This study discusses the utilization of the non-pharmacological methods for alleviating postoperative pain and existing barriers. The study was conducted using a standard questionnaire which was applied in different settings, making it useful for comparisons. Since the study was conducted in the major hospitals, it gave an informative picture of the degree of utilization of these methods.
Utilization of Non-pharmacological methods for postoperative pain management
This study found out that non-pharmacological pain reliving methods are less utilized by the nurses. A recent study conducted among Eritrean nurses indicated a gap in the knowledge and attitude in pain management. This knowledge gap seems to have resulted from inadequate training in the nursing curriculums (21). A study conducted in the same setting reported negligence in pain management (22). Moreover, the common complains in the National hospitals have been shortage in number of nurses which hindered the utilization of these methods.
Among the cognitive behavioral methods, breathing and relaxation were often used, while the rest of the methods were the least used. In support to the above assertion, a study done by Faigeles et al, (2013), stated that the most frequently used non-pharmacological interventions during acute pain were calming voice, providing information, and deep breathing. It had been rationalized that those methods are easy to implement and doesn’t require equipment or specific training (24). A study done in Westminister, England on non-pharmacologic pain management for postoperative coronary artery bypass in graft surgical patients, reported that deep breathing followed by distraction were commonly used as pain relieving methods. The majority of the patients stated it helped them to minimize both the perception and sensation of pain in contrast to pharmacological methods alone (25).
The preparatory information involved entities done at the preoperative period and in this current study, they were found to be the least used. This was similar to a study conducted in Singapore (18), in which items; sensory information, paying enough attention to the ways of giving information, and the use of materials to help with informing were found to be less frequently utilized. In both studies those findings could be attributed to the fact that preparatory information is provided mainly by surgeons and/or anesthetists.
Alleviating pain by positioning of patients was the most frequently used physical method due to its routine application, acceptability, easy to administer and requires less time compared to the other methods. Massage application and thermal regulation with heat and cold application were rarely used. This is explained by lack of heating and cooling devices, lack of training and cultural influences. Similar studies done in Finland, China and Singapore reported that positioning was the most commonly used physical method during postoperative pain, whereas, thermal regulation and massage were the least used (16, 18, 23). Furthermore, Kooten (1999) stated that positioning was frequently used, whereas cold packs were rarely used (25). Another study conducted in Finland on postoperative pain management after hip surgery, stated that positioning was the most commonly used non-pharmacological method (26). A study done by Gelinas and his colleagues, nurses were found to practice simple massaging as a pain relieve method on critically ill patients (27).
In this study on emotional support, nurses presence was (45.5%) which was less frequently utilized compared to the Finland (77%) and Singapore (49%) nurses on relieving postoperative pain (18, 23). This discrepancy could be explained by the less time surgical nurses spend with patients or nurses lack of understanding on the actual meaning of presence. In this study therapeutic touch was less used by the nurses. Results of Bonnie Faigeles (2013), was incongruent with this study, stating that nurses provided pain relief by frequently holding hands and gentle touch during acute pain. This study found out that the nurses always helped patients during their daily activities and created a comfortable environment. This findings concurred with a study done by He et al., (2010) which reported similar findings.
Over all nurses’ age, educational status, experience in healthcare and prior hospitalization with a close relative had a significant difference in the utilization of non-pharmacological methods. The utilization of non-pharmacological methods is proportionate to the increase in age, experience and educational level of the nurses. These findings were similar to a study carried out in Finland, China and Singapore which found out nurses age, educational status, work of experience had effects on the use of some non-pharmacological methods (16, 18, 23).
Statistical differences prevailed across the provision of preparatory information, the nurses’ educational level, work place, experience in health care, availability of pain assessment tools, and prior experience of hospitalization. This study findings was congruent to the research study done by Pölkki in 2001 where by ‘the nurses' age, education and nursing experience showed statistically significant associations with the preparatory information.’ There was a statistical significance among the study sites in which variation on the use of the non-pharmacological methods was disproportionately distributed. The uneven distribution resulted from the type of services, their specialties, affordability of the services, the catchment population served, accessibility and previous experience.
Perceived barriers that hinder the utilization of non-pharmacological methods
A number of barriers on the utilization of the non-pharmacological methods has been perceived by the nurses and the barriers were related to health care system, nurses and patients related indicating a statistical significance of (p<0.001).
In this study health care system related barriers such as heavy workload, less time and limited equipment’s were the most commonly perceived barriers. This study was consistent with the study done by Elcigil in 2011, in which heavy work load and less time were reported as barriers (28). A study done by Batiha in 2014 identified lack of pain management policies, lack of proper pain assessment tool, less number of nurses, interruptions of activities relating to pain and unavailability of alternative non-pharmacologic therapy as healthcare related barriers (29). A similar study done in Poland, found out that limitations such as lack of standard operating procedures and guidelines by the administration interfered with pain management (17). Moreover, a study done in China stated the most common limiting factors were less nurse to patient ratios and heavy workload leading to less attention on post-surgical pain which was consistent with the findings of this study (16).
On nurse related barriers, lack of knowledge and experience on non-pharmacological methods were stated as existing barriers. This was associated with less experience and specialization on non-pharmacological methods and poor positive opinion on its efficiency. This study finding agreed with the results of Batiha in 2014 in which time limitations, less communication and inadequate staff knowledge were pointed out. In addition to this, a study done in South Korea indicated that time constraints and insufficient knowledge were the most encountered barriers (30). Furthermore, a study done in Iran identified limited nurse-patient interaction, lack of pain management interventions and inadequate time to deliver non-pharmacological pain relief measures as barriers (31). On patient related barriers lack of cooperation and the limitation in language were found out to affect negatively the use of non-pharmacological methods in pain management. In this study it is postulated that positive attribute to the pharmacological methods hinders the effective use of the non-pharmacological methods.
The use of questionnaires in data collection for this study might have created limitation on the side of respondents since, selected non-pharmacological methods were captured. This study took in to account non-pharmacological methods as practiced at major referral facilities hence, the picture could be different if the study was all inclusive of other lower level facilities. The study did not focus on the benefits attributed to the combination of non-pharmacological methods and pharmacological methods.