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School of Public Health Thesis and Dissertations

2022-08-20

þÿNurses Pain Management Practice and

Associated Factors for Admitted
Patients at The Comprehensive
Specialized Hospitals of Amhara
Region, Ethiopia, 2022, A Multi-Center
Cross-Sectional Study

Legese, Fekede

http://ir.bdu.edu.et/handle/123456789/15072
Downloaded from DSpace Repository, DSpace Institution's institutional repository
 BAHIR DAR UNIVERSITY
COLLEGE OF MEDICINE AND HEALTH SCIENCE
SCHOOL OF HEALTH SCIENCES
DEPARTMENT OF ADULT HEALTH NURSING

NURSES’ PAIN MANAGEMENT PRACTICE AND ASSOCIATED

FACTORS FOR ADMITTED PATIENTS AT THE
COMPREHENSIVE SPECIALIZED HOSPITALS OF AMHARA
REGION, ETHIOPIA, 2022, A MULTI-CENTER CROSS-
SECTIONAL STUDY

BY: LEGESE FEKEDE (BSc.)

A RESEARCH THESIS TO BE SUBMITTED TO BAHIRDAR UNIVERSITY,

COLLEGE OF MEDICINE AND HEALTH SCIENCES, DEPARTMENT OF
NURSING IN PARTIAL FULFILMENT FOR THE DEGREE OF MASTER OF
SCIENCE IN ADULT HEALTH NURSING

AUGUST/2022

BAHIR DAR, ETHIOPIA

 BAHIR DAR UNIVERSITY
COLLEGE OF MEDICINE AND HEALTH SCIENCES
SCHOOL OF HEALTH SCIENCES
DEPARTMENT OF ADULT HEALTH NURSING

NURSES’ PAIN MANAGEMENT PRACTICE AND ASSOCIATED

FACTORS FOR ADMITTED PATIENTS AT THE
COMPREHENSIVE SPECIALIZED HOSPITALS OF AMHARA
REGION, ETHIOPIA, 2022

PRINCIPAL INVESTIGATOR: LEGESE FEKEDE (BSc.)

Beet964@gmail.com

A RESEARCH THESIS SUBMITTED TO BAHIR DAR UNIVERSITY,

COLLEGE OF MEDICINE AND HEALTH SCIENCES, SCHOOL OF HEALTH
SCIENCE, DEPARTMENT OF ADULT HEALTH NURSING FOR THE
PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE DEGREE OF
MASTER OF SCIENCE IN ADULT HEALTH NURSING

ADVISORS:
1. WORKU ANIMAW (Ph.D.)
2. HALEYESUS GEDAMU (MSc.)

AUGUST, 2022
BAHIR DAR, ETHIOPIA
ACKNOWLEDGEMENT
First and foremost, I would like to express my deepest gratitude to my advisors Dr. Worku Animaw
and Mr. Haileyesus Gedamu for their unreserved guidance and support throughout this thesis work.
Next, I would like to thank Bahir Dar University, College of medicine and health science,
department of adult health nursing for providing me the chance for doing this thesis.

I would also like to extend my heartfelt thanks to health professionals, study participants, and
administrators at Felege-Hiwot, Tibebe-Ghion, Debre-Tabor, Debre-Markos, and Debre Berhan
comprehensive specialized hospitals for providing me with valuable information necessary for this
research paper. I would also like to express my gratitude to the data collectors and supervisors for
their commitment and valuable support throughout the data collection period. Lastly, I would also
like to express my gratitude to my family and friends for their valuable support throughout my
work.

i
 Table of Contents
ACKNOWLEDGEMENT ............................................................................................................... i

ABBREVIATIONS AND ACRONYMS ...................................................................................... iii

LISTS OF TABLES ....................................................................................................................... iv

LISTS OF FIGURES ...................................................................................................................... v

ABSTRACT ................................................................................................................................... vi

1. INTRODUCTION ................................................................................................................... 1

2. LITERATURE REVIEW ........................................................................................................ 5

3. OBJECTIVES .......................................................................................................................... 9

4. METHOD AND MATERIALS............................................................................................. 10

5. RESULT ................................................................................................................................ 19

6. DISCUSSION ........................................................................................................................ 25

7. LIMITATIONS OF THE STUDY ........................................................................................ 28

8. CONCLUSION ..................................................................................................................... 29

9. RECOMMENDATION ......................................................................................................... 30

10. REFERENCES .................................................................................................................. 31

11. ANNEX.............................................................................................................................. 36

ii
ABBREVIATIONS
AOR Adjusted Odds Ratio
CI Confidence Interval
COR Crude Odds Ratio
DTCH Debre-tabor Comprehensive hospital
ESA Ethiopian Standard Agency
FHCSH Felege-Hiwot Comprehensive Specialized Hospital
GRS Graphic Rating Scale
HMIS Health Management Information System
IASP International Association for the Study of Pain
ICU Intensive Care Unit
JUMC Jimma University Medical Center
NRS Numerical Rating Scale
PI Principal Investigator
SPSS Statistical Package Software for Social Students
TGSH Tibebe-Ghion Specialized Hospital
UoGCSH University of Gondar Comprehensive Specialized Hospital
VAS Visual Analog Scale
VRS Verbal Rating Scale
WHO World Health Organization

iii
LISTS OF TABLES
Table 1: Sample size calculation to assess factors associated with pain management practices of
nurses for admitted patients at the Comprehensive Specialized Hospitals of the Amhara region of
Ethiopia, 2022. .............................................................................................................................. 12
Table 2: Socio-demographic characteristics of nurses (n=430) and patients (n=430) at Amhara
Region Comprehensive Specialized Hospitals 2022 .................................................................... 19
Table 3: Knowledge of nurses toward pain management practices for admitted patients (n=430) at
Amhara Region Comprehensive Specialized Hospitals, 2022 G.C. ............................................. 20
Table 4: Clinical characteristics of patients to nurses’ pain management practices and associated
factors for admitted patients (n=430) at Amhara Region Comprehensive Specialized Hospitals,
2022............................................................................................................................................... 21
Table 5: Pain management practices nurses for admitted patients (n=430) at Amhara Region
Comprehensive Specialized Hospitals, 2022. ............................................................................... 22
Table 6: Bivariable and Multi-variable ordinal logistic regression analysis to factors associated
with pain management practices of nurses for admitted patients (n=430) at Amhara Region
Comprehensive Specialized Hospitals, 2022 ................................................................................ 24

iv
LISTS OF FIGURES
Figure 1: Conceptual Framework adapted from different literature to assess pain management
practices and associated factors of nurses for admitted patients at the Comprehensive Specialized
Hospitals Amhara region, 2022. ..................................................................................................... 8
Figure 2: Schematic presentation of sampling procedure on pain management practices and
associated factors of nurses for admitted patients at the Comprehensive Specialized Hospitals of
the Amhara region of Ethiopia, 2022. ........................................................................................... 14

v
ABSTRACT
Background: Pain is the most common challenge that most hospitalized patients complain of
during their hospital stay. It is influenced by several patients, nurses, and institutional-related
factors. Most prior studies in Ethiopia on pain are focused on surgical illnesses.
Objective: To assess nurses' pain management practice and associated factors for admitted patients
at Comprehensive Specialized Hospital of the Amhara Regional State, Ethiopia, 2022.
Methods and materials: A multi-center institution-based cross-sectional study was conducted at
the Comprehensive Specialized Hospitals of the Amhara region. A total of 430 nurses and patients
for whom the nurses responsible were included in the study. Data were collected from nurses,
patients, and charts of patients using self-administered, structured, and checklist questions
respectively. The overall practice was categorized as good, moderate, and poor using the modified
bloom’s criteria. An ordinal logistic regression model was applied, and variables with a p-value of
≤ 0.25 in the bivariable analysis were taken to multivariable analysis. Variables with a p-value <
0.05 with a 95% CI were considered significant. The results were presented in text, tables, and
graphs.
Results: The study evaluated the pain management practices of 430 nurses. Of those, 25.8%,
27.5%, and 46.7% had good, moderate, and poor pain management practices respectively. The
odds of being in a higher level of pain management practice was higher for nurses with degrees
and above (AOR=2.282: 95%CI [1.181, 4.41]), who attended in-service training (AOR=2.465:
95%CI [1.317, 4.614]), providing care for patients with painful procedures (AOR=5.648: 95%CI
[3.237, 9.856]) and severe pain (AOR=2.573: 95%CI [1.35, 4.899]), and working in the institutions
having a pain-free initiative focal person (AOR=6.339: 95%CI [3.611, 11.13].
Conclusion and recommendation: Overall, the majority of nurses had poor pain management
practices. Five variables from nurses, patients, and institution were found to have a statistically
significant association with nurses' pain management practices. Patients would be benefited
considerably if hospitals focus on providing training and assigning focal persons for advocating
regular management for patients at any pain level.
Keywords: pain, hospitalized patients, nurses, pain management practice, Amhara region

vi
 1. INTRODUCTION
1.1.Background of the Study
The International Association for the Study of Pain (IASP) defined pain as an unpleasant sensory
and emotional experience associated with actual or potential tissue damage or described in terms
of such damage(1). It is inherently subjective and influenced by biological, psychological, and
social variables. Nowadays, pain is considered the fifth vital sign and is the most common reason
which drives patients to seek health care services(2). It can be categorized based on anatomic
location, body system, duration, severity (intensity), frequency, and etiology(3). Pain also can be
classified as acute, sub-acute, or chronic based on its duration (3-5).

Pain is a subjective sensation caused by high-intensity stimuli triggering pain receptors in the
skin, muscle, bone, and other tissues. When the receptors are triggered, they produce electrical
signals which travel through afferent pathways to the spinal cord and brain in milliseconds,
causing a physiological or behavioral reaction(6). Pain is often difficult to measure objectively
and thus it is difficult to determine its severity by objective assessment. It can be subjectively
measured by the visual analog scale (VAS), the verbal rating scale (VRS), the numerical rating
scale (NRS), and graphic rating scales (GRS). These are the most commonly used pain assessment
tools in clinical practice (7-9). Based on the numerical rating scale, pain can be 1-3 (mild), 4-6
(moderate), and 7-10 (severe)(10, 11).

Pain management practices refer to those activities done by health care providers, particularly
nurses to relieve those who are in pain, which includes pain assessment using organizationally
accepted tools, providing pharmacological and non-pharmacological pain management, and
evaluation of pain management by reassessing patients’ status. It is effective when patient
outcomes, satisfaction level, and quality of life are all improved(12, 13). Untreated pain affects
almost every aspect of the life of the patient as well as the family. Pain is now recognized as the
"fifth vital sign," which is assessed and managed regularly by nurses(10, 14). Nurses have a leading
role to improve pain management practice and thereby reduce the prevalence of pain among
hospitalized patients; because they spend much more time than any other health care team.
Therefore, to obtain optimal patient outcomes, they must be well-informed, competent, and skilled
in the assessment and management of pain(15).

1
 1.2.Statement of the Problem
Pain is the most prevalent difficulty for hospitalized patients, which necessitates a considerable
deal of attention from health care personnel. It is common among hospitalized patients, particularly
in surgical and oncological departments. According to various studies, roughly half of admitted
patients suffer pain, and every third of admitted patients has severe pain (10, 16-19).

The severity (intensity) of pain among hospitalized patients varies by location. According to a
study conducted in Belgium, 36.7 percent of patients graded using the numerical pain rating scale
had mild pain, 19.1 percent had moderate pain, and 8.0 percent had severe pain(10). Another study
found that 36.8% of patients with pain reported mild pain, while 27 percent reported moderate to
severe pain(17). According to a study carried out at the three government hospitals in Ethiopia,
88.2 percent of post-operative patients experienced moderate to severe pain(20). Another study
conducted at Debre-tabor Comprehensive Hospital showed that the prevalence of pain among post-
operative patients ranged from 37.7% to 76.7%, which is recorded 1 to 72 hours after surgery(21).
These all indicate that pain is still a problem among admitted patients and pain management
practice in the inpatient departments is inadequate which requires determining the reason behind
the inadequacy of nurses’ pain management practices.

Pain has a detrimental impact on a patient's total health condition if it is not assessed and managed
early, including physical, mental, emotional, social, and economic consequences(9, 22). It's linked
to a reduction in physical function, sleep disturbances, and the incapacity to exercise. Patients with
pain (acute or chronic) are more likely to experience sadness, anger, the anxiety of pain
intensifying, and a lack of hope for pain treatment. Furthermore, persons with pain are unable to
engage in social activities, which can lead to sadness(23, 24). They are also expected to pay for
their medical services, but they are unable to do so because they are unable to work, which may
lead to economic dependence(25). In general, repeated exposure to moderate to severe pain has a
considerable impact on patients' quality of life(26).

Despite regular pain assessments and management protocols, the magnitude and intensity of pain
among hospitalized patients remain significant indicating inadequate pain management practices
(10, 27). Few studies focus on nurses’ pain management practice who are caring for hospitalized
patients. Certain studies in different areas including Ethiopia revealed that nurses’ pain
management practice for hospitalized patients is inadequate (28-30).

2
The factors; particularly the patient-related factors that influence the nurses’ pain management
practices weren't studied well in Ethiopian studies. Another limitation with Ethiopian studies on
pain management practices is they frequently rely on surgical patients, particularly post-operative
ones. Therefore, the study aimed to investigate pain management practices and factors that act as
barriers or facilitators to nurses’ pain management practices which subsequently increase the
burden of pain among patients admitted to the comprehensive specialized hospitals of Amhara
region, Ethiopia.

3
 1.3.Significance of the Study
The primary aim of this study was to identify factors that influence the pain management practices
of nurses in the inpatient departments who were caring for admitted patients which had direct or
indirect impacts on the physical, social, economic, and emotional aspects of patients. The majority
of prior studies in Ethiopia on pain and its management had been focused on surgical illnesses so
more studies were needed to determine pain management practices at every unit of health care
facilities. In addition, few studies in Ethiopia focused on factors that affect nurses’ pain
management practices in admitted patients, particularly patient-related factors. As a result, this
study looked into how it looks like the nurses’ pain management practice and how pain was
managed in all adult departments including surgical units. It also focused on various factors
including patients, nurses, and institutional-related factors that influence the pain management
practices of nurses.

The study's findings will provide useful information to various stakeholders such as ward heads
and hospital managers for establishing effective pain treatment practices and reducing patients
suffering from untreated pain. For policymakers, the study will support to design of pain
management protocols for hospitalized patients. The findings of this study will also provide
frameworks for researchers to further investigate pain management practices for hospitalized
patients.

4
 2. LITERATURE REVIEW
Nurses’ pain management practice is inadequate which is indicated by the high prevalence and
intensity of pain among admitted patients. More than 40% of admitted patients suffer moderate to
severe pain, according to research conducted at Italy's St. Anna General Hospital (16). An average
of 2.2 pain intensity was recorded among hospitalized patients in a study conducted in Belgium
(10). In another study conducted at teaching hospitals in India, 70.6 percent of patients experienced
moderate to severe pain(18). According to a study conducted at the University of Ilorin Teaching
Hospital in Nigeria, from the first to third post-operative days, over 71% of patients experienced
moderate to severe pain(31). Various studies in Ethiopia show that despite the implementation of
a regular pain assessment and management protocol, the prevalence and intensity of pain among
hospitalized patients remain high. For instance, according to a study in Ethiopia, over 67 percent
of patients experienced moderate to severe pain, with an average pain level of 5.33 measured over
four consecutive times(20).

The pain management practices of nurses working at the intensive care units of the government
hospitals of Addis Ababa was inadequate(30). Based on the finding of the study conducted at
Jimma University, around 23.53 percent of nurses working at the post-operative units of the
hospital had poor pain management practices. These all indicate that there is inadequate pain
management practice by nurses for hospitalized patients in our country(28).

There are multiple factors associated with pain management practices among nurses which
subsequently increase the burden of pain on admitted patients. Generally, those factors can be
broadly categorized as patient-related, nurses-related, and institution-related factors. The interplay
of these three elements can act as barriers or facilitators for proper management of pain by nurses
and also determine the patients’ outcomes (10, 17).
2.1.Patient-Related Factors
These are factors related to patients which can influence nurses’ pain management practice in
hospitalized patients. Age of patients was one the patient-related characteristics that was found to
have a significant relation with the pain level of patients thereby influencing the pain management
practices according to the findings of the studies in Taiwan and Australia(13, 32). Gender of
patients was another patient-related characteristics that was found to have significant relationship

5
with the level of patients’ pain which in turn influence the pain management practices of nurses
according to studies done in Turkey, Australia, and Debre Tabor of Ethiopia (13, 21, 32).

A study carried out in Turkey revealed that Disease category (surgical and gynecology) was one
of the patient-related factors that was found to be significantly associated with the pain level
thereby influencing the nurses’ pain management practices (13). Another patient-related factor
discovered to be significantly related to the pain management practices in research done in Turkey
and at the University of Gondar was pain severity (13, 33). According to an Australian study, low
patient educational status was one of the key patient-related variables related to nurses' pain
management practices (32).
2.2.Nurses’-Related Factors
It is known that nurses have the leading role in caring for patients, especially in managing the pain
of hospitalized patients. They have a great role in reducing the magnitude as well as the intensity
of pain as they spend much more time with patients than any others. According to certain research
findings, there are a variety of nurse-related factors that influence the pain management practice
of nurses thereby either increasing or decreasing the burden of pain among admitted patients.

Studies carried out at Belgium, the Case Medical Center of Kampala, and the Federal Hospitals of
Addis Ababa, Ethiopia found that knowledge of pain assessment and management was one of the
significantly associated variable with nurses' pain management practices (10, 34). Based on the
results of research conducted in Rwanda and Asmara, the age of nurses was another factor that
was found to be significantly related with the nurses’ pain treatment practice (35, 36). According
to research conducted in the Rwanda, Eritrea, Hawassa, and Amhara region of Ethiopia, level of
education was another nurse-related characteristic that was found to have a significant association
with the pain management practices of nurses (29, 35-37).

Work experience was another crucial nurse-related feature that was discovered to have a strong
relationship with the nurses' pain management practice in studies conducted in Rwanda, Eritrea,
and referral hospitals of the Amhara region of Ethiopia (35, 36, 38). According to a study
conducted at the referral hospitals in the Amhara region, another nurse-related variable that was
discovered to have a strong association with the nurses' pain management techniques was the
gender of the nurses (38). According to the findings of studies conducted in Asmara of Eritrea and
referral hospitals of the Amhara region of Ethiopia, the working unit was found to be significantly

6
associated factors with the pain management practices of nurses(35, 38). An in-service pain
management training was another important nurse-related factor which was found to have a
statistically significant relationship with the nurses’ pain management practices base on the
findings of studies conducted in Jimma, public hospitals of Oromia region, and federal hospitals
of Addis Ababa(28, 30, 39).
2.3.Institution-Related Factors
Similarly, there are several institutions-related factors that influence nurses’ pain management
practice, resulting in a significant burden of pain among hospitalized patients. According to the
findings of studies in Turkey, Iran, Ghana, and federal hospitals of Addis Ababa, Ethiopia; nurse-
to-patient ratio is one of the institutional-related factors that was found to have a significant
relationship with the pain management practices of nurses. This was indicated by insufficient
number of patients for the number of patients was associated with inadequate pain management
practices (30, 40-42).

Pain management guidelines was another institutional-related factor that was found to be
associated significantly with the nurses’ pain management practice based on the findings of studies
conducted in Turkey, Wolaita, federal hospitals of Addis Ababa, and referral hospitals of Amhara
region. Nurses who had been working in the institutions that didn’t incorporate pain management
found to have inadequate pain management practice for hospitalized patients (30, 38, 40, 43).

7
 2.4.Conceptual Framework
By taking into account the above literature, the conceptual framework below summarizes the
review of nurses' pain management practices and associated factors for admitted patients. In order
to establish this conceptual framework, it was assumed that nurses' pain management practices and
associated factors (patient, nurse, and institution-related factors) for admitted patients could be
related, as reviewed from different literature, majorly from articles (10, 17, 21, 37, 38, 40-46).

Patient-related factors
1. Socio-demographic characteristics
I. Age
II. Sex
III. Marital status
IV. Educational status
V. Religion
VI. Occupation
2. Clinical factors
I. Pain intensity

Nurses’ related factors Nurses’ pain

1. Socio-demographic management
Institutional-related factors
characteristics practice
1. Nurse-to-patients ratio
I. Age
2. Pain assessment tools
II. Gender
3. Pain management guidelines
III. Educational level
4. In-service training
IV. Year of experience
V. Working unit
2. Knowledge of nurses

Figure 1: Conceptual Framework adapted from different literature to assess pain management
practices and associated factors of nurses for admitted patients at the Comprehensive Specialized
Hospitals Amhara region, 2022.

8
 3. OBJECTIVES
3.1.General Objective
To assess nurses’ pain management practice and associated factors for admitted patients at the
Comprehensive Specialized Hospitals of Amhara Region, Ethiopia, 2022.
3.2.Specific objectives
I. To determine nurses’ pain management practices for admitted patients at the
Comprehensive Specialized Hospitals of Amhara Region, Ethiopia, 2022.
II. To identify factors associated with nurses’ pain management practice of nurses for
admitted patients at the Comprehensive Specialized Hospitals of Amhara Region, Ethiopia,
2022.

9
 4. METHOD AND MATERIALS
4.1.Study Design
An institutional-based multi-center cross-sectional study was conducted to determine pain
management practices and associated factors of nurses providing care to admitted patients.
4.2.Study Area and Period
This study was conducted at comprehensive specialized hospitals in the Amhara regional state,
Ethiopia. There are eight comprehensive specialized hospitals in the region and five of the
hospitals (Debre-Berhan, Felege-Hiwot, Debre-Tabor, Debre-Markos, and Tibebe-Ghion
comprehensive specialized hospitals) were selected randomly for better representativeness of the
region.
Felege-Hiwot Comprehensive Specialized Hospital (FHCSH) is one of the referral hospitals in the
city that provides health care services for patients in Amhara as well as neighboring regions. The
hospital has five adult inpatient departments serving over 12 million people from the surrounding
area. On average about 900 patients were admitted to the hospital per month. Currently, 120 nurse
professionals were working in the inpatient departments of the hospital.
Tibebe-Ghion Comprehensive Specialized Hospital (TGSH) is a recently established hospital that
provides health care services to the community in Amhara and other neighboring regions. On
average, 950 patients were admitted to the five wards (Medical, Surgical, Orthopedics, Oncology,
and Maternal wards). There were 144 nurses and midwives working in the adult inpatient
departments of the hospital.
The Debre-Berhan Comprehensive Specialized Hospital (DBCSH) is found in Debre-Berhan
which is the capital of the North Shoa Zone, Ethiopia. There were 105 nurses and midwives
working in the inpatient departments of the hospital. Around 730 patients were admitted to the
four units (medical, surgical, maternity, and oncology) of the hospital per month.
Debre Tabor Comprehensive Specialized Hospital (DTCSH) is one of the eight governmental
Hospitals in the region. It provides health care services for patients from Debre Tabor town and
other surrounding areas. There were a total of 164 nurse professionals working in the hospital
during the study period.
Debre-Markos Comprehensive Specialized Hospital (DMCSH) is one of the eight Hospitals in the
Amhara region of Ethiopia which provides health care services for patients from Debre-Markos

10
and the surrounding areas. According to the information obtained from the nursing director of the
hospital, about 120 nurses were working in the inpatient departments of the hospital.
Five adult inpatient units were included in each hospital based on the study objectives. These are
medical, surgical, orthopedics, oncology, and maternity. The total number of nurses in each unit
of each hospital and the number of samples drawn from each unit of each hospital are presented in
the figure-2 below.
4.3.Population
4.3.1. Target Population
All nurses working in the inpatient departments of Comprehensive Specialized Hospitals of
Amhara Region.
All patients admitted to the inpatient departments of Comprehensive Specialized Hospitals of
Amhara Region.
4.3.2. Study Population
All nurses working in the inpatient departments of the selected Comprehensive Specialized
Hospitals of the Amhara Region during the study period fulfilled the eligibility criteria.
All patients admitted to the inpatient departments of the selected Comprehensive Specialized
Hospitals of the Amhara Region during the study period fulfilled the eligibility criteria.
4.3.3. Study Unit
Those nurses who provide care to patients in the selected wards of the selected hospitals from
whom actual data were collected.
Patients who were followed by the selected nurses in the selected wards of the hospitals.
4.4.Inclusion and Exclusion Criteria
4.4.1. Inclusion Criteria
Nurses working at the participating wards of the selected hospitals who had a diploma and above
and work a daytime shift during the study period.
Patients admitted to the selected units of the hospitals who could communicate and describe their
pain status verbally were included in the study.
4.4.2. Exclusion Criteria
Nurses on annual leave and sick leave during the data collection period were excluded from the
study. Patients admitted to the selected wards of the hospitals with critical illness and impaired
level of consciousness were excluded from the study.

11
 4.5.Sample Size Determination
The sample size for the first objective was determined using a single population proportion formula
(𝑍𝑎⁄2 )2 × 𝑝(1 − 𝑝)
𝑛=
𝑑2
Where: n=Sample size
Z= standard normal value at the level of confidence which at 95% confidence level is 1.96
P= proportions of poor pain management practices among nurses
d= margin of error (0.05)
A proportion was obtained from a study conducted at Jimma University Medical Center (JUMC),
i.e. 23.53 percent of nurses had poor pain management practice(28). So using a single population
proportion formula, with 95% CI, 5% margin of error, P of 23.53 %, and Q of 76.47%, the sample
size:-
(1.96)2 × 0.2353 × 0.7647
𝑛= = 277
0.0025
The sample size for the second objective is determined using a double population proportion. The
percent outcome of both unexposed (P1) and exposed (P2), and crude odds ratio (COR) each
variable are taken from different previous related studies in Ethiopia. Each variable is observed
and checked using their respective P1, P2, and COR. All the sample size estimation procedure is
performed using Epi-Info version-7. Some of the significant variables and their respective sample
are shown in the table below.
Table 1: Sample size calculation to assess factors associated with pain management practices of nurses for
admitted patients at the Comprehensive Specialized Hospitals of the Amhara region of Ethiopia, 2022.
Variables P1, P2 & COR n
Patient-related Gender Male P1=65.15, P2=83.87, 190
Female COR=2.78(21)
Nurse-related Knowledge Adequate P1=43.5, P2=73.1, 98
Inadequate COR=3.52(46)
Institution-related Insufficient nurse to Yes P1=10.9, P2=31.7, 138
patients ratio No COR=3.81(46)
Where, P1 implies percent (%) outcome in the unexposed group, P2 implies percent (%) outcome
in the exposed group, and COR is the crude odds ratio.

12
The sample size of the first objective is the largest minimum required sample size and is therefore
taken as the study sample. By adding a 5% non-response rate to the initial sample, the sample size
becomes 291. The sample was again multiplied by a design effect of 1.5 yielding the final sample
size of 437, which is the number of nurses who were included in the study(47).

The same number (437) of patients were included in the sample to assess pain intensity directly
from the patients and the pain management practices of nurses from the corresponding patient’s
chart.
4.6.Sampling Procedure
A multi-stage sampling technique was employed to select the study samples. First of all, a list of
all comprehensive specialized hospitals had been obtained from the Amhara health bureau. Five
hospitals (Tibebe-Ghion, Felege-Hiwot, Debre-Tabor, Debre-Markos, and Debre-Berhan) were
selected randomly from the eight comprehensive specialized hospitals. Then, the number of nurses
working in the inpatient departments was obtained from each institution. Then the calculated
sample size was proportionally allocated to the size of the population in the selected hospitals.
Five inpatient departments (Medical, Surgical, orthopedics, Oncology, and Maternity) were
selected in each hospital, and nurses working in those departments again were allocated
proportionally based on their number. Finally, simple random sampling by lottery method was
employed to select the study samples.

The total number of patients admitted per month was obtained from the Health Management
Information System (HMIS) database in each department. A total of 437 patients with their
hospital patient charts were selected similarly from the selected units of each hospital to determine
pain intensity. Before selecting a nurse for the study, the bed numbers he is responsible for were
determined. Then, one of the patients that the nurse is responsible for was selected.

13
 Amhara Region Comprehensive Specialized Hospitals (8)

Simple random sampling

TGCSH FHCSH DBCSH DTCSH DMCSH

Nurses=144 Nurses=120 Nurses=105 Nurses=100 Nurses=114

Proportional allocation to sample size=437

108 90 79 75 85

Proportional allocation of nurses in each inpatient units of the hospitals

Med=2217 Med=3425 Med=3123 Med=2519

Surg=2720 Surg=4735 Med=3526
Surg=3325 Surg=2317
Orth=1914 Ortho=2017 Surg=3325
Onco=54 Ortho=3828
Onc=32 Onco=97 Mat=4634
Mat=3627 Mat=1511
Mat=7355 Mat=86

Lottery method simple random sampling

Nurses=437

Figure 2: Schematic presentation of sampling procedure on pain management practices and

associated factors of nurses for admitted patients at the Comprehensive Specialized Hospitals of
the Amhara region of Ethiopia, 2022.

14
 4.7.Variables
4.7.1. Dependent Variables
Nurses’ pain management practice
4.7.2. Independent Variables
Independent variables are categorized into three groups, which include:-
Patient-related variables: Socio-demographic variables (age, sex, educational status, marital
status, religion, occupation) and Clinical factors (painful procedure, latest pain score record, type
of analgesics, and pain intensity)
Nurse-related variables: Socio-demographic characteristics (age, sex, educational status, work
experience, and working unit), and knowledge were nurses-related variables
Institutional-related variables: In-service training, nurse-to-patient ratio, written policy for pain
as the “5th vital sign”, pain assessment tools, pain management guidelines, number of working
shifts, and pain-free hospital initiative implementation focal person were institutional-related
variables.
4.8.Operational Definitions
Nurses’ pain management practices: are activities done by nurses which include regular
assessment and management of pain among hospitalized patients as well as evaluation of pain
management practice(13).
Pain intensity: Pain intensity is the magnitude of pain experienced by individual patients when
measured using a numerical or verbal rating scale(48).
Patients with Mild pain: are those patients whose pain score ranged from one up to three (1-3)
numerically(49, 50).
Patients with Moderate pain: are those patients who report pain that ranged from four up to six
(4-6) numerically(49, 50).
Patients with Severe pain: are those patients who are in pain whose pain score ranged from seven
to ten (7-10) numerically(49, 50).
Good pain management practice: According to the checklist evaluation, nurses with scores ≥
75% were regarded as having good pain management practice (29, 51, 52).
Moderate pain management practices: Based on the checklist evaluation, nurses with scores
between 50 and 74.99% were considered as having moderate pain management practices(29, 52).

15
Poor pain management practice: Based on the checklist evaluation, nurses with scores less than
50% were considered as having poor pain management practices (29, 51, 52).
Adequate Nurse to Patient Ratio: When a nurse serves ≤6 patients in all units other than the
Intensive Care Unit (ICU) which is based on Ethiopian Standard Agency (ESA) for
Comprehensive hospitals(53, 54).
Good knowledge: Those nurses who scored above or equal to 80% of the knowledge questions
were regarded as having adequate knowledge about pain management(51).
Poor knowledge: Those who scored below 80% of the knowledge questions were categorized as
having poor knowledge(29, 51).
Painful procedure: Any procedure that could reasonably be anticipated to result in more than
mild or transient pain and/or distress in the patients to whom it is applied(55).
Type of analgesics: Classifications of anti-pain medications based on the WHO analgesics ladder
as non-opioids, weak opioids, and strong opioids(56).
Latest pain record: Based on the pain-free hospital initiative implementation guideline of
Ethiopia, it refers to a record of patients’ pain on the chart by the responsible nurse within the last
four hours(57).
4.9.Data Collection Tools and Procedures
Data were collected using a self-administered questionnaire from nurses and an interviewer-
administered questionnaire from patients as well as a checklist for chart review and observation
which were developed after reviewing different literature and modified accordingly. The
questionnaire contained different parts including questions related to socio-demographic
characteristics of nurses, nurse-related factors, pain management knowledge assessment, pain
management practice assessment, socio-demographic characteristics and clinical characteristics of
patients, institutional-related factors, and pain intensity measurement.

A data extraction checklist was used to evaluate the pain management practices of nurses by
reviewing patients’ charts. It consisted of 8-items with binary scoring (yes/no) for all items. Data
were reported as good, moderate, or poor pain management practices depending on the score
obtained from the checklist. The tool was adapted from the Pain-Free Initiative Implementation
Manual and different studies in Ethiopia (28, 30, 57).
A knowledge questionnaire was used to assess the level of nurses’ knowledge on pain management
for admitted patients. It consisted of 12 items with binary scoring (yes/no) for each question. Data

16
were reported as good or poor knowledge depending on the score of the respondents. It was
adapted from different Ethiopian studies (30, 43, 58).

A checklist was used to determine institutional-related factors to nurses’ pain management

practices for admitted patients. It consisted of a 6-item question that was adapted from the Pain-
Free Initiative Implementation Manual and different studies of Ethiopia (30, 47, 57).

An eighteen (18)-item question, including the socio-demographic and clinical characteristics, was
used to assess patient-related factors to pain management practices of nurses for admitted patients.
It was adapted from previous Ethiopian studies (21, 30, 45). Finally, the WHO pain ladder was
used as a tool to assess the pain intensity of patients(59).

Before selecting a nurse for the study, the bed numbers that he/she was responsible for were
determined. Then, one of the patients for whom the nurse is responsible was chosen at random so
that the chart could be reviewed and patient-related characteristics could be evaluated. Nurses play
a key role in the management of patients' pain and they are in charge of the patient care during
their scheduled working hours (39, 54, 60). So, the pain management practice was evaluated from
the records of the patients’ charts. From the patients’ charts, data about administered medications
such as anti-pains and vital signs’ incorporating latest pain score were collected. The charts were
reviewed for about four hours back to evaluate the corresponding nurses’ pain management
practices. During this time the nurse involved in this study was assumed to be responsible for the
care and records that have been done to the patients participated. Because nurses are only assigned
to a certain number of patients for a specified amount of time in hospital settings(54).
The patients were assessed for pain intensity using a numerical pain rating scale. Using a checklist,
institutional factors were also assessed and at the same time, self-administered questionnaire was
given to the nurses to assess their socio-demographic characteristics and their knowledge level
towards pain management.

Data collection tools were prepared in English, translated to Amharic, retranslated to English, and
checked for their consistency and clarity. Three diploma nurses and two BSC nurses were recruited
to collect and supervise the data collection process in each hospital. The data collectors and
supervisors were trained for one day on procedures, techniques, and ways of collecting the data.
During the actual data collection, the supervisor evaluated each study site at least once per day,
and anything unclear or ambiguous, and incomplete was corrected immediately.

17
 4.10. Data Quality Control
The data quality was maintained by using a carefully designed questionnaire and collected by well-
trained data collectors and supervisors. Every day, the collected data were reviewed and checked
for completeness and consistency by the supervisors and the principal investigator. A pretest was
done on 5% of the sample size at the University of Gondar Comprehensive Specialized Hospital
(UoGCSH) to check the consistency of the questionnaires. A reliability test was done for
knowledge and practices questionnaires using SPSS and yields a Cronbach’s alpha of 0.73 and
0.78 respectively. And some rearrangement of the questionnaire was done.
4.11. Data Processing and Analysis Procedure
Data were checked, coded, and entered into Epi-Data version 4.6 and exported to SPSS version 25
for analysis. Descriptive statistics such as frequency distribution, proportion, and percentages were
done. The extent of multi-collinearity between independent variables was checked using variance
inflation factor (VIF) and tolerance and the values of both statistics for all independent variables
were within acceptable range (VIF<10 and Tolerance>0.1). Regression model assumptions were
checked using a test like the Hosmer & Lemeshow goodness of fit with a P-value (Pearson chi-
square=0.096 and Deviance-0.776). The proportional odds assumption was checked with a test of
parallel lines with a P-value ≥0.05 that is an indicator for the fulfillment of the assumption. A P-
value for the test of parallel line for this study was 0.421.

A bivariable ordinal logistic regression model were fitted for each explanatory variable.
Accordingly, those variables having a p-value ≤ to 0.25 in the bivariable regression analysis were
taken as the candidates for the multivariable ordinal logistic regression model. In multivariable
regression, variables with a P-value of less than 0.05 with a 95% CI were considered statistically
significant. Finally, results were presented in text, tables, charts, and graphs.
4.12. Ethical Consideration
Ethical clearance was obtained from the ethical review board of Bahir Dar University with a
protocol number of 410/2022 and permission letters were obtained from each institution. Each
study participant was adequately informed of the necessary information about the research; the
right to withdraw at any time during the interview, the importance of their participation in this
research, and confidentiality was maintained, and also, they were informed about the information
collected was used only for this research. Finally, informed written and verbal consent from nurses
and patients respectively was obtained before data collection from each participant.

18
 5. RESULT
5.1.Nurse-related factors for pain management practices
5.1.1. Socio-demographic characteristics of nurses
The study included 430 nurses in total, with a response rate of 98.4%. The majority 228 (53%)
were males and the mean age was 30.44 with a standard deviation (SD) of 4.311. According to the
data obtained from nurse professionals themselves, only 58 (13.5%) had taken in-service training
regarding pain management in the past two years (as shown in the table-1 below).
Table 2: Socio-demographic characteristics of nurses (n=430) and patients (n=430) at Amhara
Region Comprehensive Specialized Hospitals 2022
Nurses’ socio-demographic characteristics Patients’ socio-demographic characteristics
Variables Category n % Variables Category n %
Gender Male 228 53.0 Gender Male 170 39.5
Female 202 47.0 Female 260 60.5
Age 21-30 274 63.7 Age 18-35 177 41.2
35-555 67 15.6
≥31 156 36.3 ≥56 186 43.3
Education Diploma 56 13.0 Education Unable to read & write 148 34.4
Degree & 374 87.0 Primary education 132 30.7
above Secondary education 67 15.6
College & above 83 19.3
Experience 0-4 years 150 34.9 Marital status Married 323 75.1
5-10 years 206 47.7 Single 65 15.1
Divorced 25 5.80
≥11 years 74 17.2 Widowed 17 4.0
Working Medical 113 26.3 Occupation Gov’t employee 102 23.7
unit Surgical 122 28.4 Housewife 140 32.6
Orthopedics 58 13.5 Farmer 127 29.5
Oncology 19 4.4
Maternity 118 27.4 Merchant 45 10.5
In-service Yes 58 13.5 Others 16 3.7
training No 372 86.5
1Others=student and daily laborers, *mixed: non-opioids, weak opioids, strong opioids
5.1.2. Knowledge of nurses toward pain management practices
The mean nurses’ knowledge of pain management score was 8.84 with a Standard deviation of
1.92. The most correctly answered item is “Pain should be assessed before and after administering
anti-pain drugs” with a 98.8% correct response rate. The question “Acetaminophen and non-

19
steroidal anti-inflammatory agents are effective analgesics for severe pain” was the least answered
item with only a 24% correct response rate. Of all nursing professionals, majority 273 (63.5%) had
poor knowledge towards pain management practices (as shown on table-2 below).
Table 3: Knowledge of nurses toward pain management practices for admitted patients (n=430) at
Amhara Region Comprehensive Specialized Hospitals, 2022 G.C.
Variables Category n %
Patients are the most accurate judge of their pain Yes 246 57.2
Currently, pain is regarded as one of the vital signs Yes 421 97.9
Pain assessment before and after administering anti-pain Yes 425 98.8
Placebo is helpful to assess a patient if he/she is really in pain Yes 122 28.4
Patient should be advised to use non-drug techniques with pain medication Yes 398 92.6
Distraction using relaxation can decrease the perception of pain Yes 384 89.3
Side effects of opioids should be observed at least 20-30 minutes after Yes 354 82.3
administration
Combining analgesics may result in better pain control with fewer side effects Yes 198 46.0
providing comfort and positioning may help to reduce pain Yes 419 97.4
Assessment is the priority for effective pain management Yes 400 93.0
Acetaminophen and NSAIDS are not effective for severe pain Yes 103 24.0
Subsequent doses of anti-pain should be adjusted according to the patient’s Yes 360 83.7
response
Level of nurses’ knowledge toward pain assessment and management Good 157 36.5
Poor 273 63.5

5.2.Patients’-related factors for pain management practices

5.2.1. Socio-demographic characteristics of patients
In this study, 430 patients were interviewed, their pain level was assessed using NRS, and the
charts of the corresponding patients were reviewed. The majority were females 260 (60.5%) and
the mean age was 45.32 years with a range of 18-86 years. Regarding the educational status of the
patients, 148 (34.4) were unable to read and write, while 132 (30.7%), 67 (15.6%), and 83 (19.3%)
had primary, secondary, and diploma and above educational levels respectively. Most of the
patients were farmers (25.3%) and housewives (35.1), while the remaining were government
employees (22.6%) and merchants (8.8%) with their occupations (as shown in table-1 above).

20
 5.2.2. Clinical characteristics of patients
Regarding the clinical characteristics of patients, only 207 (48.1%) of all patients’ pain was
recorded within 24 hours before to the chart review. More than half 238 (55.3%) of patients had
undergone painful procedures. When assessed using NRS, 351 (81.63%) had reported mild to
severe pain with a median and IQR of 3 and 4 respectively (as shown table-3 below).
Table 4: Clinical characteristics of patients to nurses’ pain management practices and associated
factors for admitted patients (n=430) at Amhara Region Comprehensive Specialized Hospitals,
2022.
Variables Category Frequency Percent
Latest pain record Yes 207 48.1
No 223 51.9
Type of anti-pain Non-opioids 76 17.7
Weak opioids 154 35.8
Strong opioids 30 7.0
Mixed 42 9.8
None 128 29.8
Patients with a painful procedure Yes 192 44.7
No 238 55.3
Pain intensity No pain 79 18.4
Mild pain 163 37.9
Moderate pain 106 24.7
Severe pain 82 19.1

5.3.Institutional-related factors for pain management practices

Five of the Comprehensive Specialized Hospitals of the Amhara region were included in the study.
4 (80%) of the five hospitals had two working shifts and 3(60%) hospitals had a 1 to 6 nurse-to-
patient ratio for working hours. Of those hospitals, 4 (80%) had a written policy for pain as the 5th
vital sign, 3 (60%) had pain management guidelines, and only one (20%) of the institutions had
pain-free hospital initiative focal person.
5.4.Pain management practices of nurses
About 222 (51.6%) of the charts revealed pain was assessed and recorded at least once within the
past four hours by the nurses. Among those nurses evaluated by chart review of their particular
client, only 152 (35.3%) had performed a regular pain assessment during their stay at the
workplace. Regarding the level of practice, only 111 (25.8%) of nurses had good pain management
practices while 118 (27.4%) and 201 (46.7%) had moderate and poor pain management practices
respectively. The mean score and SD of a “yes” response to the pain management practice
questions were 3.44 and 2.08 respectively.
21
Table 5: Pain management practices nurses for admitted patients (n=430) at Amhara Region
Comprehensive Specialized Hospitals, 2022.
Variable Category Freq %
Pain score sheet attached and incorporated with the patient’s chart Yes 427 99.3
Pain assessment and recording using the standard pain assessment tools Yes 222 51.6
at least once over the past 4 hours
Regular pain assessment for the particular patient Yes 152 35.3
Patient with pain provided anti-pain medications Yes 292 67.9
Pain managed based on WHO pain management standards Yes 125 29.1
Non-pharmacological pain management Yes 124 28.8
Pain management before and after every procedure Yes 120 27.9
Monitoring side effects of anti-pain medications as per protocol Yes 7 1.60

5.5.Factors associated with Nurses’ pain management practice

A total of 23 variables were included in the model of bivariate ordinal logistic regression level.
Those variables are nurse’s age, gender, educational level, working experience, working unit, in-
service training regarding pain assessment and management, knowledge about pain management,
patient’s age, gender, marital status, educational status, religion, occupation, painful procedure,
latest pain record, type of anti-pain they have received, pain intensity, nurse to patient ratio,
number of working shifts, availability of written policy for pain as a fifth vital sign, availability of
pain assessment tools, availability of pain management guidelines, and presence of assigned pain-
free hospital initiative focal person in the institutions.

However, only 11 variables were found to be eligible for the multivariable ordinal logistic
regression test with a p-value of less than 0.25. These include nurses’ educational level, years of
experience, working unit, in-service training, knowledge, patients’ age, gender of patients, patients
with painful procedures, pain intensity, availability of pain management guidelines in the
institutions, and the presence of an assigned focal person for pain-free hospital initiative
implementation. On the multi-variable ordinal logistic regression, five (5) variables become
significantly associated with the pain management practices at a P-value less than 0.05. These
variables are nurses’ educational level, having in-service training, patients with the painful
procedure, pain intensity, and assigned pain-free initiative implementation focal person in the
institutions.

22
Educational status of nurses was found to have a statistically significant relationship with the pain
management practices of nurses. The odds of being in a higher level of pain management practice
was 2.282 times (AOR-2.282, with 95%CI: [1.181-4.41]) higher on average for those having
educational qualification of degree and above as compared to those having diploma.

An in-service pain management training was found to be significantly associated with the pain
management practices. The odds of being in a higher category of pain management practices was
2.47 times (AOR=2.465 with 95%CI:[1.317-4.614]) higher on average for those nurses who
attended an in-service pain management training as compared to those who didn’t attend. In other
words, those nurses who attended a pain management training had a 71% probability of having
higher level of pain management practices.

From the patient-related factors, patients with painful procedures become a significant predictor
of nurses’ pain management practices. The odds of being in a higher category of pain management
practice was 5.648 times (5.648 with 95%CI: [3.237-9.856]) higher for those nurses who provide
care for patients with painful procedures as compared to the contrary group. Those nurses who
follow those patients with painful procedures had 85% probability of falling in the higher category
of pain management practices.

The other patient-related significant variable was pain intensity. The odds of being in a higher level
of pain management practice was 2.573 times (2.573with 95%CI: [1.35-5-4.899]) higher on
average for those nurses who follow patients with severe pain as compared to those who follow
patients with mild pain. Similarly the odds of being in a higher category of pain management
practice was 3.236 times (3.236with 95%CI: [1.771-5.914]) higher on average for those nurses
who follow patients without pain as compared to those who follow patients with mild pain.

From institutional factors, a pain-free initiative implementation focal person was found to have a
statistically significant relationship with the nurses’ pain management practices. The odds of being
in a higher category of pain management practice was 6.34 times (6.339 with 95%CI: [3.611-
11.13]) higher on average for those nurses working in the institutions having a pain-free hospital
initiative implementation focal person as compared to the contrary group. Those nurses working
in the hospitals having a pain-free hospital initiative implementation focal person had 86.4%
probability of having a higher level of pain management practices.

23
Table 6: Bivariable and Multi-variable ordinal logistic regression analysis to factors associated
with pain management practices of nurses for admitted patients (n=430) at Amhara Region
Comprehensive Specialized Hospitals, 2022
Variables Category Pain mgt (1=poor, COR (95%CI) AOR (95%CI) P-
2=moderate& value
3=good)
1 2 3
Nurses’ Diploma 36 10 10 1
Education ≥Degree 165 108 101 2.136[1.207-3.782]* 2.282[1.181-4.41]** 0.014
Working 0-10 years 172 91 82 0.557[0.360-0.862]* 0.76[0.451-1.282] 0.304
experience ≥11 years 29 27 29 1 1
Working Medical 62 28 23 1.791[1.066-3.007]* 2.163[0.995-4.70] 0.051
unit Surgical 39 33 50 4.975[2.99-8.28]* 1.667[0.794-3.50] 0.177
Orthopedic 15 22 21 5.035[2.756-9.199]* 2.136[0.946-4.82] 0.068
Oncology 6 7 6 4.042[1.649-9.905]* 1.96[0.629-6.11] 0.246
Maternity 79 28 11 1 1
In-service Yes 14 18 26 2.910[1.736-4.877]* 2.465[1.317-4.614]** 0.005
training No 187 100 85 1 1
Knowledge Good 52 51 54 2.234[1.545-3.229]* 1.305[0.826-2.061] 0.254
Poor 149 67 57 1 1
Age of 18-35 96 44 37 0.545[0.369-0.805]* 0.997 [0.587-1.692] 0.991
patients 36-55 32 21 14 0.652[0.389-1.095] 0.671[0.367-1.228] 0.196
≥56 73 53 60 1 1
Patient Male 67 45 58 1.775[1.234-2.553]* 1.282 [0.795-2.065] 0.308
gender Female 134 73 53 1 1
Painful Yes 45 65 82 5.887[3.994-8.677]* 5.648[3.237-9.856]** 0.001
procedure No 156 53 29 1 1
Pain No pain 28 22 29 4.143[2.434-7.052]* 3.236[1.771-5.914]** 0.001
intensity Severe 12 28 42 9.130[5.337-15.62]* 2.573[1.35-5.4.899]** 0.004
Moderate 51 36 19 2.045[1.264-3.307]* 1.022[0.574-1.82)] 0.942
Mild 110 32 21 1 1
Pain mgt Yes (277) 118 79 79 1.554[1.069-2.258]* 1.471[0.901-2.40] 0.123
guide No (153) 83 39 32 1 1
Focal Yes (317) 16 30 44 4.41[2.884-6.934]* 6.339[3.611-11.13]** 0.001
person No 185 88 67 1 1
2
*P-value<0.20, CI-95 (Confidence Interval), COR-Crude odds ratios, AOR-Adjusted Odds
Ratios, **- Remained statistically significant (p<0.05) at adjusted odds ratios, P-value is for
adjusted odds Ratios

24
 6. DISCUSSION
The objective of this study was to determine nurses' pain management practices and associated
factors for admitted patients at the Amhara region comprehensive specialized hospitals. The study
indicated that only 111 (25.8%) with a 95%CI [0.217, 0.302]) of the nurses had good pain
management practices, while 118 (27.4%) and 201 (46.7%) had moderate and poor pain
management practices respectively. The finding of this study was consistent with the study
conducted at Hawassa Referral Hospital (24.4%) (61). However; it was lower compared to the
studies done at the Federal Hospitals of Addis Ababa (56.5%), governmental hospitals of Harari
region and Dire Dawa city administration (33.6%), and Jimma University Medical Center (JUMC)
(76.47%) (28-30, 61).

This gap could be explained by the difference in sample size, as the sample sizes in the earlier
research were generally less than those in this study. On the other hand, the discrepancy may have
arisen from the study's use of an objective tool to evaluate nurses' pain management practices. The
disparity in the study populations may be another factor contributing to the discrepancy. The study
done in Addis Ababa was on the practices of nurses for critically ill patients and that of Jimma and
Dire Dawa were for post-operative patients. Whereas the current study was in all adult inpatients
units as well as multicenter.

This study was multicenter which was in contrast to the studies of Jimma, Hawassa, and Dire Dawa
which might result in a difference in the level of nurses' pain management practices. The other
reason that might have brought the difference in the level of nurses' pain management practices
could be the difference in the provision of pain management training. For example, only 13.5% of
professionals attended pain management training in this study which was lower compared to the
finding of Jimma in which 23.5% of professionals had attended in-service pain management
training which might have resulted in the difference in the level of pain management practices of
nurses.

The result of this study was relatively higher as compared with the study done in Rwanda in which
only 2% of the study participants had good pain management practices (36). The possible reason
for the discrepancy could probably be attributed to the educational level of nurse professionals in
which only 4% of nurse professionals had an educational qualification of degree which is far less
than the current study in which 87% had a degree and above level of education. When patients'

25
pain is not managed sufficiently, they may experience serious negative effects, including
socioeconomic, clinical, and emotional ones. It could lead to chronic persistent pain, unexpected
readmission, and delayed recovery. A regular assessment and management of pain are essential
for a better patient outcome (62).

The educational status of nurses was found to have a statistically significant relationship with the
nurses' pain management practices. The odds of being in a higher level of pain management
practice was nearly 2.3 times higher on average for those with educational qualifications of a
degree and above than those with a diploma. The possible reason would be that nurses with a
degree and higher levels of education typically have better knowledge and comprehension of pain,
its assessment, and management mechanisms, which in turn leads to better pain management
practice. The knowledge and clinical skills of professionals will be greatly enhanced by advanced
nursing education, which will lead to better pain management for patients. Patients would also
benefit when they get attention to their pain by skillful professionals throughout their hospital stay.
The finding was supported by the studies conducted in Hawassa and Rwanda in which those nurses
with an educational qualification of degree and above had good pain management practices as
compared to those with a diploma (29, 36).

This study indicated that in-service pain management training was found to be significantly
associated with pain management practices. A higher category of pain management practice was
more likely for nurses who participated in in-service pain management training compared to those
who did not in the previous two years, by a factor of 2.47. This could probably be since in-service
training can provide nurses with more knowledge, insight, and understanding of patient's pain,
which may enhance their pain management practices. In other words, it serves to update the nurses'
pain management knowledge and practical skills and improve the best practices for fulfilling their
responsibilities in regular assessment and management of pain for patients. It also plays an
essential role in improving the standard of inpatient pain management practices (63, 64). This
finding was supported by the study conducted at Jimma University, Federal Hospitals of Addis
Ababa, and the two public hospitals in the Oromia region (28, 30, 39).

In this study, patients with painful procedures become a significant predictor of nurses' pain
management practices. Nurses who care for patients with painful procedures had a 5.65-times
higher odds of falling into a higher category of pain management practice than the opposite group.

26
This could probably be because painful procedures increase the likelihood of high-intensity of pain
that drives patients to report their pain to their care providers. Nurses who take part in caring for
patients with painful procedures might be able to reduce the suffering of patients with procedural
pain which put them in the higher category of pain management practices (65).

The other patient-related significant variable was pain intensity. Nurses who care for patients with
severe pain had, on average, nearly 2.6 times higher odds of practicing higher levels of pain
management than nurses who care for patients with mild pain. The possible reason could probably
be because patients with severe pain are more likely to report their pain status and get more
attention from their health care providers. According to findings studies of Gondar and Central
Africa, patients with severe pain are managed more frequently, relatively early, and regularly than
those with mild and moderate ones which put nurses who follow patients with severe pain in the
higher category of pain management practices (33, 66).

From institutional factors, a pain-free initiative implementation focal person was found to have a
statistically significant relationship with the nurses' pain management practices. The odds of being
in a higher category of pain management practice was nearly 6.34 times higher on average for
those nurses working in the institutions having a pain-free hospital initiative implementation focal
person as compared to the contrary group. The possible reason behind this could probably be
because nurses may improve their pain management activities if they are guided by trained
professionals who feel responsible for the proposed area of practice. Additionally, the pain-free
hospital initiative would be implemented when there is a responsible individual who can advocate
a regular patient assessment and management of patients with any pain level. Those who are
assigned as focal persons have vital importance in the improvement and continual provision of
pain management for hospitalized patients. This could be achieved by preparing a work plan,
evaluating pain management activities, and coordinating patient education programs (57, 64).

27
 7. LIMITATIONS OF THE STUDY
The study used only patients’ charts to evaluate nurses’ pain management practices for their
corresponding patients as it was difficult to observe and follow all of the nurses within the specified
period. Social desirability bias during data collection was another drawback of this study. The
other limitation was that it didn’t include the pain management practices for patients who were
with critical illness and impaired level of consciousness since the pain assessment tool (NRS) was
not suitable for them.

28
 8. CONCLUSION
This study aimed to determine nurses' pain management practices and associated factors for
admitted patients. So, the study's overall results showed that the majority of nurses had poor pain
management practices for admitted patients. Among numerous factors that affect the practices of
nurses; the educational level of nurses and having in-service training were significantly associated
among the nurses' perspectives. Patients with painful procedures and pain intensity remained
significant factors from the patients’ side. From several institutional factors, the assigned pain-free
hospital initiatives implementation focal person was another factor that remained significant to the
pain management practices of nurses.

29
 9. RECOMMENDATION
Health care providers (Nurses)
Health care providers need to give special attention and provide continuous care for patients with
pain regardless of their pain level. It would be better if they follow the pain management protocols
to obtain a good patient outcome and a pain-free hospital environment.

Hospitals administrators
It would be better if hospitals’ administrations provide due attention to the pain management of
hospitalized patients by providing an in-service continuous training to improve the capacity of the
health care providers. It would also be better if there is a focal person for a pain-free hospital
initiative implementation who can advocate a regular pain assessment and management for each
admitted patient regardless of their pain severity.

Researchers
It will provide better findings if future researchers do an observational follow-up study to
determine the pain management practices of nurses.

30
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 11.ANNEX
Interviewer: Name_________ Father’s name: _____________Respondent‘s code: _______
11.1. Annex I: Information sheet (English version)
My name is ______. I am here representing Legese Fekede, Adult Health Nursing Student at Bahir Dar
University, College of Health Sciences, department of adult health nursing, Graduate Study Program, and
he is conducting a research on a topic entitled as pain Management Practice and Associated Factors of
nurses for admitted patients at Comprehensive Specialized Hospitals of Amhara Region.
I am inviting you to participate in this research. You may choose to take part or not and if you choose to,
you are free to withdraw from the study at any time during the study. If you do not want to take part, your
service in the hospital will not be affected by your decision. The necessary information regarding the study
is mentioned below.
Purpose of the study: the purpose of this study is to assess pain management practices and associated
factors of nurses for admitted patients at the Comprehensive Specialized Hospitals of Amhara Region.
Benefits and risks of the study:
Benefits: For your participation in the study no payment will be granted. Your responses to the following
questions are beneficial to you, other patients, as well as to a good nursing outcome.
Risks: Your participation will not cause any harm to you. The study will be conducted by a self-
administered questionnaire and it may take 15 – 25 minutes to complete the forms.
Confidentiality: to establish the confidentiality of research data, the principal investigator (PI) will use
codes during the data collection period instead of using names to keep confidentiality.
Right of the participant: Participating and not participating in the study is the full right and participants
can stop from participating in the study at any time. This would not affect at all your health and nobody
will enforce you to explain the reason for withdrawal.
Person to contact: This research work is approved by the institutional review board of the college of
medicine, and health sciences of Bahir Dar University. If you have any questions you can contact any of
the following individuals.
1. Legese Fekede: BDU, CMHS, School of Health Science, Department of Adult Health Nursing:
principal investigator: Cell phone: +251-924850479, E-mail: Beet964@gmail.com
2. Dr. Worku Animaw (Ph.D.): BDU, CMHS, School of Health Science, Department of Adult Health
Nursing: Advisor
Cell phone: +251-9 12272634, E-mail: workimaw@gmail.com
3. Mr. Haileyesus Gedamu (MSc.): BDU, CMHS, School of Health Science, Department of Adult Health
Nursing: Advisor----Cell phone: + 251 -9-18 715182, E-mail- Haileyesusg5@gmail.com
Interview: _____ date________ month_______ year.

36
 11.2. Annex II: Informed Consent form (English version)
I am ------------------- MSc student in Bahir Dar University College of medicine and health science
department of Adult Health Nursing. I administer this questionnaire to assess pain Management
Practice and Associated Factors of nurses for admitted patients at Amhara Region Comprehensive
Specialized Hospitals. The study will be helpful to provide important information so as improve
pain management practice which subsequently reduces the burden of pain among hospitalized
patients. Therefore I kindly request your cooperation to participate in this study. If you are
volunteering to participate I would like to assure you that your name not be mentioned or
anonymity will be kept and the information you will give us will be kept confidential and used
only for the research propose. You have full right to refuse, to take part or interrupt at any time.
The document will take 10-15 minutes to complete and it needs your patience and collaboration.

Are you volunteering to participate in the study?

If yes, thank you for your willingness to participate in my research and fill out the questionnaire.

DATE ----------------- Time started----------------------------------- END

37
 11.3. ANNEX-III: ENGLISH VERSION QUESTIONNAIRE
Self-administered questionnaire to assess nurses’ pain management practice and related factors of
nurses for admitted patients
Part-1: Socio-demographic factors of nurses to nurses’ pain management practices
S.NO Questions Response
101 Age Age in year------------
102 Gender Male Female
103 Educational status Diploma Bachelor’s degree
Masters and above
104 How many years of experience do you have? Number of years-----------
105 Where is your working unit currently? Medical Surgical Orthopedics
Oncology Maternity
Part-2: Institution-related factors to pain management practice
Please read the following questions and give appropriate answer
S.NO Questions Responses Skip
201 Have you taken any training regarding pain Yes If your response is
assessment within the last two years? No  no go-to Qno 203
202 If your answer to QNo201 is yes, when did you In the last 6 months
take the training? Within one year 
Before one year
203 Have you taken training regarding pain Yes If your response is
management? No no go-to next part
204 If your answer to QNo203 is yes, when did In the last 6 months
you take the training? Within one year 
Before one year
Part-3: Knowledge of nurses toward pain management practice for admitted patients
The following are questions designed to assess the knowledge of nurses on pain management. Please answer
each question by saying Yes-for the question you consider correct and No- for the incorrect. Put this
symbol “” for the answer you would like to choose.
S.NO Questions Responses
Yes No
301 The most accurate judge of the intensity of the patient’s pain is the patient
302 Currently, pain is regarded as one of the vital signs of the patient
303 Pain should be assessed before and after administering anti-pain drugs
304 It may often be useful to give a placebo to a patient in pain to assess if he is
genuinely in pain.

38
 305 The patient should be advised to use non-drug techniques along with pain
medication.
306 Distraction, for example, by the use of music or relaxation, can decrease the
perception of pain
307 Side effects of opioids should be observed at least (20-30) minutes after
administration.
308 Combining analgesics that work by different mechanisms may result in better pain
control with fewer side effects than using a single analgesic agent
309 During caring for a patient, providing comfort and positioning may help to
reduce muscle tension which in turn, can reduce pain
310 Appropriate assessment of pain is the priority for effective pain management
311 Acetaminophen and non-steroidal anti-inflammatory agents are effective
analgesics for severe pain
312 After the initial recommended dose of opioid analgesics, subsequent doses should
be adjusted according to the individual patient’s response
A checklist to assess patient-related factors to nurses’ pain management practices
Part-4: Patients’ socio-demographic factors to nurses pain management practices
S.NO Questions Responses Skip
401 Age of the patient Age in year-------------
402 Sex Male Female
403 Marital status Married Single
DivorcedWidowed
404 Educational status Cannot read and write Primary education 
Secondary education  Diploma and above
405 Religion Orthodox Muslim Protestant
406 Occupation Governmental employee Private employee
Housewife Farmer Daily laborerMerchant
Part-5: patients’ clinical factors to nurses pain management practices
501 Ward (disease category) Medical Surgical
OrthopedicOncologyMaternity
502 Has the patient undergone any painful Yes If no, go-to
procedure to treat his illness? No  QNo 505
503 Is there any record of latest pain score Yes No
504 If yes for Q503, the latest pain score ---------
of the patient
505 What type of anti-pain had he/she Specify----------
received?
Pain assessment (directly from a patient using a numerical pain scale)

39
 506 Think of your current pain status and ----------------
rate it with the number from 0 to 10 by
considering 0-as no pain and 10-as the
worst possible pain
Part-6: An observational checklist to determine pain management practices of nurses from chart
S. No Questions Responses
Yes No

601 Is the pain score sheet attached and incorporated with the patient’s chart?
602 Was the pain assessed and recorded using the standard pain assessment tools at
least once over the past 4 hours for this patient?
603 Was the pain assessment carried out regularly for this patient?
604 Was the patient with pain managed with anti-pain medications?
605 Was the pain managed based on WHO pain management standards?
606 Was the patient with pain managed with non-pharmacological methods?
607 Was the patient’s pain managed before and after every procedure?
608 Were the side effects of pain medications monitored as per protocol?
Part-7: A checklist to assess institution-related factors to nurses’ pain management practices
S.NO Questions Responses
701 Currently, what is the nurse-to-patient ratio of this unit? 1 to 6 1 to 8
Other-------------
702 Working shifts in the inpatient departments of the institution? 2 shifts 3 shifts
703 Availability of a written policy on “pain is 5th vital sign and must be Yes No 
assessed and managed”
704 Are there pain assessment tools in this ward? Yes
No 
705 Is there pain management guideline in the ward? Yes
No 
706 Have assigned Pain-Free Hospital Implementation Focal person or Yes
team No 

40
 11.4. ANNEX-IV: ለተጠያቂዎች የሚሰጥ መረጃ
ጤና ይስጥልኝ!! ስሜ __________________እባላለሁኝ፡፡ እዚህ የተገኘሁት በባህር ዳር ዩኒቨርሲቲ ጤና ሳይንስ ኮሌጅ

የድህረ ምረቃ መርሃ ግብር ተማሪ የሆኑት ለገሰ ፈቀደን ወክዬ ነው፡፡ እሳቸውም በአማራ ክልል ስፔላይዝድ

ሆስፒታሎች ውስጥ ያሉ ነርሶች ተኝተው ለሚታከሙ ታካሚዎች የሚያደርጉት ህመምን የማከም ተግባርና ተያያዥ

ጉዳዮች በተመለከተ ጥናት እያካሄደ ነው፡፡ በዚህ ጥናት እንዲሳተፉ እጋብዛችኋለሁኝ፡፡ ተሳታፊ ለመሆንም ላለመሆንም

መምረጥ ይችላሉ፡፡ ከፈለጉ በጥናቱ ወቅት በማንኛውም ጊዜ ጥናቱን ማቋረጥ ይችላሉ፡፡ እርስዎ የጥናቱ አካል ለመሆን

ካልፈለጉ, በውሳኔዎ ምክንያት ምንም የሚደርስቦት ተጽዕኖ አይኖርም፡፡ ስለ ጥናቱ አስፈላጊ የሆኑ መረጃዎች ከዚህ

በታች ተዘርዝረዋል፡፡

የጥናቱ ዓላማ፡- የዚህ ጥናት ዓላማ በአማራ ክልል ስፔላይዝድ ሆስፒታሎች ውስጥ ያሉ ነርሶች ተኝተው ለሚታከሙ

ታካሚዎች የሚያደርጉት ህመምን የማከም ተግባርና ተያያዥ ጉዳዮች በተመለከተ መገምገም ነው፡፡

ጥቅሞች፡- በጥናቱ ሲሳተፉ ክፍያ አይሰጥዎትም ፡፡ ይሁን እንጂ መልስዎ ለታካሚዎች እና በሆስፒታል ውስጥ

ለሚሰሩ ነርሶች ዘንድ ጥሩ የስራ ውጤት ለማምጣት ያግዛል፡፡

ጉዳቶች፡- ተሳትፎዎ ምንም ጉዳት አያስከትልም፡፡ ጥናቱ የሚካሄደው በራስ በሚሞላ ቅጽ ሲሆን ጥያቄዎቹ ቀላል እና

ለማጠናቀቅ ከ15-25ደቂቃዎችን ይወስዳል፡፡

የጥናቱ ሚስጥራዊነት፡- የተሳታፊውን ማንነት እና የሚሰጠው መረጃ በሚስጥር ይያዛል፡፡ ስለሆነም ከተሳታፊ ስም

ይልቅ የሚስጥር ኮድ መረጃ በሚሰበሰብበት ጊዜ እንጠቀማለን፡፡

የተሳታፊው መብቶች
 ተሳታፊው በዚህ ጥናት ላይ የመሳተፍ ወይም ያለመሳተፈፍ መብቱ የተጠበቀ ነው፡፡

 በመሳተፍ ላይ እያሉ በማንኛውም ሰዓት ማቋረጥ ወይም ለመመለስ የማይፈልጉትን ጥያቄ አለመመለስ

ይቻላል፡፡

 በቃለ መጠይቁ ወቅት ግልፅ ያልሆነ ነገር መጠየቅ ይቻላል፡፡

ስለ ጥናቱ ማንኛውም ጥያቄ ካለዎት የሚከተሉትን ግለሰቦች ማነጋገር ይችላሉ እና በፈለጉት ጊዜ መጠየቅ ይችላሉ ፡

1. ለገሰ ፈቀደ (BSc. nurse)

ሞባይል: + 251-9 26 85 04 70, ኢ-ሜል: beet964@gmail.com

2. ዶ/ር ወርቁ አንማው (Ph.D.)

ሞባይል: +251-9 12272634, ኢ-ሜል: workimaw@gmail.com

3. መ/ር ኃይለኢየሱስ ገዳሙ (MSc.)

ሞባይል +251 -9-18 715182, ኢ-ሜል:- Haileyesusg5@gmail.com

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 11.5. ANNEX-V: ተሳታፊ የፈቃደኝነት ቅፅ
ይህንን ቅፅ በመፈረም ጥናቱ ላይ ለመሳተፍ ፈቃዴን እሰጣለሁ ፡፡ የዚህ ጥናት ዓላማ በአማራ ክልል ስፔላይዝድ

ሆስፒታሎች ውስጥ ያሉ ነርሶች ተኝተው ለሚታከሙ ታካሚዎች የሚያደርጉት ህመምን የማከም ተግባርና ተያያዥ

ጉዳዮች መገምገም ነው፡፡ በዚህ ጥናት መሳተፌ ሙሉ በሙሉ በፈቃዴ ውስጥ የተካተተ እንደሆነና የእኔን ማንነት

ለሶስተኛ ወገን እንደማይሰጥ ተረድቻለሁ፡፡ በተጨማሪም የእኔ መሳተፍ ወይም ለመሳተፍ ፈቃደኛ አለመሆኔ ምንም

አይነት ተጽዕኖ እንደማይኖረው ተነግሮኛል ፡፡በዚህ ጥናት ውስጥ መሳተፍ ለእኔ ላይ ምንም አደጋ እንደማያስከትል

ተረድቻለሁ ፡፡ ስለ ጥናቱ ወይም እንደ ጥናት ተሳታፊ ስለ መብቶቼ አስልመክቶ ጥያቄዎች ካሉኝ ለገሰ ፈቀደን እና

የጥናቱን አማካሪዎች መጠየቅ እንደምችል ተረድቻለሁ ፡፡ በዚህም መሰረት በፈቃደኝነት በጥናቱ ለመሳተፍ ፈቃዴን

እስማማለሁ ፡፡

የተሳታፊው ፊርማ ________________ መጠይቁ የተደረገበት ቀን _____________

የጠያቂው ስም ________________ ፊርማ__________ ቀን _______________

42
 11.6. Annex-VI: Amharic version Questionnaire
ነርሶች በሆስፒታል ውስጥ ተኝተው ለሚታከሙ ታካሚዎቻቸው የሚያደርጉት ህመም የማስታገስ እና ተዛማጅ ሁኔታዎችን የያዘ
በራስ የሚመለስ መጠይቅ

ክፍል-1፡ የነርሶች የሥነ-ሕዝብ ባህሪያት

እባኮትን ከዚህ በታች ያለትን ጥያቄዎች አንብበው ተገቢውን መልስ ይስጡ፡፡

ተ.ቁ ጥያቄዎች ምላሽ
101 ዕድሜ --------አመት
102 ጾታ ወንድ ሴት
103 የትምህርት ደረጃ ዲፕሎማ የመጀመሪያ ዲግሪ ማስተርስ እና ከዚያ በላይ
104 የስራ ልምድ --------------አመት/ወር
105 የሚሰሩበት ክፍል የውስጥ ደዌ ክፍል የቀዶ ህክምና ክፍል የአጥንት ህክምና ክፍል የካንሰር ህክምና ክፍል
የወሊድ ህክምና ክፍል
ክፍል-2፡ በነርሶች የህመም የመመርመርና የማከም ሂደት ከተቋማት ጋር የተዛመዱ ምክንያቶች፡፡
እበባክዎን የሚከተሉትን ጥያቄዎች ያንብቡና ትክክለኛውን ምላሽ ይስጡ
ተ.ቁ ጥያቄዎች ምላሾች ዝለል
201 ባለፉት ሁለት ዓመታት ውስጥ የህመም ምርመራን አዎ አልወሰድኩም መልስዎ አልወሰድኩም ከሆነ

በተመለከተ ስልጠና ወስደዋል? ወደ ተ.ቁ 203 ይለፉ

202 ለተ.ቁ 201 የሰጡት መልስ አዎ ከሆነ፣ ስልጠናውን መቼ ባለፉት 6 ወራት ውስጥ

ነው የወሰዱት? በ1 አመት ውስጥ

ከአንድ አመት በፊት

203 ባለፉት ሁለት ዓመታት ህመምን ስለመቆጣጠር አዎ መልስዎ አልወሰድኩም ከሆነ

(ስለማከም) በተመለከተ ስልጠና ወስደዋል? አልወሰድኩም ተ.ቁ 204ን ይዝለሉ

204 ለተ.ቁ 203 የሰጡት መልስ አዎ ከሆነ፣ ስልጠናውን መቼ ባለፉት 6 ወራት ውስጥ

ነው የወሰዱት? ከ 1 አመት በፊት

ከአንድ አመት በፊት

ክፍል-3 ፡ ህመም ስለመመርመርና ስለማከም የነርሶች እውቀት ለመለካት የተዘጋጀ መጠይቅ

የሚከተሉት ጥያቄዎች በህመም አያያዝ ላይ የነርሶችን እውቀት ለመገምገም የተነደፉ ናቸው፡፡እባኮትን እያንዳንዱን ጥያቄ ትክክል ነው ለሚሉት
ጥያቄ- አዎ - እና ለስህተት ለሚሉት- አይደለም በሚለው ላይ የ “” ምልክት በማድረግ መልስዎን ይስጡ፡፡
ተ.ቁ ጥያቄዎች ምላሾች
አዎ አይደለም
301 የታካሚውን ህመም መጠን በትክክል አውቆ ሊነግረን የሚችለው ራሱ ታካሚው ነው፡፡
302 በአሁን ወቅት ህመም ከታካሚው ወሳኝ ምልክቶች አንዱ እንደሆነ ይቆጠራል፡፡
303 የህመም ማስታገሻ መድሃኒቶችን ከመሰጠታቸው በፊት እና በኋላ የታካሚው የህመም መጠን መገምገም
(መለካት) አስፈላጊ ነው፡፡
304 በህመም ላይ ያለ ታካሚ በእውነት ህመም እንዳለበት ለማወቅ ብዙውን ጊዜ ፕላሴቦ (placebo) መስጠት
ጠቃሚ ሊሆን ይችላል፡፡
305 ታካሚው ከህመም ማስታገሻ መድሃኒቶች ጋር ከመድሃኒት ውጪ ሌሎች ዘዴዎችን እንዲጠቀም ምክር ሊሰጠው
ይገባል፡፡
306 ማዘናጋት፣ ለምሳሌ ሙዚቃን ወይም ማዝናናትን በመጠቀም የህመም ስሜትን መቀነስ ይቻላል።
307 ኦፒዮይድ (opioids) የህመም ማስታገሻ ለታካሚዎች ከተሰጠ በኃላ የጎንዮሽ ጉዳቶች ቢያንስ (ከ20-30)
ደቂቃዎች መታየት አለባቸው.

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308 በተለያዩ ዘዴዎች የሚሰሩ የህመም ማስታገሻ መድሃኒቶችን በማጣመር መጠቀም አንዱን ከመጠቀም
በበለጠ ህመም ለማስታገስ ይረዳል፤ የጎንዮሽ ጉዳቶችንም የመቀነስ ጥቅም አለው፤፤
309 ለታካሚ እንክብካቤ በሚደረግበት ጊዜ ምቾትንና አቀማመጥን ማስተካከል የጡንቻን ውጥረት ለመቀነስ
ይረዳል ይህም፤ህመምን ይቀንሳል፡፡
310 የታካሚን ህመም በውጤታማነት ለማስታገስ የታካሚን ህመም በትክክል መለካት ቅድሚያ የሚሰጠው
ጉዳይ ነው
311 Acetaminophen (ፓራሴታሞል) እና non-steroidal anti-inflammatory የተባሉ መድኃኒቶች ለከባድ ሕመም
ውጤታማ የሕመም ማስታገሻዎች ናቸው
312 ከመጀመሪያው የሚመከረው የኦፒዮይድ የሕመም ማስታገሻ መድሃኒት መጠን በኋላ፣ የሚቀጥሉት መጠኖች
በታካሚው ግለሰብ ምላሽ መሠረት መስተካከል አለባቸው።

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 DECLARATION SHEET
I declared and affirmed that this thesis is my work through my signature below. I have followed
all ethical principles of scholarship in the preparation, data collection, data analysis, and
completion of this thesis work. All scholarly matter included in the thesis has been recognized
through citation. I affirm that I have cited and referenced all sources used in this document. Every
effort has been made to avoid plagiarism in the preparation of this thesis work. This thesis is
submitted for partial fulfillment of a Master of Science in Adult Health Nursing College of
Medicine and Health Sciences, Bahir Dar University. The thesis would be deposited in the library
of Bahir Dar University and will be made accessible for readers under the library's rules that this
thesis has not been submitted to any other institution anywhere for the award of any academic
degree, diploma or certificate.

Student Name: Legese Fekede (BSc)

Signature: ___________________

Place of submission: Department of Adult Health Nursing, School of Nursing, College of

Medicine and Health Sciences, Bahir Dar University.

Date: ----/----/---------

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