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Pain management is a complicated process, and it includes many variables that play an important role in the process. Pain can be inadequately treated because of a combination of cultural, societal, educational, political and religious constraints (Zuccaro et al., 2012).

Barriers that interfere with adequate pain management have been classified as problems related to nurses, patients and the healthcare system, as outlined below.

2.2.8.1 Nurse-related Barriers.

Poor assessment of pain and inadequate knowledge regarding pain have been identified as major barriers to adequate pain management (Bruera et al., 2005). Some studies suggest that nurses are not properly assessing patients. In this regard, research has shown a variety of contributing factors, such as nurses’ disbelief of what patients say about their pain (Clarke & Iphofen, 2008). Nurses do not always ask patients about their pain and are not always able to assess it adequately (Watt-Watson, Stevens, Garfinkle, Steiner & Gallop, 2001). In one study, nurses said that their actions depended on how patients described their pain; however, many of them actually rely on how patients look rather than listening to them (Chang, Kim, Sjöström &Schwartz-Barcott, 2001).

In some instances, the barrier to effective nursing in pain management can result from a lack of cooperation from physicians. Van Niekerk and Martin (2003) utilised a survey to examine the barriers to providing optimal pain management. The subjects were a sample of 1,015 nurses in hospitals in Tasmania, Australia. The results showed that more than one-third of the participating nurses indicated a lack of cooperation from physicians as a barrier. In the nurses’ opinion, physicians were not allowing adequate analgesic medication. In such situations, the patients’ pain was inadequately treated (McCaffery, 2002). For instance, a study conducted by Sawyer et al. (2010) indicated that 50 % of medical patients were prescribed PRN, but only 14 % of these orders were administered to patients.

Several studies indicated a high nurse–patient ratio as an additional contributing factor, particularly because it affects patient education, which is an essential part of pain

management (Van Niekerk &Martin, 2003; Elcigil et al., 2011). Education should extend beyond the patient and include the medical and nursing staff in training on standardised clinical pain guidelines, which will have a positive influence on pain management practices (Musclow, Sawhney &Watt-Watson, 2002). It is essential to adopt evidence-based

approaches, standardised orders and protocols to ensure consistent standards of care in order to uphold the criteria of professional practice and improve patient care outcomes (Canadian Nurses Association, 2011).

Nurses provide pain education to patients during their stay in hospital. This helps patients to prevent and recognise the side effects of analgesics and enforce good pain management techniques. A lack of support from nurses’ institutions and colleagues in developing

knowledge, making decisions and effecting change can result in feelings of tension, learned helplessness and low self-efficacy (Wilson, 2007).

2.2.8.2 Patient-related Barriers.

Due to factors such as language, beliefs and cultural influences, as well as certain misconceptions regarding pain, not all patients are able to report their pain experience

adequately (Huffman &Kunik, 2000). Further, many patients are reluctant to complain of pain unless specifically asked, or they may avoid reporting pain because of a fear of medication addiction (Erdek & Pronovost, 2004). Patients may not complain of pain because they want to be ‘good’ patients. Culture also affects patients’ attitudes and motivation to cooperate. Some worry about being thought of as a nuisance, so they will not interrupt busy nurses, while others are afraid of not being taken seriously by staff or think they will not be believed.

Certain patient-related problems, such as economic, social and cultural barriers that prevent them from seeking health treatment, together with personal and societal beliefs, discourage patients from accessing pain management. Brennan et al. (2007) described the extent to which such defeatist views of pain are part of an individual’s state and pervade belief systems. These perceptions about pain may result in patients struggling to attain credibility regarding their pain (Monsivais, 2011).

Culture can impact on the experience of pain at several levels. In some cultures, even when people are in pain, they would like to project themselves as ‘good’ patients, and they attempt to face pain stoically (Lasch et al., 2000). Such patients may under-report their pain to nurses for the fear of being judged as weak. Further, some people are reluctant to take opioid pain medications because of cultural taboos or fears about their use (Lovering, 2006). These patients would be more comfortable with familiar, culture-based remedies such as medicinal herbs or energy therapies (Cherniack et al., 2008). Such practices may not meet the approval of Western medical practitioners, thereby creating a conflict between the patient and the clinician, and a barrier to the latter’s ability to help the patient.

A study conducted by Weech-Maldonado, Elliot, Schiller, Allyson and Hays (2012) used the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score system to examine the relationship between the cultural competency of a hospital and in- patients’ expectations of healthcare. It was a comprehensive study involving 19,583 HCAHPS respondents from 66 hospitals throughout the US. The variables being studied included

caregiver–patient communication, pain control, general hospital rating and willingness by patients to recommend the hospital. The findings led to the conclusion that those hospitals with greater cultural competence provided better experiences and outcomes for patients in their interactions with nurses and other hospital staff. Not surprisingly, the survey also

revealed that minorities, such as Hispanics, scored higher in the level of satisfaction with the hospital stay and care they received at hospitals with better cultural competence (Weech- Maldonado et al., 2012). These findings lend credit to the importance of nurses having cultural competence in their approach to pain management and control in patients.

2.2.8.3 Healthcare system-related Barriers.

Organisational factors can be a hindrance to pain management. For example, people who are kept in institutions such as jails, rehabilitation centres or care facilities for lengthy periods have a higher probability of developing comorbid conditions connected with pain, which are likely to remain undiagnosed, and consequently left untreated (Baidawi et al., 2011; Baldridge & Andrasik, 2010). Additionally,, badly designed policies, deficiencies in healthcare delivery and poor accessibility to care and pain management facilities in distant locations are all obstacles in this context. Chen, Gelgor and Bajorek (2004) drew attention to distance, the shortage of professional personnel and rural cultural factors as the main reasons that prevent a rural population from receiving appropriate care services. The nurses ranked inadequate staffing—particularly at times of overcrowding with acutely ill patients—as the number one barrier to pain intervention. Other listed barriers include methods of health service provision and service funding. Concerns have often been expressed about the financial arrangements for funding pain care centres and how such funds are managed (Gatchel &Okifuji, 2006).

A study was conducted in Iran by Rejeh, Ahmadi, Mohammadi, Anoosheh and Kazemnejad (2008) to clarify Iranian nurses’ perceptions of the barriers and facilitators influencing their management of postoperative pain. This qualitative study was based on interviews with 26 nurses. The barriers to effective postsurgical pain treatment as perceived by the nurses included their powerlessness in making decisions, the policies of the organisation (Coker et

al., 2010), physicians that lead the practice, time constraints (as a result of staff shortage), limited communication and interruption of pain management activities as a result of work overload (Rejeh et al., 2008).

A recent study conducted by Elcigil et al. (2011) utilising a self-report questionnaire to explore the barriers to pain management. The sample of the study included 114 nurses working in medical, oncology and surgery clinics. The findings indicated that the most commonly perceived barriers to pain management were system-related, such as the lack of psychosocial support services, patient-to-nurse ratio and inadequate time for nurses to engage in health education with patients (65 %). The most common barriers related to physicians were inadequate assessment and management of pain by doctors (63 %) and physicians’ indifference (47 %) (Elcigil, Maltepe, Esrefgil & Mutafoglu, 2011). A lack of support from nurses’ institutions and colleagues in developing knowledge, involvement in decision-making and effecting change can result in feelings of tension, helplessness and low self-efficacy (Wilson, 2007).

Advanced Practice Services (APS) has introduced important changes, including creating special categories of nurses such as clinical nurse specialists (CNSs) and nurse practitioners (NPs) who are authorised to prescribe.

2.3 Part 2: Critical Review of Nurses’ Knowledge and Attitudes Regarding Pain: