that influence pain management
4.3.4.1 Negative Factors 4.3.4.2 Positive Factors 4.3.5 Pain assessment and
management practices
4.3.5.1 Pain assessment practices in verbal patients 4.3.5.2 Pain assessment practices in non-verbal patients 4.3.5.3 Measures that will improve pain assessment 4.3.5.4 Pharmacological interventions
4.3.5.5 Non-pharmacological interventions
4.3.5.6 Measures that will improve pain management 4.3.6 Patients education on pain 4.3.6.1 Pre-operative education on post-operative pain
4.3.6.2 Methods of improving patient’s education on pain
4.3.4 Medico-Socio-Cultural Factors That Influence Pain Management
These factors, which were identified by doctors, are related to patients, the doctors themselves, the system in the hospital where they work and cultural factors that influence their pain management. Sub-themes arising from this theme included positive and negative factors.
4.3.4.1Negative factors
These are factors, which were found to influence the management of pain negatively, according to the data obtained from the doctors. As with the data collected from the nurses, it was found that patient related, doctor related, nurse related, health system and cultural factors all negatively affect the management, with some procedures also contributing to pain.
• Patient related factors - Patients reluctant to report their pain were reported by doctors, as well as by nurses, in their focus group interview. As seen in the interview with the nurses, that patients are expected to have pain and patients may believe that
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pain is expected so they find it unnecessary to report the pain but rather endure it. Some doctors (D1, D8) shared similar sentiments.
“Patients are supposed to communicate and at times you don’t hear them say… some will just keep the pain, you know they are in pain…but they will not say anything (D1).
“Yes, pain is subjective…They are supposed to communicate and at times you don’t hear them say anything” … (D8).
• Doctor Related Factors - Doctors confirmed that the fear of overdose and sedation influences their management of patient’s pain. According to one doctor (D2), when a patient is overdosed or over-sedated they need more attention in terms of monitoring. Thus, patients are not given analgesia regularly due to fear of overdose and to keep them awake. He said:
“… if analgesia is given regularly at regular intervals, it will work better. The only problem is that over here, we are always worried about one overdose and then two, if you give a lot and the patients are sedated, then they need more attention in terms of monitoring, in terms of nursing care and all that so we want the patient to be a little bit more awake so we sort of prolong the intervals” (D2).
There is a misconception about children and sedated patients and that appears to be a factor influencing their management of patient’s pain. Misconceptions that children and the unconscious do not have pain are real and need to be addressed. A doctor said:
“There is a misconception that children and sedated patients don’t feel pain. It’s a wrong thing in our environment that children… don’t feel pain. They are not able to express it but they feel pain ... Children feel pain a lot. No, it’s not true that pain threshold of children is higher” (D3).
There is a lack of uniformity among the anaesthetists who run the ICU and no collaboration among doctors, because apparently, their “bosses” find nothing right in what the “juniors” say or do. One doctor said:
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“… we have different anaesthetists and the way they want things done and it’s not uniform…. so, once it’s not uniform, we have a problem…we still have people who are and still think differently once they are your bosses and where, once coming from a junior person, it doesn’t make it right. Whatever, comes from the senior most is what everybody expects to do…” (D5).
Subramanian et al (2011) found that limited autonomy was a challenge in the management of pain. Teamwork that creates a positive environment for every healthcare professional could lead to improved management of pain, which would lead to patient satisfaction (Meterko, Mohr &Young, 2004). Lack of collaboration, thus teamwork, between junior and senior doctors could have a great impact on patient care in the ICU as the junior doctors may feel unappreciated and intimidated by senior doctors and therefore lack motivation to give their best. Adequate pain management requires teamwork, thus the need for collaboration among the health team to promote the patient’s welfare. One doctor further explained the lack of collaboration with the statement that he feels “remote controlled”. He said:
“…we live like we are being remote controlled meanwhile, the level of care and the people around and you think this fellow is better at managing the pain but it should not be individualized, it should be something that is universal, something that is standard that anybody coming in will know where we can follow…” (D5).
“…We need the whole team of doctors and nurses to work together to achieve results. Teamwork is sometimes a problem here” (D6).
Another doctor also thought that pain assessment was a nursing role. Research however states that effective collaboration among health professionals could enhance post-operative pain management in Ghana (Aziato & Adejumo, 2013). Pain assessment should therefore not be considered as the role of the nurse only, since pain management takes a team effort. A multidisciplinary and patient-centred continuous quality improvement process is essential for identifying barriers and in implementing evidence based solutions to the problem of undertreated pain in critically ill patients (Pasero, Puntillo, Li et al, 2009). He stated that:
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Erdek and Pronovost (2004) found that doctors assessing patients pain and reforming their clinical forms to include sections for patients’ pain scores greatly improved pain scores of ICU patients. Thus, pain assessment should not be for nurses only, doctors need to assess and document pain assessment to improve pain management.
Some doctors had negative impressions about how pain was managed in the ICU. The doctors thought that pain management was inadequate. They (D1, D3, D4, D5, D8) said:
“… Is at times when we do the small thoracic cases like we do a PD or we do a BT shunt ...we don’t give the perfuser but we give them prn when the patient wants it. That is where l believe we are running short in terms of managing pain, the thoracic cases” (D1).
Another doctor (D5) said patients need not be sedated all the time, but they are always sedated because they are always in pain. He said:
“I mean that patient pain is not well controlled, anaesthesia is not well controlled… Patient can be on ET tube without being sedated and then comfortable if the pain is ok and is not secreting a lot but we must sedate the patient because they are in pain” (D5).
Pain management, according to one doctor (D8), post-extubation is not adequate. Pain is not adequately managed post-extubation because it is assumed patients are no longer in pain. This assumption can be from doctors and nurses. Lewis et al (2015) also found that bias existed towards treating unconscious and mechanically ventilated patients He said:
“When the person is on the ventilator, I think the instructions are adhered to but probably once the person is extubated and they start feeding, they may be in pain because it’s a sternal wound and it takes a longer time to heal. Probably that is where those lapses will come because the assumption will be that the person has been extubated so they have no pain…” (D8)
• Nurse related factors - Doctors also stated that sometimes, even when they prescribe drugs, it is “skipped” for fear of addiction. Since drugs are administered by nurses,
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it is assumed that the fear of addiction is on the part of those administrating the drugs, thus this is a nurse-related factor that affects the management of pain according to the doctors. Fear of addiction is frequently reported as both a provider and a patient barrier to effective pain management (Sullivan & Ferrell, 2005). The nurses in the previous interview also stated that fear of addiction was a factor that negatively influenced their management of the patient’s pain.
“I think that people will adhere and then we have the protocols designed and pasted there because sometimes when you even write, it is skipped by assumption that this person likes or is demanding they will get addicted that is one of the things that they develop an addiction to some specific opioid analgesics” (D8).
Another doctor said that patients do not get enough analgesia because nurses do not follow the doctor’s prescriptions; they expect the nurses to call them if they are “not comfortable with the prescription and not assume” that the patient is not in pain.
“…the patient is not getting adequate analgesia because they are not following the instructions from the doctor. So, what the doctor has written if you are not comfortable with it the call facility here is excellent just a matter of calling…. but not assume that he is not in pain. No, you can’t determine… (D2).
The doctors also reported on the negative attitude of some nurses, which influenced pain management. He mentioned the attitude towards pain is something “nurses need to pay attention to.” He said:
“ And somebody (a nurse) will say l just gave morphine and it’s not due but in- between, you walk in and like l said previously the heart rate is going up, blood pressure is going up meanwhile there is no reason why these things should go up …but you don’t have to take things for granted …Somebody is very tarchypnoea, there is no reason for that patient to have tarchypnoea so this are some of the things that the nurses need to pay attention to” (D3).
• Health system factors - The doctors identified factors in the management of the hospital that influenced their management of patient’s pain. Nurses shared similar
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sentiments. It is therefore imperative that protocols be developed in the ICUs in Ghana to promote pain management. The doctors (D5, D1, D6, D8) mentioned the effect of lack of protocols on their pain management.
“...If you want to develop, we follow systems, we follow protocols, we don’t have that yet. I don’t know whether you have heard this, we all want to make things look good as if the systems are working but we still have deficiencies that need to be corrected…” (D5).
Batiha (2014) found that hospitals’ policies and rules were barriers to the management of pain. Most of the doctors found lack of protocols and systems as a factor that negatively influenced their pain management. The useful effect of protocols on improving pain management in the ICU has been documented (Mansouri et al, 2013).
The doctor again said that because they do not have protocols, patients are mostly sedated and on narcotics.
“…we do not have a protocol… most of them are sedated and are always on narcotics…” (D5).
“… As l said, we do not have intensivist, we have anaesthetist, who act as the intensivist... and in proper systems, we work through systems and we use protocols that guide practice for the advancement and betterment of our clients” (D5).
Doctors also reported lack of equipment as a factor that influences their management of pain negatively. Riviello, Letchord, Achieng and Newton (2011) stated that equipment and support services are some of the key areas of consideration in developing critical care in resource poor settings. The local setting of this study does not use patient controlled analgesics in the management of patient’s pain.
“There are other things that we can employ, one will be to get reliable infusion pumps dedicated for the regional techniques …the other one is to get a PCA or nurse controlled analgesia” (D2).
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The efficacy of analgesics for pain management, especially in Africa, was of concern to the doctors. Doctors identified that the efficacy of some of the analgesics cannot be assured, thus patients are in pain when put on oral analgesics. The challenge of fake drugs seems to be a worldwide phenomenon but seems more widespread in Africa. One doctor said:
“… in Africa, you can’t be too certain especially the Paracetamol that we have you can’t be too certain of the efficacy because l know there is a brand called Tylenol which is very good. Often times we have to switch our patients to Tylenol and they have done well on that…” (D4).
Another negative factor in the health system, according to the doctors, is the poor adherence to prescriptions and the patient’s inability to afford pain medications that are not on the National Health Insurance. Cost of healthcare is another factor that negatively affects the management of pain in the ICU. According to Chaibou, Sanoussi, Sani et al, (2012), poverty among other things contributes significantly to the underutilisation of post-operative analgesia.
“… you see a lot of the patients complaining of pain one because they probably are not able to buy the pain medications and the other thing, there is poor adherence to the pain management regimen that we prescribe and the other thing too is that some of the pain medications are not on National Health Insurance and it becomes a problem getting the drugs” (D8).
Another health system related factor, according to the doctors, is that cardiac patients seem to get better treatment at the cardiothoracic centre compared to thoracic patients.
“…most of cardiac cases get the best of this centre. The thoracic don’t get much…the thoracic cases, normally we don’t do much” (D5).
• Cultural Factors - As found during the interview with nurses, the Ghanaian culture has an effect on pain management. The doctors said:
“Some tribes believe that the ability to endure pain you know makes you a man so for them, they hardly complain. I would think, especially those from the North, they
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would hardly complain of pain. The same procedure, the same age, the same number of post op days they are more comfortable, not demanding so much of analgesia. Others would demand even analgesia when in the least movement; they would complain of pain” (D8).
“… you know our culture some will just keep the pain…” (D1).
• Surgical procedures that cause the most pain - Most of the doctors said thoracotomies and sternotomies were the most painful surgical procedures CT-ICU patients undergo. Literature states that patients after thoracotomy suffered moderate to severe pain and experienced extremely high interference with daily activities (Yin, Tse & Wong, 2012). The researchers also found there was inadequate treatment of post-thoracotomy patients’ pain. All doctors (D1-D8) mentioned procedures they thought were most painful for patients.
“…Essentially you will say that thoracotomy wounds are most painful…” (D5). “Thoractomies are more painful than the stenotomies so l will say thoracotomies are more painful because we have to open the ribs,” (D6).
As mentioned earlier, the procedures in themselves are not negative but rather therapeutic. The fact they remain quite painful, according to the doctors, after so much advancement in medicine makes it negative. Doctors (D1, D4) stated that the patients who complain most of pain are the thoracic patients. They said:
“For what we do, we believe that the stenotomies give more pain ... but the ones who complain of pain is the thoracic cases…” (D1).
Doctors (D2, D7) also mentioned that abdominal surgeries in addition to chest surgeries cause pain.
“They do thoracotomies they get a lot of pain, we do stenotomies they get pain. These are the two main things we do occasionally we do laparotomy. But thoracotomy and stenotomy” (D7).
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Chest tube insertion, according to some doctors (D3, D8), was also painful. They said: “…and then of cause when you pass chest tube, the site of insertion is also another problem” (D8).
4.3.4.2Positive factors
This sub-theme describes factors according to the data that positively influences pain management in the ICU. Having nurse supervisors, adequate pain management, knowing the effects of analgesics, role of anaesthetists in pain management, understanding the positive effects of analgesia, knowing indications for types of pain medication are positive factors that influence the management of pain.
• Nurse Supervisors - Doctors also believe that having nurse supervisors is a factor that ensures pain medications are given as prescribed.
“…l think the nurses also have supervisors that also go through with each shift they have to hand over so I think they are given as and when due” (D4).
According to Aziato and Adejumo (2014b), pain management education for practicing nurses, with regular monitoring and evaluation of the impact of the education given, will promote post-operative pain management in Ghana. Supervision will therefore constitute monitoring which will enhance pain management.
• Adequate pain management - Doctors (D1, D2, D3, D4, D6, D7) believed they were “doing their best” and their pain main management is generally good.
“…I think we are doing our best” (D3).
“I think the pain management is quite adequate” (D4).
According to another doctor, although they are not doing badly, they could improve. He said:
“For now, I think we are above average we are not doing too badly…But once somebody can have pain I think we can improve” (D6).
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• Effects of Analgesics - Doctors appreciated the positive effects of analgesics and the consequences of inadequately managing pain. It is therefore positive that doctors were mindful of these effects.
“…For cardiothoracic, we are dealing with the chest. If you have pain, the risks are clearly obvious the persons work of breathing will be affected, he will not be able to expectorate, risk of chest infection, if it’s an adult you are concerned about DVT, pulmonary embolism and chest infection also and so good pain management, the person has a good work of breathing and then the person can expectorate so you have good post-operative outcomes. Once we deal with the chest, we should be very comfortable and confident in giving analgesia so we avoid all the complications associated” (D8).
He again said:
“As l said, because it’s the chest, the person does not have adequate analgesia, respiratory effort is poor, you can easily develop pulmonary embolism, chest infections and prolonged stay in the hospitals and all that and even proceed to develop par pneumonic effusion, will be lying in bed and all that because of pain” (D8).
Literature has extensively documented the effects of untreated pain to include an increase in cardiac work and oxygen consumption, increased stress hormone response, which results in catabolism with sodium and water retention, and hyperglycemia, which leads to immunosuppression and delay in wound healing. Ineffective cough and retention of secretions leads to reduced oxygenation and infection. Pain also leads to delayed weaning from ventilation, increased risk of chest infection among patients, prolonged ICU stay and poor quality sleep (IASP, 2010).
• Role of Anaesthetists - Anaesthetists seem to play a big role in the management of pain in the ICU, according to the doctors interviewed. They act as intensivists since there is none in the ICU. The role of the anaesthetists according to the doctors (D1, D3, D7) interviewed enhances pain management.