NURSES’ KNOWLEDGE, ATTITUDE AND PRACTICE REGARDING POSTOPERATIVE PAIN MANAGEMENT AT SELECTED HOSPITALS, BHARATPUR, NEPAL

Methods: A descriptive cross-sectional study design was used to find out the nurses’ KAP regarding postoperative pain (POP) management. Total 74 nurses of postoperative wards were selected from four hospitals at Bharatpur with non-probability enumerative sampling technique. Data were collected with the structured self-administered questionnaire for knowledge, five-point Likert scale for attitude and observation checklist for practice. Data were analyzed by using descriptive statistics for levels of KAP; Chi-square for association between levels of KAP with selected variables and spearman rank correlation to determine relationship among KAP regarding POP management.


INTRODUCTION
Pain is regarded as a fifth vital sign which demands continuous assessment and management on time. It is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. 1 Pain management is an integral part of every healthcare professionals' practices in the hospitals. 2 Pain after surgery is so much distressing to patients and is a significant problem in postoperative ward. Ineffective pain management in the postoperative period can prolong the patient's length of stay in hospital which may lead to complications and increased cost of care. Hence, nurses, as important members of the health team, have unique opportunities to assess continuously and involve in pain management. 3,4 Thus for effective pain management, nurses must be well-educated and knowledgeable about pain and perform the activities properly. 5 Postoperative pain management refers to comprehensive actions in relieving pain after surgery by both pharmacological intervention that is with use of analgesics and non-pharmacological approaches which is without use of analgesics. 6 So, post-operative pain management strategies should focus on combining use of medicines and other comfort measures to ensure maximum pain relief for each patient. 7 The nurses' holistic approach with an adequate knowledge, positive attitude and competent practice on postoperative pain management can minimize the patients' discomfort caused by pain in the postoperative period and have a satisfactory recovery without complications and optimal patient outcomes. 8,9 So the study was conducted to assess the nurses' knowledge, attitude and practice regarding postoperative pain management at selected hospitals, Bharatpur.

METHODS
A descriptive, cross-sectional research design was used in the study to find out the nurses' knowledge, attitude and practice regarding postoperative pain management. The study was carried out at four hospitals located at Bharatpur 10, Chitwan of Nepal. The hospitals were College of Medical Sciences Teaching Hospital (CMSTH), Chitwan Medical College Teaching Hospital (CMCTH), Bharatpur Government Hospital and Narayani Samudayik Hospital. The study population were all the nurses who were working in postoperative wards in those four hospitals.
Non-probability, enumerative sampling technique was used in the study for data collection. The total respondents were 74 nurses. Ethical approval was taken from Chitwan Medical College (CMC) Institution Research Committee (CMC-IRC). The data were collected from 25 th June to 22 nd July, 2017.
Structured self-administered questionnaire was used to assess the knowledge and five-point Likert Scale to assess the attitude of nurses regarding post-operative pain management. The tools regarding knowledge and attitude were modified pattern of the standard tool 'Knowledge and Attitude Survey Regarding Pain' developed by Betty R. Ferrell and Margo McCaffery (2014) 10 after their ethical permission.
Structured observation checklist was used to assess practice which was developed on the basis of in-depth literature reviews. For the reliability of knowledge related instrument, item analysis of the questionnaire was done. The internal consistency of the attitude scale was tested by calculating Cronbach's alpha. The obtained value was within acceptable range (0.75). Likewise, the internal consistency of practice related observation checklist was tested by using Kuder-Richardson 20 (KR 20) formula. The value was obtained within acceptable range (0.77).
The purpose of data collection was explained and written informed consent was obtained from each nurse. The practice of the nurses regarding postoperative pain management was observed for four to six hours after receiving patients from operation theatre. After observing practice, self-administered questionnaire related to knowledge and attitude were distributed to the nurses to fill up before leaving duty which required 25-30 minutes. The distributed forms were collected immediately after the completion of filling entirely.
The collected data were reviewed, checked for completeness and organized daily for their accuracy and consistency. Then the data were entered into Statistical Package for Social Science (SPSS) version 20 for analysis. Data were analyzed using descriptive statistics such as frequency, percentage, mean, median and standard deviation to identify the nurses' socio-demographic and professional related variables as well as the levels of knowledge, attitude and practice; Chi-square for association between level of knowledge, attitude and practice with selected variables and spearman rank correlation to determine relationship among knowledge, attitude and practice regarding postoperative pain management. Table 1 shows that out of 74 nurses, 51.4% nurses were 21 to 23 years of age, 67.5% were Brahmin/Chhetri whereas 85.1% were Hindus and 73.0% were unmarried. Regarding nurses' self-experience of operation, 14.9% had self-experience and 60.8% nurses' family members had experience of operations.  Nurses who had ≤2 years of experience in nursing profession were 67.6%. Regarding experience in postoperative ward, 78.4% nurses had ≤2 years of experience and only 13.5% nurses had received training or in-service education on pain management.  Table 3 represents that 85.1% nurses had low level of knowledge, 14.9% had moderate level of knowledge, none had high level of knowledge whereas 55.4% nurses had satisfactory level of attitude and 52.7% nurses had low level of practice. Significance level at 0.05 #Likelihood Ratio Table 4 reveals that there was statistically significant association between nurses' level of practice regarding postoperative pain management and age of the nurses (p-0.010). It shows that as the age is increased the level of practice is also increased. However, there was no significant association between nurses' level of practice regarding postoperative pain management and ethnic group, religion, marital status, self-experience of operation and family member's experience of operation.  Significance level at 0.05 #Likelihood Ratio Table 5 depicts that there was statistically significant association between nurses' level of practice and professional qualification (p-0.002). It represents that if the professional qualification is high, the level of practice regarding postoperative pain management is also high. However, there was no significant association between the nurses' level of practice and working hospital, professional designation, experience in nursing profession, experience in postoperative ward and training or inservice education on pain management. Significance level at 0.05 Table 6 represents that there was no relationships among knowledge and attitude score (r=0.141) including knowledge and practice score (r=0.047) and no correlation between practice and attitude score (r=-0.063). So it shows that there was no statistically significant relationships among knowledge, attitude and practice scores of the nurses regarding postoperative pain management. The study revealed no significant association between nurses' knowledge and attitude with socio-demographic characteristics which is similar to the study by Shakya and Shakya. 14 However there was statistically significant association be-tween nurses' practice level and age (p=0.010) and professional qualification (p=0.002) which is similar to Basak. 4 The study found positive but weak correlation between knowledge score of nurses and attitude score (r=0.141) as well as with practice score (r=047). It also found that there was negative correlation of practice score with attitude score (r=-0.063).

DISCUSSION
Overall, it revealed that there was no statistically significant relationship among knowledge, attitude and practice scores of the nurses regarding postoperative pain management. The finding is contrasted with the study by Darjee, Dungpaeng and Masingboon who had found that there was a positive correlation among nurses' knowledge (r=0.161), attitude (r=0.274) and self-efficacy (0.427) on postoperative pain management. 6

CONCLUSION
It was concluded that majority of the respondents had low level of knowledge and practice regarding postoperative pain management although more than half of the nurses had satisfactory level of attitude. The age and the professional qualifications of the nurses was found to be associated with the practice of postoperative pain management. Hence, it was recommended for the provision of nurses' professional development, training or in-service education and hospital protocol related to postoperative pain management to enhance the nurses' knowledge, attitude and practice on postoperative pain management.

ACKNOWLEDGEMENT
Authors would like to express sincere gratitude to Betty R. Ferrell and Margo McCaffery for providing permission to use their tool in modified form and also grateful to the hospital authorities of Chitwan Medical College, College of Medical Sciences Teaching Hospital, Bharatpur Government Hospital and Narayani Samudayik Hospital for providing permission to conduct the study in their hospitals and all the nurses of postoperative wards for their voluntary participation in the study.