and 134(66.0%) of them encourage breastfeeding to relieve pain in newborns. In addition, 119(58.6%) of nurses always use skin-to-skin contact to manage pain in newborns and the majority 109(53.7%) of the respondents use more than one non-pharmacological, while 139(68.5) use pharmacological and non-pharmacological combined to relieve pain in the newborn (Table 3).

Factors associated with the practice of nurses toward neonatal pain management

To determine the set of predictor variables for nurses’ practice of neonatal pain management, bivariate logistic regression was utilized. From those predictors, knowledge level, sex of participants, receiving training on neonatal pain management at university /college, presence of protocols and guidelines, support from leadership on neonatal pain management, presence of standard neonatal pain scale measurement, in-service training, and presence of pain management policy in place were significantly associated with nurses’ practice on managing neonatal pain in bivariable logistic regression analysis (p<0.25). In the multivariable logistic regression model with (p<0.05), the effects of the confounding variable were controlled, and getting training on neonatal pain management, knowledge category, and pain management policy remained insignificant in multivariate analysis.

Nurses who had training in neonatal pain management at college or university were 2.6 times more likely to good practice neonatal pain management than those who didn’t get training at college/university (AOR=2.55 CI=1.09,5.97). Nurses who had adequate knowledge levels were 3.3 times more likely to practice neonatal pain management than compared with inadequate knowledge (AOR=3.26; CI =1.14,9.32). Those nurses’ who had a pain management policy in place were 5.4 times (AOR=5.44; CI=1.92, 15.37) more likely to have good practice in neonatal pain management (Table 4).

Discussion

Knowledge of neonatal intensive care units nurses on neonatal pain management

As shown from the result 62.56% (CI: 55.7-  69.9) of the nurse had adequate knowledge of neonatal pain management. It indicates the majority of the nurses were knowledgeable regarding neonatal pain management. Factually, as the knowledge of nurses on neonatal pain management increases, the practice of neonatal pain management will also advance⁽¹⁸⁾. This might be due to the sampling technique and their qualifications as almost the majority of them are bachelor’s degree holders.  This finding is significantly higher than the study conducted in Rwanda (25.8%), Malaysia (40.5%), and Iran (45.5%) which shows adequate knowledge of neonatal pain management among nurses^(11, 22). 

However, this finding was in line with the study conducted in Ghana 61.1%, University of Gondar comprehensive specialized hospital (67.9%), and Addis Ababa city public hospital 68.7% on pediatric and neonatal pain management respectively^{(9, 18, 23).}

Factors associated with neonatal intensive care unit nurses on neonatal pain management 

The present study indicated that the knowledge of nurses on neonatal pain management is positively associated with getting training on neonatal pain management at university/college (p=0.008). This implies that those nurses’ who get training were 2.3 times more likely to have adequate knowledge of neonatal pain management than those who didn’t get training on neonatal pain Management at University/college AOR, 2.31 CI;1.29,4.27. This finding was similar to the study conducted in Turkey (0.017) and Addis Ababa public hospitals (0.042), in which a lack of training on neonatal pain management at university/college was negatively associated with neonatal pain management^(8, 18).

The practice of neonatal intensive care unit nurses in neonatal pain management

The current study revealed that one-six (16.3%) of nurses had good practice of neonatal pain management, while 170(83.7%) of the study participant had a poor practice of neonatal pain management. This finding was in line with the study in Rwanda (15.2%)⁽¹¹). Though it is lower than the study in Malaysia, Ghana, and Addis Ababa public hospitals in which 41.67%, 42.2%, and 32.2% of them had good practice in neonatal pain management respectively _{(7, 9, 18).} 

Factors associated with neonatal intensive care unit nurses' practice toward neonatal pain management

As regards the current study the availability of pain management policy, knowledge level, and getting training on neonatal pain management at university /college persisted significantly associated with the practice of neonatal pain management. 

Those nurses who had an infant pain management policy in place were 5.4 times more likely to practice neonatal pain management when compared with those nurses who didn’t have a pain management policy in place AOR, 5.44 CI;1.92,15.37 (p=0.001). This finding was similar to the study conducted in Addis Ababa public hospital⁽¹⁸⁾. Consequently, the result shows that the presence of a pain management policy in each unit is crucial to more practice neonatal pain management. The current result also revealed that receiving training on neonatal pain management at university/ college was corresponding with good practice in neonatal pain management. Those nurses who had training on neonatal pain management at university/college were 2.6 times more likely to practice neonatal pain management than those nurses who didn’t get training on neonatal pain management at university/college AOR, 2.55 CI;1.29-4.27(p=0.032). This finding was in line with the study conducted in Rwanda and Addis Ababa public hospitals ^(11, 18).

Those nurses who had adequate knowledge resulted in 3.3 times more likely to good practice neonatal pain management when compared to those who had inadequate knowledge AOR, 3.26 CI;1.14-9.32 (p=0.028). This is consistent with the study conducted in Rwanda and Addis Ababa Public hospitals ^(11, 18). The Pearson correlation coefficient test showed a positive significant relationship between knowledge and practice (r=0.203, p=0.004*). This implies as the knowledge of the nurse's increases regarding neonatal pain management the practice will also advance and be effective in pain management. However, the result of this study may not accurately reflect the actual clinical practice in which the data were based on the participant's self-report.

Conclusions

Declarations

Acknowledgement

The authors thank the University of Gondar (UoG) College of Medicine and Health Science, School of Nursing department of pediatric and child health nursing for providing this opportunity to conduct this study.

Authors’ contributions

Wandimu M. Topic selection, literature searching, writing literature, performing analysis, interpretations, manuscript write up, reviewing manuscript, submission and corresponding author. Mengistu B. Topic selection, frequently advising throughout the research process, data analysis, interpretations and manuscript write up. Addis B. Topic selection, frequently advising throughout the research process, data analysis, interpretations and manuscript write up. All authors equally read and approved the manuscript for publications. 

Funding

The authors didn’t receive any financial support for these research article/publications.

Availability of data and materials

The authors, particularly the corresponding author can provide the data sets used for the current study upon request if it was accepted for publication. If you confirm the research article was accepted anybody from your member can ask the corresponding author and get any time convenient for him.

Ethics approval and consent to participate

Ethical clearance with reference number 230/2014 was obtained from the Institutional Review Board (IRB) of the University of Gondar, College of Medicine and Health Science Department of Pediatric and Child Health Nursing. Letter of the permission was secured from administrative bodies of the hospitals to communicate with the relevant bodies in the health institutions. Written Informed consent was obtained from each study participant. All of the study participants were informed verbally about the purpose of the study, burden and benefits, their right to participate or not, or withdraw from the study at any time. Privacy and confidentiality were strictly maintained by avoiding writing the name of study participants during data collection and all methods were carried out in accordance with relevant guidelines and regulations.  

Consent for publication

Not applicable

Competing interest 

The authors declare that they have no competing interest

Author’s details

¹Wandimu Muche; Wollega University, Institute of Health Science, School of Nursing Department of Pediatric and Child health Nursing, ²Addis Bilal; University of Gondar, College of Medicine and Health Science School of Nursing Department of Pediatric and Child health nursing, ²Mengistu Birhanu; University of Gondar (UoG), College of Medicine and Health Science School of Nursing Department of Pediatric and Child health Nursing.

Abbreviations

References

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Tables

Table 1: Nurse's knowledge in managing neonatal pain in Public Hospitals at West Oromia, Ethiopia, 2022 (n=203).

Table 2: The association between associated factors and knowledge of nurses towards neonatal Pain management in Public Hospitals at West Oromia, Ethiopia, 2022(n=203).

Table 3: Nurse's practice in managing neonatal pain in Public Hospitals at West Oromia, Ethiopia 2022 (n=203).

Table 4: The association between associated factors and practice of nurses towards neonatal pain management in Public Hospitals at West Oromia, Ethiopia, 2022(n=203).