ALTERNATIVE PAIN RELIEF MEASURES USED BY NURSES IN THE MANAGEMENT OF ORTHOPAEDIC PATIENTS IN FEDERAL MEDICAL CENTRE, EBUTE-METTA, LAGOS STATE.

ABSTRACT

Pain is one of the most frequently encountered symptoms in the hospital environment making it the 5^th vital sign yet pain is often untreated and patients continue to suffer the ill effect of pain. The nature of pain being complex, medications alone may not be sufficient to pain relief and therefore multiple strategies must be used of which alternative pain relief strategy is one. There is need therefore to investigate the knowledge and effective use of these strategies. The purpose of this study was to determine the alternative pain relief measures used by nurses in the management of orthopaedic patients’ pain in federal medical centre, Ebute-Metta. The research design was a descriptive survey method. The subjects of study were all the target population comprising of 72 nurses working in orthopaedic in FMC. Data were collected using researchers constructed and validated questionnaire. Descriptive statistical method of analysis was used in the analysis and chi –square cross tabulation used to test for hypothesis of data obtained. The major endings of the study showed that nurses have good knowledge of some of the physical, psychological and cognitive behavioural methods of alternative pain relief and their benefits. However the nurses’ reasons for not using these Alternative Pain Relief methods were: lack of time, excessive workload for the nurses, lack of equipments, lack of knowledge of some of the various alternative measures. A fair implementation of these measures was found among nurses in this tertiary institution. However, there was a statistically significant difference among nurse educational level and their use of these alternative pain relief measures. There was also statistically significant difference found between nurses’ years of experience and their uses of these alternative pain relief measures. It is recommended that nurses need training and education on the implementation of non-pharmacological pain relief methods, particularly on methods that have been shown to be effective which is less often used by nurses in the management of orthopaedic patients’ pain.

TABLE OF CONTENT

Title page           -           -           -           -           -           -           -           i    

Certification page    -           -           -           -           -           -           ii

Dedication      -        -           -           -           -           -           -           iii

Acknowledgement      -           -           -           -           -           -           iv

Table of content     -           -           -           -           -           -           v

List of tables            -           -           -           -           -           -           vi

Abstract               -           -           -           -           -           -           vii

CHAPTER ONE: INTRODUCTION

Background of the study           -           -           -           -           -           1

Statement of the problem       -           -           -           -           -           5

Purpose of the study             -           -           -           -           -           7

Objectives of the study         -           -           -           -           -           7

Research questions    -           -           -           -           -           -           7

Hypotheses          -           -           -           -           -           -           8

Significance of the study         -           -           -           -           -           8

Scope of the study         -           -           -           -           -           9

Operational Definition of Terms        -           -           -           -           10

CHAPTER TWO: LITERATURE

Concept of pain              -           -           -           -           -           13

Types of pain         -           -           -           -           -           -           15

Pathophysiology of pain   -           -           -           -           -           17

Factors influencing pain response    -           -           -           -           20

Pain assessment          -           -           -           -           -           22

Pharmacological approaches to pain management   -           23

Concept of non-pharmacological (alternative) pain management -    24

Theoretical review   -           -           -           -           -           40

Empirical review     -           -           -           -           -           -           41

Summary of literature review      -           -           -           -           50

CHAPTER THREE: RESEARCH METHODOLOGY

Research Design               -           -           -           -           -           51

Research method              -           -           -           -           -           51

Area of study         -           -           -           -           -           -           52

Population              -           -           -           -           -           -           52

Sample and sampling technique  -           -           -           -           52

Research Instrument     -           -           -           -           -           52

Validity of Research Instrument    -           -           -           -           53

Reliability of Research Instrument              -           -           -           53

Procedure for Data Collection   -           -           -           -           54

Procedure for Data Analysis          -           -           -           -           54

CHAPTER FOUR: PRESENTATION AND ANALYSIS OF DATA

Summary of major findings          -           -           -           -           55-71

CHAPTER FIVE: DISCUSSION OF RESEARCH FINDINGS

Implication for nursing         -           -           -           -           72

Limitation of study     -           -           -           -           -           79

Suggestion for further study          -           -           -           -           79

Summary               -           -           -           -           -           -           80

Conclusion           -           -           -           -           -           -           81

Recommendation               -           -           -           -           -           81

References      -        -           -           -           -           -           -           83

Appendices     -        -           -           -           -           -           -           86

CHAPTER ONE

INTRODUCTION

Background to the study

Pain is a distressing feeling often caused by intense or damaging stimuli, such as stubbing a toe, burning a finger, putting alcohol on a cut, or bumping the "funny bone. Because it is a complex, subjective phenomenon, defining pain has been a challenge. The International Association for the Study of Pain (2015), widely used definition states that pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. In medical diagnosis, pain is regarded as a symptom of an underlying condition.

Pain is an unpleasant sensation ranging from mild discomfort to agonized distress associated with real or potential tissue damage (Oxford Medical Dictionary, 2003). It could also be defined as an unpleasant sensory and emotional experience associated actual or potential tissue damage or described in terms of such damage (American pain society (APS), 2003; Gordon, 2002).

Pain is a universal human experience which is as old as the universe itself and most common reason people seek medical care. The presence of pain is an indicator that something is wrong in the structure and function of the body related to injury or damage to the structure and function of the body. Thus the need to carry out the intervention to alleviate suffering and improve comfort especially in orthopaedic patients’ who experience pain resulting from several degrees of fractures, trauma, accidents and burns, medical and surgical procedures becomes important (Innis, Bikaunicks, Retryshen, Zellermeyer & Ciccarelli, 2004).

The need to alleviate pain stems from the fact that pain alters the quality of life more than any other health related problem. It interferes with sleep, mobility, nutrition, thought, sexual activity, emotional well-being, creativity and self actualization, increases the heart rate and blood pressure. It may also result in patiens’ not reporting pain accurately because of its interference with the quality of life (peter and watt Watson, 2002). Pain may get worse or intense when patients’ is in anxiety, stress or sad.

Pain cannot be objectively measured in the same way as blood pressure, pulse rate and temperature, thereby making pain a subjective individual phenomenon which only the person (patient) experiencing it could say whenever it is existing (Mc Caffery & Pasero, 2002). Thus patients self reporting (expression) of their pain is regarded as the gold standard of pain assessment measurement as it provides the most valid measurement of pain (Arnstein, 2002). The American pain society (2005), therefore stated that it is the responsibility of the clients to inform the nurses about their pain and also the nurses responsibility to accept the clients report of pain during pain assessment. This pain if not well reported by the patients’ to the nurses could affect its thorough management and control, thus increasing the intensity of pain.

As pain is one of the most frequently encountered symptoms in hospital environment making it the 5^th (fifth) vital signs, every nurse must develop the skill to assess and manage patients’ pain properly. Most of the time, drugs are prescribed to relieve the pain including narcotics’ and non-steroidal anti-inflammatories. However, pain is often under-treated and patients continue to suffer from the ill effects of pain and lack of management (Yales et al. 2001). The medications also have their adverse effects which often result from the long use of these pain killers caused by prolonged nature of the health problems of these patients. Such side effects like stomach irritation, gastrointestinal bleeding, respiratory depression, nausea, pruritis, vomiting, urinary retention e.t.c, have been reported (Helmrich et al 2001).

Nature of pain being complex, therefore, medications alone may be insufficient for relief and multiple strategies must be utilized (Nadler, 2004) of which alternative (non-pharmacologic) pain management strategies are used. Thus both pharmacological and alternative (non-pharmacologic) methods of pain relief have been used by health professionals to alternative the various categories of pain experienced by patients.

Alternative pain relief measures have been advocated for by many healths professional to augment the effects of drugs and to reduce the various degrees of side effects caused by the use of medications in pain management in orthopaedic patients (Helmrich, Yales, Nash, Hobman, Pouton & Berggren 2001). Alternative or non-pharmacological pain reliefs are therefore orthodox medicine to alleviate pain, such measures could be physical, psychological, or cognitive behavioural interventions.

Physical interventions or methods are concerned with the use of massage, heat and cold application, position change, transcutaneous electrical nerve stimulation (TENS) to reduce pain. Psychological method includes relaxation or rest and music, while cognitive behavioural method include distraction techniques by the use of music, playing cards, games or watching television to divert patients mind from the pain he is feeling at that moment thus focusing his mind on something else different from the pain. Many of these alternative approaches are non-invasive, low risk, inexpensive, easily performed at the clinical settings. They achieve their effects in numerous ways, not only in reducing the pain but also by reducing the emotional components, thus reducing anxiety, facilitating coping skills, providing a sense of control, enhancing comfort, promoting sleep, reducing fatigue and improving quality of life (Mc Caffery & Pasero, 2002). Considering these advantages, there is no need not only to educate the patients about the various non-pharmacological interventions and how to implement these interventions, but the health professionals themselves need to embark on its use.

In spite of the popularity of these alternative pain relief therapies, nurses are reported to have poor knowledge in the application of these alternative pain relief measures (Brolinson, Prince, Ditmyer & Reis 2001). Health professionals especially nurses’ level of knowledge and attitude about these non-pharmacologic pain relief management greatly affect whether a patient s given these options. Researchers (Polkki, Laukkala, Vehilainen, Julkunen & Pietila, 2003) found that the factors that promoted the use of non-pharmacologic interventions included the nurses’ knowledge of the techniques, the nurse’s desire to promote non-pharmacologic pain relief techniques and the nurse having a small enough workload and enough time to devote to implementing the techniques. According to King, Pettigrew and Reed (2000), nurses’ need to be able to assess patient’s use of these alternative and complementary therapies. But before suggesting or instructing patients in the use of non-drug techniques, nurses need to be aware of the methods used effectively and preferred by the patient and be able to implement it themselves (nurses).

Since observation and research (Brolinson, Price, Ditmyer & Reis 2001) show that there is poor knowledge in the applications of these alternative pain reliefs and since it still remains an important aspect of pain relief management in orthopaedic patients, it becomes necessary to investigate the extent to which nurses implement these measures. This is aimed at providing information for possible solutions. Thus the study on alternative pain relief measures uses by nurses in the management of orthopaedic patients’ pain.

Statement of the problem

Patients in orthopaedic hospitals usually present with symptoms of shoulder, knee, hip, joint, rib, neck, low back pain and headache for over a period of days, months or years. This pain arises from fractures, inflammatory reactions trauma, accident, diseases of the bones and nerve compression. The pain ranges from mild, moderate to severe. The pain as the researcher observed leads to discomfort, disturbed sleep pattern, altering the quality of life of patients and patients normal daily activities, anxiety, depression loss of interest and immobility.

This excruciating pain encountered by these patients and its consequencies were also noticed by the researcher to be worsened by the numerous side effects of the medications patients were placed on. These side effects include bleeding, stomach irritation, chest pain, nausea and vomiting. These medications also offered temporary pain relief thus making the patients dependent on them, which could lead to drug lasting dependency thus there is need for the combination of the non-pharmacologic and pharmacologic methods to give a lasting pain relief.

However, alternative or non-pharmacologic pain relief measures which have been found to be effective and with less side effects were mostly done by the physiotherapist periodically. There does not seem to be much being done by nurses who are in continous daily contact with these patients and who could administer these alternative methods of pain relief alongside with other nursing intervention. To what extent do these nurses use them in relieving patient’s pain? It is assumed that a more frequent use of these non-pharmacological methods by nurses could augment the use of medications, thus reduce patients hospital stay, cost of health care services and medications, drug addiction and dependence and patience numerous complaints of the adverse effects caused by pain medications. The researcher thus aroused, decided to empirically ascertain the nurse’s knowledge and use of alternative pain relief measures in managing orthopaedic patients,.

Purpose of the study       

The purpose of the study is to determine the alternative pain relief measures used by nurses in the pain management of orthopaedic patients in Federal Medical Centre Ebute-Metta, Lagos State.

Objective of the study                            

The specific objectives of the study are to:

i.    Determine the nurses’ knowledge of non-pharmacological methods of pain relief measures in the pain management of orthopaedic patients.

ii.    Determine the nurses’ use of physical non-pharmacological methods of pain relief measures in the pain management of orthopaedic patients.

iii.   Assess the nurses’ use of psychological non-pharmacological methods of pain relief measures in the pain management of orthopaedic patients.

iv.   Assess the nurses’ use of cognitive behavioural non-pharmacological methods of pain relief measures in the pain management of orthopaedic patients.

v.     Assess if the alternative pain relief measures used by nurses are determined by their demographic characteristics.

Research Questions

i.            What do nurses’ know about the non-pharmacological methods of pain relief measures used in the pain management of orthopaedic patients?

ii.            What physical non-pharmacological methods of pain relief measures do nurses use in the pain management of orthopaedic patients?

iii.            What psychological non-pharmacological methods of pain relief measures do nurses use in the pain management of orthopaedic patients?

iv.            What cognitive behavioural non-pharmacological methods of pain relief measures do nurses use in the pain management of orthopaedic patients?

v.            How is the relationship between the nurse’s demographic characteristics and their use of alternative pain relief measures?

Hypotheses

i.     There is no significant relationship between educational level and the alternative pain relief measures used by nurses in pain management of orthopaedic patients.

ii.   There is no significant relationship between the number of years of practice and the alternative pain relief measures used by nurses in pain management of orthopaedic patients

Significance of the study

i.    The study will provide information on the non-pharmacological methods of relieving pain in the pain management of orthopaedic patients. This information will be significant because if the nurses use of alternative pain relief is found to be deficient, it will serve as a pointer to the need for nurse educators to include these important measures for alleviating pain in orthopaedic patients in the curriculum for training orthopaedic nurses or nursing education in general.

ii.   It could also be used by nurse administrators and clinicians to plan continuing education programmes in form of workshops, conferences, seminars e.t.c, for nurses so as to improve their knowledge and skills in the use of these methods. It is expected that when these measures are taken and the knowledge and skill are acquired or improved, nurses will engage more in the use of the methods, this is significant as it will help in reducing the excessive use of drugs and their consequent side effects ranging from gastrointestinal bleeding, respiratory depression, pruritis and urinary retention e.t.c, reduce the cost of medications and where medications are used will augment its effect. These on the long run will help in the effective management of pain in orthopaedic patients.

iii.    The findings may also provide useful information for other researchers who would wish to work in this field.

Scope of the study

The study is delimited to nurses working in orthopaedic units of Federal Medical Centre, Ebute-Metta irrespective of gender or professional cadre. It is also delimited to the use of alternative pain relief measures in the management of orthopaedic patients. Specifically, it is delimited to nurses knowledge of non-pharmacological methods of pain relief; physical, psychological and cognitive behavioural methods of non-pharmacological methods of pain relief.

Operational definition of terms

i.    Pain relief measures: In this study, is the management of pain measures used to reduce or control pain using such interventions like medications ( pharmacological: analgesics, non steroidal anti-inflammatory drugs (NSAID) and/or non-pharmacological or alternative measures to relief pain.

ii.    Knowledge of non-pharmacological methods of pain relief: In this study, it means what the nurses know about the types and the uses of these various non-pharmacological methods of pain relief and their benefits.

iii.    Alternative pain relief measures: In this study are those measures that are used in combination with conventional or orthodox medicines to alleviate pain. It could also be used interchangeably in this work as non-pharmacological methods of pain relief and they are physical methods, psychological methods and cognitive behavioural methods.

iv. Physical methods of non-pharmacological pain relief: In this study, it means manipulation or methods that help in controlling or in relieving pain, inflammation and stiffness. These measures include massage, heat and cold application, position change and Trans cutaneous electrical nerve stimulation (TENS).

v.  Psychological methods of non-pharmacological of pain relief: methods that reduce or control pain through manipulation of emotions aimed at diverting patient’s attention from the pain he is experiencing. Examples are: relaxation/rest, music e.t.c.

vi.   Cognitive behavioural methods of non-pharmacological pain relief: Methods that help to reduce or control pain by managing  patients thoughts and feelings and the body’s physical response to such feeling. Examples are distraction, guided imagery, breathing techniques, meditation and exercise e.t.c.

vii. Demographic characteristics: the demographic characteristics used in this study are educational level and years of professional experience.

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