COLLAGE OF HEALTH SCIENCE

SCHOOL OF NURSING AND MIDWIFERY DEPARTMENT OF NURSING

TITLE: ASSESSMENT OF NURSES’ KNOWLEDGE, ATTITUDE, PRACTICE, AND

BARRIERS REGARDING NON-PHARMACOLOGICAL PAIN MANAGEMENT AT
TIKUR ANBESSA SPECIALIZED HOSPITAL, ADDIS ABABA, ETHIOPIA, 2024,
CROSS-SECTIONAL STUDY.

1. Metasebiya Gadissa
2. Minase Wakgari
3. Mulusew Tewelign
4. Nahom Wondimu
5. Nejat Jemal

A Research thesis Submitted to the Addis Ababa University, College of Health

Sciences, School of Nursing and Midwifery, Department of Nursing in partial
fulfillment of the Requirements for the degree of Bachelor of Science in Nursing.

JUNE 2023, ADDIS ABABA, ETHIOPA

1
TITLE: ASSESSMENT OF NURSES’ KNOWLEDGE, ATTITUDE, PRACTICE, AND
BARRIERS REGARDING NON-PHARMACOLOGICAL PAIN MANAGEMENT AT
TIKUR ANBESSA SPECIALIZED HOSPITAL, ADDIS ABABA, ETHIOPIA, 2024,
CROSS-SECTIONAL STUDY.

Name of Investigators
Metasebiya Gadissa

Minase Wakgari

Mulusew Tewelign

Nahom Wondimu

Nejat Jemal

Name of the advisor: Sr. Fikrtemariam A. (BSc, MSc,)

Research committee approval

Name Signature Date

1.______________________ _____________ _____________

2.______________________ _____________ _____________

3.______________________ _____________ _____________

Research Advisor/s Name Signature Date

1._____________________ _____________ _____________

JUNE 2023, ADDIS ABABA, ETHIOPIA

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 Abstract
Background: Effective non-pharmacological pain management is crucial for patient recovery, as
poor pain control can prolong hospitalization. This study focuses on the significant impact of
pain management on nursing and aims to pinpoint deficiencies in nurses' pain management
knowledge and attitudes.

Objective: To assess knowledge, attitude, practice and barriers regarding non-pharmacological

pain management techniques among nurses working in Tikur Anbessa Specialized Hospital,
Addis Ababa, Ethiopia, 2024.

Methods and Materials: A descriptive cross-sectional design was used for the study; the target
population for the study was 800 nurses who are working in Tikur Anbessa Specialized Hospital.
A validated, self-administered questionnaire was used to collect the data from 286 nurses. The
respondents were selected using convenience sampling of all departments in Tikur Anbessa
Specialized Hospital. Data was collected and analyzed using kobocollect v2024.1.3 and
Microsoft excel.

Result: about 53.15% nurses had good knowledge about non pharmacological pain management:
positive attitude 64.69% and about 53.5% had good non pharmacological pain management
practice, the top three barriers regarding non pharmacological pain management listed by
participants were lack of patient/ family awareness (82.52%), work load (79.02%) and lack of
facilitation in service training program (78.32%).

Conclusion: we conclude that knowledge, attitude and practice of non-pharmacological pain

management among nurses in the study area were positive attitude but poor knowledge and
practice. The significant barriers regarding non pharmacological pain management were lack of
patient/ family awareness, work load and lack of facilitation in service training program

Recommendation: To address these gaps, continuous education and training programs are
essential. Regular workshops, seminars, and hands-on simulation training can significantly
enhance nurses' knowledge and skills.

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Keywords: assessment, nurse, knowledge, attitude, practice, pain, barriers

Acknowledgement
First and foremost, we would like to express our sincere appreciation to Addis Ababa University
College of Health Science, School of Nursing, and Midwifery for providing the necessary
resources and academic guidance that made this research possible. We would gratefully
acknowledge our advisor, Sr. Fikertemariam A. (BSc, MSc), for her constant inspiration and
support. We are actually highly obliged to be very thankful for her instruction and guidance that
have served as a major contribution to the completion of this project. We would like to extend
our special thanks to the nurses who participated in this study. We are also grateful for all our
group members, whose individual contributions were invaluable. The completion of this project
could not have been possible without teamwork. This acknowledgement serves as a testament to
the collective efforts that have made this research study possible.

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Table of Contents
Abstract......................................................................................................................................................... i
Acknowledgement ....................................................................................................................................... ii
List of Tables and Figure ........................................................................................................................... v
Acronym/ Abbreviation ............................................................................................................................. vi
Keywords ................................................................................................................................................... vii
Chapter One: Introduction ........................................................................................................................ 1
1.1 Background ....................................................................................................................................... 1
1.2 Statement of the Problem ................................................................................................................. 2
1.3 Significance of the Study .................................................................................................................. 3
Chapter Two: Literature review ............................................................................................................... 5
2.1 Reviewed literature ........................................................................................................................... 5
2.1.1. Introduction of pain .................................................................................................................. 5
2.1.2 Nurses role in Pain management .............................................................................................. 6
2.1.3 Non-pharmacological pain management ................................................................................. 7
2.1.4 Knowledge related to non-pharmacological pain management ............................................. 9
2.1.5 Attitudes related to non-pharmacological pain management .............................................. 11
2.1.6 Practices related to non-pharmacological pain management .............................................. 11
2.1.7 Barriers of non- pharmacological pain management ........................................................... 12
2.2 Conceptual Framework .................................................................................................................. 14
Chapter 3: Objectives ............................................................................................................................... 15
3.1 General objective ............................................................................................................................ 15
3.2 Specific objectives ........................................................................................................................... 15
Chapter 4: Methods and Materials ......................................................................................................... 16
4.1 Study Area ....................................................................................................................................... 16
4.2 Study Design and Study Period ..................................................................................................... 16
4.3 Population ........................................................................................................................................ 16
4.3.1 Source Population .................................................................................................................... 16
4.3.2 Study Population ...................................................................................................................... 16
4.3.3 Study Unit ................................................................................................................................. 16
4.4 Eligibility Criteria ........................................................................................................................... 17
4.4.1 Inclusion Criteria ..................................................................................................................... 17
4.4.2 Exclusion Criteria .................................................................................................................... 17
4.5. Sample Size Determination ........................................................................................................... 17

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 4.6. Sampling Technique ...................................................................................................................... 18
4.7. Study Variables .............................................................................................................................. 18
4.7.1. Dependent Variables ............................................................................................................... 18
4.7.2. Independent Variables ............................................................................................................ 18
4.8 Operational Definitions of Terms .................................................................................................. 19
4.9 Data Collection Instruments and Procedures............................................................................... 19
4.10 Data Processing and Analysis ...................................................................................................... 20
4.11 Data Quality Control .................................................................................................................... 20
4.12 Ethical Approval and Consent to Participate............................................................................. 21
4.13 Dissemination of the Result .......................................................................................................... 21
Chapter Five: Result ................................................................................................................................. 22
5.1 socio-demographic characteristics of participant ........................................................................ 22
5.2. Non-pharmacological pain management methods utilization.................................................... 25
5.3 Knowledge of respondents about non-pharmacological pain management .............................. 26
5.4. Attitude of respondent regarding non-pharmacological pain management............................. 28
5.5. Practice of participants regarding to non-pharmacological pain management ....................... 30
5.6 Assessment result of barriers that prevent nurses from using non- pharmacological pain
management methods ........................................................................................................................... 32
5.7 Relationship Between Socio-demographic characteristics and Knowledge, attitude, Practice of
non-pharmacological pain management ............................................................................................. 33
Chapter six: Discussion ............................................................................................................................ 36
Chapter seven: Conclusion....................................................................................................................... 37
Chapter Eight: Strength and limitation of the study ............................................................................. 38
8.1. Strength of the study ...................................................................................................................... 38
8.2. Limitation of the study .................................................................................................................. 39
Chapter Nine: Recommendation ............................................................................................................ 39
Reference ................................................................................................................................................... 41
Annex ......................................................................................................................................................... 45
AnneX I: Information Sheet Ana Participant Consent Form ........................................................... 45
Information Sheet ............................................................................................................................. 45
Greetings, Nursing Community ........................................................................................................... 45
The Consent Form ............................................................................................................................ 46
ANNEX 2: The Questionnaire ............................................................................................................. 47

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 List of Tables and Figure
1. Table 1………………………………………………………………………..22
2. Table 2……………………………………………………………………….25
3. Table 3………………………………………………………………………..27
4. Table 4……………………………………………………………………….29
5. Table 5 ………………………………………………………………………32
6. Table 6………………………………………………………………………33
7. Table 7………………………………………………………………………34
8. Table 8………………………………………………………………………35

List of Figures
1. Figure 1………………………………………………………………………14
2. Figure 2………………………………………………………………………25
3. Figure 3………………………………………………………………………26
4. Figure 4………………………………………………………………………31

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 Acronym/ Abbreviation
DC……………Data collection

EASE ………..Emotion and symptom focused engagement

GANT…….…Generalized Activity Normalization Time Table

IASP…………International association for the study of Pain

IRB ………... Institutional Review Board

NPPM……….Non-pharmacological pain management

MBCT………Mindfulness based on cognitive therapy

PI…………...Principal Investigator

RP…………...Responsible Bodies

TENS……. .Trans-electrical nerve stimulation

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 Keywords
Assessment: the process of gathering and analyzing information to evaluate a particular
situation, condition, or phenomenon.

Nurses: A nurse is a healthcare professional who is trained and licensed to provide medical care
and support to individuals who are sick, injured, or in need of assistance.

Knowledge: is information, skills, and understanding that a person has acquired through
education, experience, or training.

Attitude: is a psychological construct that refers to a person's feelings, beliefs, and behavioral
tendencies towards a particular object, person, situation, or event.

Practice: refers to the repeated performance or application of a skill or behavior in order to

improve proficiency

Pain: is a complex and subjective sensory experience that is typically associated with actual or
potential tissue damage.

Barriers: are obstacles that impede progress or access.

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 Chapter One: Introduction
1.1 Background

There are numerous ways to define the concept of pain. According to the International
Association for the Study of Pain (IASP), pain is defined as ―an unpleasant sensory and
emotional experience associated with actual or potential tissue damage‖ [1]. Pain management is
a nursing activity comprising the following basic components of the nursing process: assessment,
diagnosis, planning, intervention, and evaluation for patients in pain. Pain management involves
pharmacological and non-pharmacological treatment approaches [2]. Non-pharmacological
methods do not replace pharmacological treatments but are complementary to medication
treatments. These strategies are worthwhile, especially for managing mild-to-moderate pain [3].
Non-pharmacological pain management (NPPM) refers to the utilization of pain management
alternatives other than pharmacological therapies such as physical therapy, occupational therapy,
comfort therapy, psychosocial therapy, or counseling for the better management and reduction of
pain [4, 5].

NPPM practices are essential in that they promote comfort, which patients can use to control
their pain if they are provided appropriate information or education [6, 7]. Moreover, these
methods have advantages over conventional drug treatments in that they treat cognitive,
affective, and socio-cultural aspects of pain. They increase feelings of control, diminish pain
intensity, improve quality of life, lower the required dosage of painkillers, and minimize cost.
[7].

Nurses are one of the health professionals who may hear of pain suffered by patients and who
can manage patient suffering by themselves. Therefore, their appropriate and accurate skill is
very important in non-pharmacology and pharmacology pain management methods. Based on
research studies in different areas of the country, there is a knowledge and attitude gap on non-
pharmacology pain management among practicing nurses in hospitals. [8, 9]

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Globally, many studies stated that lack of knowledge and an unfavorable attitude of nurses
towards NPPM was the prevailing persistent challenge [10]. The nurse‘s knowledge and attitude
have a significant effect on the use of NPPM. Different studies show that, among nurses who
have inadequate knowledge and an unfavorable attitude towards NPPM, the majority of them did
not use NPPM [11]. Moreover, among previous studies conducted regarding NPPM, 90% of
them had no documented evidence of the use of non-pharmacological pain interventions to
alleviate pain [9].

1.2 Statement of the Problem

Pain is an unpleasant emotional and sensory experience associated with actual or potential tissue
damage. It has emotional and physical components. It is always subjective. Based on duration,
pain can be classified as either acute (lasting a short period of time and easily described) or
chronic (present for more than 3 months and not easily described) [12].

Nurses are often the only ones who may hear of the pain endured by patients and who carry out
the advice of the physicians on pain management. Therefore, their knowledge and attitude are
very important in pain management. The gap in knowledge about pain assessment and
management, the inability to assess pain, and poor communication between the patient and the
healthcare provider lead to ineffective pain management. Approximately 79% of hospitalized
patients suffer from moderate to severe pain, and in many cases, this pain is not managed
correctly globally [2].

It can affect patients‘ physiological and health safety. It has been identified that inadequate pain
assessment, lack of knowledge, negative attitude, workload, and absent or insufficient guidelines
regarding NPPM are among several contributory factors to the low usage of NPPM practices that
have been mentioned in the literature. Despite health professionals receiving training on pain
assessment and management, patients are still suffering from poorly controlled pain. So, further
training should be provided, along with training on nursing attitudes towards NPPM practice.
Educational programs can improve the knowledge and attitude of nurses regarding pain
management. In Ethiopia, despite the initiation of training on pain management and the
development of national guidelines on the assessment and management of pain given high
priority ever before, patients still suffer from undertreated pain. Nurses working at
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comprehensive specialized hospitals in Ethiopia, specifically in the study area, did not take
training regarding pain assessment, management, and practice.

Research related to nurses‘ knowledge, attitudes, practices and barriers regarding non-
pharmacological pain management in the hospital care setting in Ethiopia has been limited, but
there is one documented study in Tikur Anbessa Specialized Hospital that reports nurses‘
knowledge, attitudes, and practices related to non-pharmacology pain management as well as
barriers to effective practices. The aim of this study is to determine the baseline level of nurses‘s
knowledge, attitude, and practice regarding non-pharmacological pain management as well as
barriers in Tikur Anbessa Specialized Hospital. Assessment of nurses knowledge, attitudes, and
practices is a vital start in reducing barriers to adequate pain relief. This will lead to more
effective pain management.

1.3 Significance of the Study

The significance of this study lies in its potential to address a critical gap in healthcare delivery.
Non-pharmacological pain management techniques are important for providing holistic care to
patients, especially those with chronic pain conditions or those who cannot tolerate
pharmacological interventions. Nurses play a crucial role in implementing these techniques and
ensuring that patients receive comprehensive pain management.

By assessing the knowledge and practice of non-pharmacological pain management among

nurses at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, this study can identify
areas of strength and areas for improvement in the current practices. The findings of this study
can inform targeted interventions, training programs, and policy changes to enhance the quality
of pain management provided by nurses in the hospital.

Furthermore, by focusing on a specific hospital in Ethiopia, this study can provide valuable
insights into the unique challenges and opportunities faced by healthcare providers in a resource-
limited setting. The results of this study can contribute to the development of context-specific
guidelines and strategies for improving non-pharmacological pain management practices in
similar healthcare settings.

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Overall, this study has the potential to improve patient outcomes, enhance the quality of care
provided by nurses, and contribute to the advancement of pain management practices in Ethiopia
and beyond. This study shortens the gap in information about knowledge and attitudes toward
pain management among nurses in the area. Therefore, assessing the knowledge and attitude of
nurses is important to improve the pain management process; reducing morbidity and mortality
associated with pain would be possible. Hence, this study aims to assess knowledge and attitude
towards pain management among nurses working at Tukur Anbessa Specialized Hospital, Addis
Ababa, Ethiopia.

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 Chapter Two: Literature review

2.1 Reviewed literature

2.1.1. Introduction of pain

Pain is an unpleasant sensory and emotional experience associated with actual or potential
damage. It is a personal and subjective symptom that is influenced by age, gender, race, and
psychosocial factors. [13]

Pain is an unpleasant sensory and emotional experience that canonically results from actual or
impending tissue damage or is correctly describable in terms of such damage. According to the
IASP definition, pains are experiences—subjective psychological states. More precisely, they are
qualitative mental episodes. [14] Pain is a multidimensional phenomenon with sensory,
physiological, cognitive, affective, behavioral, and spiritual components. [15] Pain is a common
and frequent symptom of many disease processes that forces individuals to seek out medical
advice. It is considered a foremost distress influencing all aspects of a patient's life. [16]

Based on duration, pain can be classified as either acute (lasting a short period of time and easily
described) or chronic (present for more than 3 months and not easily described). [17] A normal
sensation that alerts you to a possible injury or discomfort has been defined as acute pain. Acute
pain typically gets better as the tissue and wound heal. Chronic pain, however, lasts for weeks,
months, and even years. Chronic pain can stem from physical ailments such as back pain,
arthritis, cancer, or other serious conditions that are not easily or quickly remedied. [18]

Approximately 42% of adults say they experience pain daily, and approximately 28–30% of the
US population suffers from chronic pain. Pain is the most common symptom in all kinds of
illnesses, but it is an extended problem among patients who live with chronic illnesses such as
HIV/AIDS and cancer. Worldwide, chronic pain is the most frequent cause of suffering and
disability that seriously affects the quality of life. According to the WHO, every day, 3.5 million
people suffer from cancer-related pain (11A). Pain is the second most common symptom in
ambulatory persons with HIV/AIDS, and according to a study in a New York cohort of 500
AIDS patients, the prevalence of pain was observed to significantly increase with the progression
of the disease from early-stage HIV to full-blown AIDS. Nearly half of the pain in HIV is

5
neuropathic, reflecting injury to the central or peripheral nervous system from direct viral
infection, infection with secondary pathogens, or neurotic side effects of drug therapy. In Africa,
each year, 2.5 million people die from HIV/AIDS and more than 0.5 million die from cancer, and
many of these deaths are accompanied by suffering that could be avoided or relieved if adequate
palliative care were delivered. Each year in five countries in Africa, including Ethiopia, 610,000
people die from HIV/AIDS and 80,800 from cancer; thus, at least 0.5% of the total population in
these countries needs palliative care. In Ethiopia, the commonest concern raised by families of
disabled patients is the pain associated with the illness mentioned by 76% of participants, and in
most of the cases, caretakers complain that adequate procedures are not taken to relieve pain and
other harmful symptoms associated with terminal illnesses [19].

According to some authors, approximately 69% of patients with cancer experience pain during
their daily activities, which may have dangerous psychosocial consequences, such as anxiety or
depression. Around 50%–70% of cancer patients suffer from uncontrolled pain, which, in many
cases, leads to anxiety, depression, suicidal tendencies, and more fear of pain than of their own
death. [20]

2.1.2 Nurses role in Pain management

Pain management practices are defined as a set of activities that should be provided by nurses to
manage the patients‘ pain effectively, which includes assessing the patients‘ pain, providing
appropriate nurse‘s interventions to relieve the patients‘ pain, and reassessing the patients‘ pain
after intervention. [21] Pain control is an integral part of nursing, and nurses have a
responsibility to effectively manage patients‘s pain. Effective pain control demands knowledge,
commitment, persistence, and creativity [22]. Pain management is a nursing activity comprising
the following basic components of the nursing process: assessment, diagnosis, planning,
intervention, and evaluation for patients in pain. [23] The core of nursing is to restore the health
of the patient and alleviate suffering. Poorly controlled pain can affect function, appetite, sleep,
mood, and quality of life significantly. [24] Studies have shown that ineffective pain control has
a twin effect on the patient and the caregiver, principally the nurse. [22]

6
Inadequate pain management has been shown to affect patient outcomes by potentially
increasing hospital stays and delaying recovery; thus, the management of pain has major
implications for nursing. [25]

2.1.3 Non-pharmacological pain management

Non-pharmacological pain management is one approach to a comprehensive method of pain

relief. They do not replace pharmacological methods of pain management and can be used in
combination with pharmacological pain management practices to increase the patient‘s relief of
pain.

The Order of Nurses defines non-pharmacological interventions as the ''application of methods

or techniques for preventing and/or treating pain that do not involve the administration of drugs''.
Therefore, it recommends that nurses have an active role in promoting care aimed at eliminating
or reducing pain using non-pharmacological interventions in conjunction with pharmacological
therapies and considering the person's wishes, the expected objectives of the treatment, and the
existing scientific evidence. [26]

Narcotic medications are prescribed every day to individuals who are seeking pain management.
Opioids are considered one of the most effective drugs to use for pain and suffering; however,
some people may encounter serious negative consequences if they become addicted to opioids.
The ongoing abuse of narcotic medications has been on the rise for many years. [18] Therefore,
as a way to counteract the effect of the above medical crisis, pressure has been exerted on pain
management to shift away from total reliance on opioids, ineffective procedures, and surgeries
towards comprehensive pain management that includes evidence-based non-pharmacological
options. [27]

Among the advantages of using non-pharmacological interventions is their low cost, reduced
side effects, and possible modification of the meaning of pain. Their use achieves cognitive
restructuring, aimed at cognitions. , expectations, evaluations, and constructions that are present
in the experience of pain, transforming. [26]

7
This pain management can be categorized into three categories. There are cognitive or behavioral
strategies, which include distraction, relaxation, imagery, and breathing techniques. The second
category are physical or cutaneous strategies, which include heat or cold, vibration, massage,
position changes, and trans-electrical nerve stimulation (TENS). Finally, there are environmental
or emotional strategies such as touch, reassurance, or interior decoration of the room [28].

Relaxation is the second cognitive-behavioral strategy that works to relieve pain because of the
reduced muscle tension. These techniques included relaxation imagery, which engages a person
in imaging a pleasant or peaceful experience. Others also included music, massage, and slow
breathing. When a person is relaxed, their heart rate, blood pressure, and respirations decrease.
Cutaneous interventions such as heat or cold work according to the gate control theory of pain
transmission. Stimulation of the skin activates the large-diameter nerve fibers and prevents the
short-diameter nerve fibers from transmitting pain to the brain. Cutaneous stimulation may be
applied to the site of pain or other sites distal or proximal to the pain. The use of cold is almost
always more effective than heat, and alternating cold and heat is even more effective than using
one thermal method alone. Both heat and cold cause a decrease in the sensitivity to pain or
decrease muscle spasms, and that may be why they work to relive pain [29].

Vibration is a second type of cutaneous stimulation that causes paresthesia or anesthesia to the
area stimulated and changes sharp pain to a dull sensation. Pain relief can last for up to 30
minutes after the vibration is removed. The use of heat with vibration is the best cutaneous
stimulation method to relieve pain. Massage is another type of cutaneous therapy to relieve pain.
The back and shoulders are the areas typically massaged. In a study of terminally ill patients, a
three-minute slow back rub lowered blood pressure, indicating relaxation and less pain [29].

According to a systematic review and meta-analysis evaluated on the efficacy and quality of the
current empirical evidence about psychological and non-pharmacological interventions for
reducing cancer-related pain in adult patients, it appears that psychological and non-
pharmacological therapies are effective for reducing pain in cancer patients. Specifically, the
results of this systematic review and meta-analysis indicate that mindfulness based on cognitive
therapy (MBCT), progressive muscle relaxation, emotion and symptom-focused engagement
(EASE), music therapy and poetry sessions, and pain coping skills training have long-term

8
efficacy regarding pain reduction in cancer patients. [16] In general, non-pharmacological
interventions are actually useful for pain management because they are low-cost, easy to provide,
safe, and easy to implement with less difficulty or resources than pharmacological pain
management. [29]

A descriptive cross-sectional study conducted in AMINU KANO TEACHING HOSPITAL,

Nigeria, The results showed that 58.8% of the respondents had poor knowledge of non-
pharmacological pain management techniques; only 3.5% of them had very good knowledge.
The study also revealed that most of the respondents, 95.3%, have practiced at least one of the
techniques. It was revealed that changing positions was the most commonly practiced technique
by 71.8% of the respondents. [27]

A study in the Philippines proved that nurses good attitude towards NPPM and good pain
assessment practice positively affect the application of these practices [24]. Another study in
Nigeria demonstrated that 65.7% of nurses ‘attitudes were positive towards these practices of
pain treatment and had a significant association with the utilization of NPPM [22].

In a study of non-pharmacological pain management practices and associated factors among

nurses working at comprehensive specialized hospitals, the prevalence of non-pharmacological
pain management practices was found to be low. [23]

According to a study in Debre Tabor Comprehensive Specialized Hospital, Ethiopia, among the
study participants, only 44 (26%) of nurses had good practice with non-pharmacology pain
management methods. [21]

2.1.4 Knowledge related to non-pharmacological pain management

Nurses need a wide range of basic knowledge about pain, its assessment, and its management
principles. Knowledge deficits‘ regarding pain assessment and management principles have been
cited as one of the clinician-related barriers to optimal pain management for patients with pain.
Nurses should have knowledge of the use of non-pharmacological approaches such as hot and
cold mechanisms, acupuncture, massages, and breathing measures, among others, employed in
pain management [30].

9
Nurses need a wide range of basic knowledge about pain, its assessment, and its management
principles. Knowledge deficits‘ regarding pain assessment and management principles have been
cited as one of the clinician-related barriers to optimal pain management for patients with pain.
Nurses should have knowledge of the use of non-pharmacological approaches such as hot and
cold mechanisms, acupuncture, massages, and breathing measures, among others, employed in
pain management [30]. But many studies do not focus nurse knowledge on non-pharmacological
pain management strategies, but rather on pharmacological pain management strategies. In
addition to the areas of pain management required of a nurse, knowledge of the existing
standards of pain management as well as the already established recommendations is considered
vital, as nurses have the potential to play a vital role in pain management and education. In a
study done at Shahid Sadoughi Hospital in Yazd, Iran, it was stated that nurses have widespread
knowledge deficits and limited training regarding cancer-related pain management [31]. The
study done by Makkah EI-Mukarramah showed that the level of nursing knowledge on
nonpharmacological pain management for hospitalized patients was satisfactory and fair [29].
But another study done in west Gojjam, Ethiopia, showed that the level of nursing knowledge on
non-pharmacological pain management in hospital care settings was unsatisfactory [28].
Insufficient knowledge remains a major barrier to achieving effective pain management. But
many studies do not focus nurse knowledge on non-pharmacological pain management
strategies, but rather on pharmacological pain management strategies. In addition to the areas of
pain management required of a nurse, knowledge of the existing standards of pain management
as well as the already established recommendations is considered vital, as nurses have the
potential to play a vital role in pain management and education. In a study done at Shahid
Sadoughi Hospital in Yazd, Iran, it was stated that nurses have widespread knowledge deficits
and limited training regarding cancer-related pain management [31]. The study done by Makkah
EI-Mukarramah showed that the level of nursing knowledge on nonpharmacological pain
management for hospitalized patients was satisfactory and fair [29]. But another study done in
west Gojjam, Ethiopia, showed that the level of nursing knowledge on non-pharmacological pain
management in hospital care settings was unsatisfactory [28]. Insufficient knowledge remains a
major barrier to achieving effective pain management.

10
2.1.5 Attitudes related to non-pharmacological pain management

Attitude is a hypothetical construct that represents an individual's like or dislike for an item.
Attitudes are positive, negative, or neutral views of an "attitude object," i.e., a person, behavior,
or event. People can also be "ambivalent" towards a target, meaning that they simultaneously
possess a positive and a negative bias towards the attitude in question. Negative attitudes of
nurses related to the experience of pain and pain management have been a barrier to effective
pain management for many years, and a positive attitude is the key to successful pain
management. The attitude of nurses toward evidence-based pain management likely affects their
ability to obtain desired patient outcomes. Nurses have the legal responsibility to manage
patients‘ pain, and medical and surgical nursing units should be staffed well enough by nurses to
carry out their duties [30]. Registered nurses at Bindura Hospital had a poor attitude regarding
the pain management of adult medical patients [32]. A study done at Makkah EI-Mukarramah
showed that nurses' positive attitudes and high level of efficiency in applying non-
pharmacological methods for pain management. The majority of subjects have achieved a
satisfactory level in patient‘s preparation, distraction, thermal regulation, massage and touch, and
environmental comfort (85%, 77.5%, 72.5%, 80%, 100%, and 95%, respectively [29]. A study
done in the west Gojjam zone of Amhara regional states that the majority of subjects had a
positive attitude of willingness to prepare the patient for the procedure, teaching the patient about
non-pharmacological methods, and encouraging the patient to use non-pharmacological methods
(80%, 79%, and 75.5%, respectively) and had a negative attitude towards family involvement in
pain management programs and environmental decoration (54.7% and 52%, respectively) [28].

2.1.6 Practices related to non-pharmacological pain management

The promotion of comfort and relief of pain are fundamental to nursing practice. They often use
non-pharmacological measures to facilitate comfort for patients within the hospital setting.
However, guidelines for the use of these measures are commonly inadequate or absent. Nursing
staff can educate patients, families, and other clinicians to use non-pharmacological strategies to
manage pain, such as relaxation, massage, and heat or cold. They can investigate patients'
attitudes and beliefs about, preferences for, and experiences with non-pharmacological pain-
treatment strategies. They can thus tailor non-pharmacologic techniques to the individual [30].

11
In a study in Makkah ElMukarramah, the percentage of applied non-pharmacological pain
management was low in hospitals, but some non-pharmacological pain management uses
included a satisfactory level in patient‘s preparation, distraction, massage, and touch (65%,
92.5%, 67.5%, and 60%, respectively) and an unsatisfactory level in thermal regulation and
environmental comfort (52.5% and 42.5%, respectively) (29). Other studies in West Gojjam
found that non-pharmacological pain management is a UN satisfactory practice. But some non-
pharmacological pain management is used, like unsatisfactory levels of practice in position
change, massage, distraction, touch, and environmental comfort (58.3%, 57.6%, 55%, 54%, and
53%, respectively), and satisfactory levels in thermal regulation and heat/cold application (64%
and 61.5%, respectively). [28].

2.1.7 Barriers of non- pharmacological pain management

It has been identified that inadequate pain assessment, lack of knowledge, negative attitude,
workload, and absent or insufficient guidelines regarding NPPM [33] are among several
contributory factors to the low usage of NPPM practices that have been mentioned in the
literature.

Nurses identified that non-pharmacological pain management techniques were one of the areas in
which they received the least amount of information, which may have prevented them from
using those therapies [34]. Significant barriers such as a lack of organizational and professional
support were also identified as delaying nurses ‗current usage of non-pharmacological therapies
[35].

Barriers identified included a lack of distraction materials, being a stranger to the child, and
nurses‘ lack of knowledge. Nurses indicated that they used simpler techniques like distraction
and focusing on breathing most frequently. The barriers to optimally managing pain and using
non-pharmacological pain techniques seem to be similar to nurses‘ knowledge, time, and attitude
toward pain management [35].

According to the study by Makkah El-Mukarramah, the most common barrier that prevents
nurses from using non-pharmacological methods for pain management for patients in hospitals is
a lack of time, followed by the unwillingness of patients, and lastly, the age level of the patient.

12
Multiple institutional-related factors invariably affect the NPPM practice of nurses. Cross-
sectional studies in Turkey [36], Cameroon [37], Sudan [38], and Debre Tabor, Ethiopia [21]
pointed out that in-service training was a significant factor associated with NPPM practice. Lack
of NPPM equipment‘s (e.g., special mattress, pillow) was also one of the significant factors with
NPPM practice [39, 41, 43]. Another cross-sectional study conducted in Eritrea showed that the
availability of pain measurement tools in the working unit determined a significant difference
among nurses regarding their practice of NPPM [40].

Studies have identified workload as one of the reasons for low NPPM practice [41, 42, 37]. A
study in Ethiopia revealed that 70.3% of nurses said that patients‘ preference to drugs was one of
the reasons not to use NPPM practices for pain alleviation. But the absence of patients‘
preference for drugs had a positive effect on nurses‘ NPPM practice [30]. It had also been
identified that about 46.8% [43] and 92.9% [39] nurses said patients‘ severity of pain was one of
the reasons not to apply NPPM practices.

According to a study conducted in West Gojjam, the most significant barriers to using non-
pharmacological therapies were lack of time (38.6%), patient unwillingness (32.5%), lack of
equipment (13.1%), family/patient needs for pills (9.9%), lack of attention, and patient age. [30]

13
2.2 Conceptual Framework

The figure below shows the study of conceptual framework. Conceptual framework developed
for the study based on the title of the study, previous literature review, non- pharmacological
pain management, and it included factors related to demographic data, patient related factors,
nurses and institutional related factors.(23)

Figure 1: Schematic representation developed to show interactions between the dependent and
the independent variables.

14
 Chapter 3: Objectives
3.1 General objective
 To assess knowledge, attitude, practice and barriers regarding non-pharmacological pain
management techniques among nurses working in Tikur Anbessa Specialized Hospital,
Addis Ababa, Ethiopia, 2024.

3.2 Specific objectives

 To evaluate the knowledge of nurses regarding non-pharmacological pain
management techniques.
 To evaluate the attitude of nurses regarding non-pharmacological pain management
techniques.
 To assess the practice of non-pharmacological pain management by nurses
 To explore the challenges faced by nurses in providing non-pharmacological pain
management at Tikur Anbessa Specialized Hospital.

15
 Chapter 4: Methods and Materials
4.1 Study Area

The study was conducted at TikurAnbessa specialized hospital, Addis Ababa the largest referral
hospital in the country. It was inaugurated by the title ―Prince Mekonnen the Dunk of Harar‖
Memorial Hospital on 3/11/1953 E.C. The name was changed to TikurAnbessa Hospital on
24/5/1975 E.C. Later on it was transferred to Addis Ababa University to become a teaching
hospital and is now the main teaching hospital for both clinical and preclinical training of most
disciplines. The hospital has 700 beds and 800 nurses. Nurses are qualified with diplomas, a
bachelor‘s degree and a master‘s degree in nursing. Tikur Anbessa specialized Hospital has been
chosen because it is also an institution where specialized clinical services that are not available in
other public or private institutions are rendered to the whole nation. The largest numbers of
nurses have contact with variety patient with pain.

4.2 Study Design and Study Period

This study was utilized a descriptive cross-sectional design to assess the effectiveness of nurses
in providing non-pharmacological pain management in patient care. The study was conducted
from March 1, 2024, to April 30, 2024.

4.3 Population
4.3.1 Source Population
The source population for this study was all nurses who were working in the Tikur Anbessa
Specialized Hospital during the study period and willing to participate in the study.

4.3.2 Study Population

The study population for this study was selected nurses who were working in the Tikur Anbessa
Specialized Hospital during the study period and willing to participate in the study.

4.3.3 Study Unit

The study unit for this research was individual nurses working at Tikur Anbessa Specialized
Hospital in Addis Ababa, Ethiopia.

16
4.4 Eligibility Criteria
4.4.1 Inclusion Criteria

 All nurses who were working in Tikur Anbessa Specialized Hospital for at least six
months
 Nurses who provide direct patient care and actively working during the study period and
available for data collection.

4.4.2 Exclusion Criteria

 Nurses who were not working at Tikur Anbessa Specialized Hospital.
 Nurses who did not provide direct patient care.
 Nurses who had less than six months of experience working in the Tikur Anbessa
Specialized Hospital.
 Nurses who were on extended leave or sabbatical during the study period.

4.5. Sample Size Determination

The sample size for this research will be determined using a statistical formula. Since the specific
formula may vary depending on the statistical analysis planned and the desired level of precision,
it is recommended to consult with a statistician or use sample size determination software.
However, some factors that may influence the sample size include the desired level of
confidence, the expected effect size, and the variability of the dependent variable.

The sample size is determined by the following formula. n=

Where n=sample size

D= 5% margin error

Z= 1.96

P= 48.1% [23]

N= Population size

n= 383.5~ 384
17
The total number of nurses in Tikur Anbessa Specialized Hospital is 800.[44]

Correction formula, na =

na = 259.8~260

Add 10% for non-response rate.

N= 10% of sample size + sample size

N= 26+260 = 286

N~ 286

4.6. Sampling Technique

In this study convenience sampling technique was used and those participants available at the
time of data collection were selected.

4.7. Study Variables

4.7.1. Dependent Variables
 Non-pharmacological pain management.

4.7.2. Independent Variables

 Patient characteristics (e.g., age, gender…)
 Years of experience.
 Training and education.
 Availability of resources.
 Nurse's workload and staffing levels.
 Nurse's attitudes and beliefs.
 Nurse-patient communication.
 Organizational culture and policies.

18
4.8 Operational Definitions of Terms
 Good knowledge: nurses who had scored mean and above (>6.7) on the knowledge-
related questions.
 Poor knowledge: nurses who scored below the mean (<6.7) on the knowledge questions.
 Positive attitude: nurses who had scored mean and above (>10.7) on the attitude-related
questions.
 Negative attitude: nurses who had scored below the mean (<10.7) on the attitude-related
questions.
 Good practice: Those nurse who able to answer above the mean (>20.9) of the practice
questions.
 Poor practice: Those nurse who able to answer below the mean (<20.9) of the practice
questions.
 Mean score: which was calculated from total sum of all individual score then dividing it
by total number of response. [30]

4.9 Data Collection Instruments and Procedures

A structured self-administered questionnaire was used to collect data from participant. It was
adapted from a different literature related to the study problem, and legal management
consultants to suit the study setting [30] the questionnaire was prepared in English. The data
collection tool consists of five sections;

 Section I: includes demographic questions (gender, marital status, education level,

residence, years of experience, and age);
 Section II: nurses‘ knowledge assessment questionnaire: It include question to assess
nurses‘ knowledge regarding non-pharmacological pain management.
 Section III: nurses‘ attitude assessment questionnaire.
 Section IV: nurses practice assessment questionnaire (practices, types of non-
pharmacological pain management therapies like thermal regulation, massage, position
change, distraction, heat /cold application and verbally comforting and reassuring the
patient)
Section V: Questionnaire that assess barriers that prevent nurses from using non-
pharmacological methods.

19
4.10 Data Processing and Analysis
To calculate the mean score of knowledge, participants who answered True were considered as
correctly answered and those who answered False were considered as not answered correctly.

To calculate the mean score of attitude, participants who answered agree were considered as
correctly answered and those who answered disagree were considered as not answered correctly.

To calculate the mean score of practice, participants who select Not at all got 1/5, Very
seldom=2/5, sometimes=3/5, Nearly always =4/5 and Always=5/5 from each question.

Therefore the mean score of knowledge, attitude and practice was calculated from total sum of
all individual score divided by total number of responses. As a result the mean score was used to
classify the knowledge, attitude and practice level of respondents as good (positive) and poor
(negative). Respondents who scored mean value of above 6.7, 10.7,20.9 from knowledge,
attitude and practice question respectively classified to have Good knowledge, positive attitude
and good practice respectively. Respondents who scored mean value of below 6.7, 10.7,20.9
from knowledge, attitude and practice question respectively classified to have poor knowledge,
negative attitude and poor practice respectively.

The collected data was checked for completeness, edited, entered, and analyzed in KoboCollect
v2024.1.3 and Microsoft Excel. Tables and graphs were used to present the results. Descriptive
statistical analysis, such as means, frequencies, and percentages, was used to describe the
characteristics of the study population.

4.11 Data Quality Control

The pre-test: was done with 5% of the sample population (nurses) from St. Paul Referral
Hospital. Content validity and reliability were assessed to enrich the data collection tool. Based
on the finding, the necessary amendment was undertaken before proceeding with the actual data
collection process.

20
4.12 Ethical Approval and Consent to Participate

An ethical clearance and official letter was obtained from the research and ethics committee of
School of Nursing and Midwifery of AAU to Tikur Anbessa Specialized Hospital. After getting
permission from the hospital to participate in the study, verbal and written consent was obtained
they was informed that there is not any incentive or harm for their participation in the study.
Finally, participants‘ identity was unnamed during data collection and analysis.

The questionnaire was not exposed to any other person other than data collectors assuring that all
the information was kept confidential, and all the study subjects were assured that they have the
right to stop at any time during data collection.

4.13 Dissemination of the Result

The result of the study will be presented and submitted to Addis Ababa University, School of
Nursing and Midwifery as partial fulfillment of the requirement for a Bachelor's degree in
nursing. The final result of this study will be accessed to Addis Ababa University, health science
college library as the source for future learning. It will also be disseminated to the study
hospitals, Schools of Nursing, and Midwifery through hard copies which will be used as input
for healthcare professional training and development.

21
 Chapter Five: Result
5.1 socio-demographic characteristics of participant

A total of two hundred eighty six (286) nurses in Tikur Anbessa hospital were participated in the
study and the response rate was 100%. Also 137(47.9%) were male and 149(52.1%) were
females. The sample include nurses in all age groups from 20 or below up to 60+ years of age;
the most common age was 21-29 age group or (50.7%) of the sample and there was Two
participant who record 60+ of years. 48.95% of nurses were married and nurses with their
Baccalaureate (73.78%) of the sample. The largest work experience study participant 0-9 years,
which was 176 (61.54%) nurses. Among all of nurses that completed survey only 132 (53.5%)
said there was assessment tool unavailable on their unit and 120 (78.43%) use it (Table 1).

Table1: Socio-demographic characteristics of nurses in Tikur Anbessa Specialized Hospital,

Ethiopia, 2024

No. Questions Coding Frequ Percentage

Categories ency
101 Sex Male 137 47.9%
Female 149 52.1%
102 Age in years <20 - -
21-29 146 51.05%
30-39 85 29.72%
40-49 38 13.29%
50-60 17 5.94%
>60 - -
103 Marital status Married 140 48.95%
Single 132 46.15%
Divorced 8 2.8%
widowed 4 1.4%
104 Level of education Diploma 6 2.1%

22
 baccalaureate 211 73.78%
Master‘s 63 22.03%
PhD 5 1.75%
105 Work experience in year 0-9 176 61.54%
10-29 98 34.27%
30-39 12 4.2%
>40 - -
10 Any class in non- pharmacological Yes 218 76.22%
6 pain management in either nursing
No 66 23.08%
school? Or continuing education
since after graduation?
10 Hours of non-pharmacological 0- 5hr 100 45.87%
7 class 5- 10 hrs. 84 38.53%
10-15 hrs. 22 10.09%
>15 hrs. 12 5.5%
10 If you answered YES to number In nursing 126 57.79%
8 106, when did you attain this practice since
education? after
Graduation.
In formal 92 42.21%
nursing school
education
10 If you answered NO to Yes 48 72.72%
9 number106 do you wish had more No 18 27.27%
education involving non-
Pharmacological pain
management?
11 Available pain assessment tool Yes 153 53.5%
0 for evaluating patient‘s pain on
No 132 46.15%
unit

23
11 If YES to number 110, do you use Yes 1 78.43
1 the tool? 2 %
0
No 3 21.57
3 %

11 Have you ever used non Yes 276 96.5%

2 pharmacological pain No 10 3.49%
management method?

113 If you answered YES to number Heat / cold 217 78.62%

112, what are they?
Position change 215 77.89%

Massage 151 54.71%

Distraction 161 56.29%

Reassurance 110 38.46%

Others 233 81.47%

114 How often do you use any of the At least 3 times 157 56.88%
above methods? a week
Once week 109 39.49%
Once every 8 2.89%
other week
Once a month 2 0.7%

24
5.2. Non-pharmacological pain management methods utilization

Majority of study participants used Heat and cold application 217(78.62%), position change 215
(77.89%), massage 151(54.71%), distraction 161(56.29%), reassurance 110 (38.46%) and others
233(81.47%) for pain management.

Percentage

Heat/cold
81.47% 78.62%
Position change
Massage
38.46%
77.89% Distraction
56.29% Reassurance
54.71.% Others

Figure 2: Utilization of non-pharmacological pain management methods of respondent

Table 2: Knowledge, attitude, and practice of respondents on non-pharmacological pain management

among nurses in tikur Anbessa hospital, Ethiopia, 2024
Characteristics Frequency Percentage Mean score
Knowledge

Poor 134 46.85%

6.7
Good 152 53.15%

Attitude

Negative 101 35.31% 10.77

25
Positive 185 64.69%

Practice

Poor 133 46.50%

Good 153 53.5% 20.9

70.00% 64.69%

60.00%
53.15% 53.50%
50.00% 46.85% 46.50%

40.00% 35.31%
Good
30.00% poor

20.00%

10.00%

0.00%
knowledge attitude practice

Figure 3: Knowledge, attitude, and practice of respondents on non-pharmacological pain

management among nurses in tikur Anbessa hospital, Ethiopia,2024

26
5.3 Knowledge of respondents about non-pharmacological pain management

Among 286 nurses, 152(53.15%) had good knowledge and 134(46.85%) had poor knowledge about
non pharmacological pain management methods

Table 3: distribution of nurses knowledge regarding non pharmacological pain management in tikur Anbessa
hospital, Ethiopia,2024.
Variables Response Frequency Percentage

Provide a suitable room True 275 96.15%

temperature and good air
False 11 3.85%
condition can relieve
pain
Provide the patient with True 265 92.66%
possibility to rest by
False 1.9 6.64%
minimizing noise can
relive pain
Including family True 260 90.91%
members in the pain
management regimen False 26 9.09%

can increase patient‘s

ability to manage pain.
Use of non - True 258 90.21%
pharmacological pain
False 28 9.79%
management method
has no value to the
patient
Try to focus a patient‘s True 260 90.91.%
thoughts/ attention
False 26 9.09%
away
from pain can decrease

27
pain
Asking the patient to True 265 92.66%
suggest ways to relive
False 21 7.34%
his/her pain can
increase patient‘s
ability to manage pain
Patients who can be True 164 57.34%
distracted from pain
False 121 42.31%
usually do not have
severe pain
Non drug interventions True 174 60.84%
(e.g. distraction, heat,
False 112 39.16%
music, imagery etc.)
are effective only for
mild pain control

5.4. Attitude of respondent regarding non-pharmacological pain management

A majority of participant have positive attitude towards non-pharmacological pain management
method such as, willingness to provide information 274(95.8%), willingness to provide non-
pharmacological pain management 263(91.96%), proper carefully for procedure 243(84.97%),
Teaching the patient the correct breathing technique 243(84.97%), interior decoration
237(82.87%) and family member involvements 240(83.92%).

28
Table 4 : Distribution of nurses attitude regarding non pharmacological pain management in Tikur Anbessa
Hospital, Ethiopia,2024
Variables Response Frequency percentage
Non-pharmacological method should be given to sick Agree 272 95.1%
people Disagree 13 4.55%
Information on issues related to non - Agree 267 93.36%
pharmacological methods should be given for Disagree 19 6.64%
patient’s family
Willingness to provide information on issues related Agree 274 95.8%
to non-pharmacological methods to sick people Disagree 12 4.2%
Willingness to provide non pharmacological methods Agree 263 91.96%
to people who have pain Disagree 21 7.34%
Patient should be advised to use non pharmacological Agree 273 95.45%
means with pain medications Disagree 13 4.55%
Preparing a patient carefully for a procedure by Agree 243 84.97%
telling him/her about what will be done can decrease Disagree 43 15.03%
pain
Willingness to encourage the patient to think about / Agree 262 91.61%
imagine pleasant and positive matter when she/he Disagree 23 8.04%
feels pain
Teaching the patient the correct breathing technique Agree 243 84.97%
can relieve his/her pain Disagree 43 15.03%
Encourage the patient by rewarding her/him verbally Agree 236 82.52%
when he/ she feel pain Disagree 50 17.48%
Encourage the patient to relax different parts of his/ Agree 271 94.76%
her body can relieve the sensation of pain Disagree 15 5.24%
Interior decoration of the unit affects patient’s ability Agree 237 82.87%
to manage pain Disagree 49 17.13%
Willingness to encouraging family members to bring Agree 240 83.92%
some of the patient’s belong to the unit Disagree 46 16.08%

29
5.5. Practice of participants regarding to non-pharmacological pain
management

In this study among 286 participants 276 (96.5%) of them have used non pharmacological pain
management method from this Thermal regulation was used always (2.17%), nearly always (5.07%),
sometimes (28.98%), very seldom (34.78%) and not at all (28.98%). Cold application was used always
(2.17%), nearly always (9.42%), sometimes (51.81%), very seldom (15.22%), not at all (21.37%). Heat
application was used always (3.62%), nearly always (3.62%), sometimes (49.2%), very seldom (22.1%),
not at all(21.37%). Massage was used always (0.72%), nearly always (3.26%), sometimes (25.36%), very
seldom (25.36%), not at all (45.29%). Spend time with patient was used always (5.43%), nearly always
(27.25%), sometimes (18.11%), very seldom(32.97%), not at all(63.77%). Position change was used
always (5.07%), nearly always (11.96%), sometimes (45.29%), very seldom (15.58%), not at all
(22.1%). Touching was used always (0.72%), nearly always(1.81%), sometimes(4.71%), very
seldom(28.98%), not at all(63.77%). Breathing technique was used always (9.42%), nearly
always(9.42%), sometimes(36.23%), very seldom(19.56%), not at all(23.36%).

A majority of participants practice all non-pharmacological pain management with in the order
of percentage on heat/cold application 217(78.62%), position change 215(77.89%) , breathing
technique 206(74.64%), thermal regulation 196(71.01%), spend time with the patient 176
(63.77%), massage 151(54.7%) , and touching 100 (36.23%).

30
 Percentage
90.00%
78.62% 77.89%
80.00% 74.64%
71.01%
70.00% 63.77%
60.00% 54.70%

50.00%

40.00% 36.23%
percentage
30.00%

20.00%

10.00%

0.00%
heat/cold thermal position massage touching breathing spend time
regulation change technique with the
patient

Figure 4: practice of respondent among nurses in TikurAnbessa hospital, Ethiopia, 2024

31
5.6 Assessment result of barriers that prevent nurses from using non-
pharmacological pain management methods

The top three barriers regarding non pharmacological pain management listed by participants were lack of
patient/ family awareness (82.52%), work load (79.02%) and lack of facilitation in service training
program (78.32%).

Table 5: Patient related and Organization related Barriers regarding non pharmacological pain
management

Variables Value Frequency Percentage

Patient related Lack Patient/family 236 82.52%
barriers Awareness
Family / patient 198 69.25%
need
Patient unwilling 148 51.75%
Others 26 9.09%
Organization Nurse patient ratio/ 226 79.02%
related barriers workload
Lack of facilitation 224 78.32%
in service training
program
Lack of equipment 192 67.13%
Inadequate or 173 60.49%
absent of guideline
Others 7 2.45%

32
5.7 Relationship Between Socio-demographic characteristics and Knowledge,
attitude, Practice of non-pharmacological pain management

The following consecutive table is going to describe briefly about the relation of socio-
demographic characteristics with Knowledge, attitude, Practice of non-pharmacological pain
management

Table 6: Relationship between socio-demographic characteristics and knowledge on non-

pharmacological pain management among nurses in Tikur Anbessa Specialized hospital

CHARACTERISTICS Non pharmacological pain management knowledge

GOOD(152) POOR(134)

Sex
Male 78 (51.3%) 59(44.02%)

Female 74(48.6%) 75(55.9%)

Age
<30 77(5.7%) 69(51.49%)

>30 75(49.3%) 65(48.5%)

Level of education
Diploma 4(2.63%) 2(1.49%)

Baccalaureate 111(73.0%) 100(74.6%)

Masters 33(21.7%) 30(22.3%)

PHD 4(2.63%) 1(0.74%)

Work experience
0-9 97(63.8%) 79(58.9%)

10-29 46(30.2%) 52(38.8%)

30-39 9(5.9%) 3(2.2%)

Took any class in non-
pharmacological pain
management:
Yes 131(86.18%) 87(64.9%)

No 20(13.1%) 46(34.3%)
Available pain assessment tool
Yes 90(59.21%) 63(47.01%)

No 61(40.13%) 71(52.98%)

33
Table 7: Relationship between socio-demographic characteristics and Attitude on non-pharmacological
pain management among nurses in Tikur Anbessa Specialized hospital

CHARACTERISTICS Attitude towards non pharmacological pain management

Positive(185) Negative(101)
Sex
Male 93(50.27%) 44(43.56%)

Female 92(49.73%) 57(56.44%)

Age
<30 88(47.57%) 58(57.43%)

>30 97(52.43%) 43(42.57%)

Level of education
Diploma 4(2.16%) 2(1.98%)

Baccalaureate 130(70.27%) 81(80.2%)

Masters 46(24.86%) 18(17.82%)

PHD 5(2.7%) 0
Work experience
0-9 110(59.46%) 66(65.35%)

10-29 63(34.05%) 34(33.66%)

30-39 12(6.49%) 1(0.99)

Took any class in non
pharmacological pain
management
Yes 152(82.16%) 67(66.34%)

No 33(17.84%) 34(33.66%)
Available pain assessment
tool 101(54.59%) 53(52.48%)
Yes
84(45.41%) 48(47.52%)
No

34
Table 8: Relationship between socio-demographic characteristics and practice on non-pharmacological
pain management among nurses in Tikur Anbessa Specialized hospital

CHARACTERISTICS Non pharmacological pain management practice

GOOD(153) POOR(133)
Sex
Male 69 (45.0%) 68(51.1%)

Female 84(54.9%) 65(48.8%)

Age
<30 68(44.4%) 78(58.6%)

>30 85(55.5%) 55(41.3%)

Level of education
Diploma 4(2.6%) 3(2.2%)

Baccalaureate 111(72.50%) 100(75.18%)

Masters 33(21.5%) 30(22.5%)

PHD 5(3.26%) -
Work experience
0-9 97(63.3%) 79(59.3%)

10-29 46(30.06%) 52(39.9%)

30-39 10(6.5%) 4(3.0%)

Took any class in non
pharmacological pain
management
Yes 121(79.0%) 97(72.9%)

No 32(20.9%) 36(27.06%)
Available pain assessment tool
Yes 80(52.28%) 63(47.3%)

No 73(47.7%) 70(52.6%)

35
 Chapter six: Discussion
The aim of this study was to assess the knowledge, attitude and practice of nurses who are
working in patient ward and barriers on non-pharmacological pain management. The current
study found that about 53.15% of respondents had good knowledge. This finding is consistent
with the study done in Benshangul gumuz, Ethiopia, 2018(51.2%) (9), however, this finding is
low as compared with study done in Makkah EI-Mukarramah, 2013 (87.5%) (15). this difference
could be due to differences in technological advancement, curriculum regarding non
pharmacological pain management.
The current study revealed that about 64.69% had positive attitude regarding non-
pharmacological pain management. This finding is comparable with study done in Benshangul
gumuz, Ethiopia, 2018 show that positive attitude of 47% (9) that is less than the current study,
this may be due to high perception of non-pharmacological pain management method and use
different scoring system.
The current study revealed that about 53.5% had good non-pharmacological pain management
practice, About 78.62% heat/cold application practice, 77.89% position change practice,74.64%
thermal regulation practice and 74.64% breathing technique practice. This good non-
pharmacological pain management practice among nurses in the study area might be due to in-
service training and good knowledge about non-pharmacological pain management method, this
finding is comparable with study done in Debre Tabor Comprehensive Specialized Hospital (21)
show that only (26%) of participants have good non-pharmacological pain management practice.

The study also showed that Barrier regarding non-pharmacological pain management practice
the largest barrier list by participant was lack of patient/family awareness (82.52%), workload
(79.02%), lack of facilitation in service training program(78.32%),family/patient need (69.25%),
lack of equipment (67.1.3%), absence guide line (60.49%) and patient unwilling (57.75%).
The current study was nearly similar with the study done in Debre Tabor Comprehensive
Specialized Hospital (21) in reporting work load (74%) as the second largest barrier to non-
pharmacological pain management practice. But it also reported inadequate cooperation of
physicians as the first largest barrier to non-pharmacological pain management practice,
comparable to the current study found that lack of patient/family awareness (82.52%) was the
largest barrier to non-pharmacological pain management practice.
36
 Chapter seven: Conclusion
This descriptive cross-sectional study investigated the knowledge, attitude, and practice of nurses
regarding non-pharmacological pain management at Tikur Anbessa Hospital in Addis Ababa,
Ethiopia, in 2024. The findings of this research highlight both the strengths and areas of
improvement in nurses' approach to non-pharmacological pain management.
In this study, we found significant differences in the knowledge, attitude, and practice (KAP) of
non-pharmacological pain management methods among various demographic groups. Our results
indicate that females have poorer knowledge (75 participants, 55.9%) compared to males (59
participants, 44.02%). This disparity may stem from differences in access to continuing
education or professional development opportunities and societal expectations that influence the
emphasis placed on acquiring knowledge in specific fields for each gender.
Regarding education levels, 73% of Baccalaureate holders have good knowledge while 74%
have poor knowledge, and 33% of Masters holders have good knowledge while 30% have poor
knowledge. These results suggest that both Baccalaureate and Masters holders have a relatively
equal number of participants with good and poor knowledge. Possible reasons for this could
include variations in curriculum content, with Baccalaureate programs possibly placing a greater
emphasis on non-pharmacological pain management, and differences in practical exposure
between the two groups.
In terms of attitude, the majority of participants, regardless of gender, age group over 30, and
education level, have a positive attitude towards non-pharmacological pain management. This
could be attributed to effective training and awareness programs that highlight the importance
and benefits of these methods, as well as a general cultural shift in the medical community
towards holistic and integrative approaches to pain management.

When it comes to practice, females and participants over the age of 30 demonstrate good practice
of non-pharmacological pain management. This could be due to their greater professional
experience and a nurturing approach that aligns well with these methods. Additionally,
participants with a Ph.D. and those with work experience ranging from 30 to 39 years also show
good practice, likely due to their advanced research training and extensive practical experience.
Participants who have taken a non-pharmacologic pain management class also exhibit good

37
practice, highlighting the importance of specialized training in enhancing both knowledge and
practical application.
It can be concluded from the present study that knowledge, attitude and practice of non-
pharmacological pain management among nurses in the study area was positive attitude but poor
knowledge and practice of non-pharmacologic pain management methods of study subjects,
46.85% had poor knowledge, 46.50% had poor practice and 64.69% had positive attitude on non-
pharmacological pain management method.
It underscores the significance of continuous education and training programs to enhance nurses'
competencies in this critical aspect of patient care. By addressing the identified gaps and
building upon existing strengths, healthcare providers can work towards implementing more
effective and comprehensive pain management strategies, ultimately leading to improved patient
outcomes and quality of care. This study contributes valuable insights to the field and serves as a
foundation for future research and interventions aimed at enhancing pain management practices
in healthcare settings.

Chapter Eight: Strength and limitation of the study

8.1. Strength of the study
 Sample size was high (approximately close with total number of nurse)
 Most of the non-pharmacological pain management barrier-were assessed in this study
 The response rate was 100%.
 Specific Population Focus: By focusing on nurses at Tikur Anbessa Hospital, the study
provides valuable insights relevant to a specific healthcare setting in Addis Ababa,
Ethiopia, which can inform localized interventions and policies.
 Descriptive Cross-Sectional Design: This design allows for the collection of data at a
single point in time, providing a snapshot of current knowledge, attitudes, and practices.
This is efficient for identifying areas needing improvement.
 Practical Implications: The findings can be directly applied to improve nurse training
programs, develop targeted interventions, and enhance patient care strategies at the
hospital.

38
8.2. Limitation of the study
 The cross-sectional study design makes determining causality impossible.
 Pain assessment tools were not assessed.
 Single-Site Study: Conducting the study at only one hospital may limit the
generalizability of the findings to other settings within Ethiopia or other countries, as the
results are specific to Tikur Anbessa Hospital.
 Snapshot in Time: The data reflects a specific moment, and the knowledge, attitudes, and
practices of nurses might change over time due to new policies, training, or other
interventions not captured in this study.

Chapter Nine: Recommendation

 The findings of this study on the knowledge, attitude, and practice of nurses regarding
non-pharmacological pain management at Tikur Anbessa Hospital highlight the need for
comprehensive strategies to improve these aspects among nurses. The study revealed that
while nurses generally have a positive attitude towards non-pharmacological pain
management, their knowledge and practice in this area are lacking, with 46.85%
demonstrating poor knowledge and 46.50% showing poor practice, despite 64.69%
having a positive attitude.
 To address these gaps, continuous education and training programs are essential. Regular
workshops, seminars, and hands-on simulation training can significantly enhance nurses'
knowledge and skills. Integrating more detailed modules on non-pharmacological pain
management into the nursing curriculum and encouraging practical assignments and
internships focused on these methods can further solidify this knowledge.
 Developing standardized protocols and advocating for policies that support non-
pharmacological pain management integration into routine clinical practice are also
39
 crucial steps. Additionally, implementing regular assessments and feedback mechanisms
will help ensure ongoing improvement in nurses' performance.
 An interdisciplinary approach, involving collaboration with physiotherapists,
psychologists, and other healthcare professionals, can foster a more holistic approach to
pain management.Research should continue to evaluate the effectiveness of training
programs and explore barriers to the implementation of non-pharmacological pain
management techniques.
 Comparative studies on non-pharmacological versus pharmacological approaches and
research into patient satisfaction and clinical outcomes related to these practices will
provide valuable insights. By addressing these areas, healthcare providers can work
towards more effective and comprehensive pain management strategies, ultimately
improving patient outcomes and the quality of care.

 Encourage nurses to educate patient about benefits of non-pharmacological pain

management
 Tikur Anbessa hospital encourage nurses for in-service training program to enhance
nurses competence on pain management
 Tikur Anbessa hospital prepare pain assessment tool and increase number of nurses
 Further study should be in other hospital and qualitative method should be use
 Higher educational organization should be review the curriculum for preparation of
nursing student in non-pharmacological pain management method

40
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44. Tikur Anbessa Specialized Hospital human resource office.

44
 Annex
AnneX I: Information Sheet Ana Participant Consent Form
Information Sheet
Greetings, Nursing Community
We are an undergraduate student at College of Health Sciences, Addis Ababa University. We are
conducting a research study about Non pharmacological pain management knowledge, attitude
and practice among nurses and associated factors at Tikur Anbessa Specialized Hospital, Addis
Ababa, Ethiopia 2024.

We are inviting nurses currently working at Tikur Anbessa Specialized Hospital to take part and
answer a questionnaire. If you decide to take part, your participation in this research study will
last about 10 – 15minutes, the research activity will take place at Tikur Anbessa Specialized
Hospital after work time.

The information will be kept confidential. Only, the researchers will have access to the data.
When we share the results of the research, we will not include your name or anything else that
could identify you. With your permission, other researchers may use the data collected from this
research study, but your name and any personal information will not be used or passed on.

If you decide to take part in the research study, it should be because you want to volunteer. You
do not have to take part. You can stop being in the study at any time. You do not have to answer
any questions if you do not want to. You will not get any direct benefits if you choose to join the

45
research study. You will not lose any services; benefits or rights you would normally have if you
decide not to join. Taking part in the research study will not cost you anything. You will not be
paid for being in this research study.

This research study will be written up as a research report. The report will be available on the
university website. If you would like to receive a summary of this report, we will be happy to
send it to you.

If you have any questions during or afterwards about this research study, feel free to contact us
on: telephone email:

Investigators Name __________________ Signature ______ Date ___/___ /____

Supervisor Name __________________ Signature ______ Date ___/___/____

The Consent Form

We would like to explore your perceptions regarding each of the processes included in the
participant information sheet attached. We require your consent before we proceed. Please tick
and sign as appropriate.

YES NO
I confirm that I have read and understood the participant information
sheet and I understand the purpose of this questionnaire and interview.

I acknowledge that participating in this study is voluntary and that I may

withdraw at any time.

I consent to the research staff collecting and processing my information.

I understand that my involvement in this study is private and that no

material, which could identify me personally will be used in any reports
on this study.

46
I know who to communicate with if I have any questions about the study
in general.

I understand my responsibilities as a study participant.

Declaration by participant:

I consent to take part in this study.

Participant‘s name:__________________

Signature: __________________ Date: _________________

ANNEX 2: The Questionnaire

Addis Ababa University; College of Health Science; School of Public Health; English Version
Questionnaire for Nurses It is a standardized questionnaire.

Answer the following questions by putting an alternative by using a _______.

Identification number of participants (code)_____

Section I: Socio-Demographic Characteristics of the Participants

No. Questions Coding Categories

101 Sex Male

Femae
102 Age in years <20
21-29
30-39
40-49
50-659
>60
103 What is your Marital status Married
Single
Divorced

47
 widowed
104 What is your Level of education Diploma
baccalaureate
Master‘s
PhD
105 Work experience in year 0-9
10-20
20-29
30-39
>40
106 Have you had any class in non- Yes
pharmacological pain management in either
nursing school? Or continuing education No
since after graduation?
107 If you answered YES to number 106 about 0- 5hr
how many hours did you have? 5- 10 hrs.
10-15 hrs.
>15 hrs.
108 If you answered YES to number 106, when In nursing practice since after
did you attain this education? Graduation.
In formal nursing school education

109 If you answered NO to number106 do you Yes

wish had more education involving non-
No
Pharmacological pain management?
110 Is there a pain assessment tool available for Yes
evaluating patient‘s pain on your unit?
No

111 If you answered YES to number 110, do you Yes

use the tool? No
If yes, which
tools you used__________________
112 Have you ever used non pharmacological Yes
pain management method? No
113 If you answered YES to number 112, what Position change

48
 are they? Massage

Distraction

Heat/ cold

Reassurances

Others, what? Please list

114 How often do you use any of the above Every day
methods? At least 3 times a week
Once week
Once every other week
Once a month

Section II: knowledge question for non-pharmacological pain management

49
 Provide a suitable room temperature and good air True
condition can relieve pain
201 False

Provide the patient with a possibility to rest by True

minimizing noise can relieve pain
202 False

Including family members in the pain management True

regimen can increase patient‘s ability to manage pain.
203 False

Use of non -pharmacological pain management method True

has no value to the patient
204 False

Try to focus a patient‘s thoughts/ attention away True

205 from pain can decrease pain False

Asking the patient to suggest ways to relive his/her pain True

can increase patient‘s ability to manage pain
206 False

Patients who can be distracted from pain usually do not True

have severe pain
207 False

Non drug interventions (e.g. distraction, heat, music, True

imagery etc.) are effective only for mild pain control
208 False

50
Section III: Attitude questions

No. Questions

Do you think that non-pharmacological method should Agree

be given to sick people?
301 Disagree

Do you think that information on issues related to non Agree

-pharmacological methods should be given for
302 Disagree
patient‘s family?

Are you willing to provide information on issues Agree

related to non-pharmacological methods to sick
303 Disagree
people?

Are you willing to provide non pharmacological Agree

methods to people who have pain?
304 Disagree

Do you agree with that, patient should be advised to Agree

use non pharmacological means with pain
305 Disagree
medications?

Do you think that preparing a patient carefully for a Agree

procedure by telling him/her about what will be done
306 Disagree
can decrease pain?

Are you willing to encourage the patient to think Agree

about / imagine pleasant and positive matter when
307 Disagree
she/he feels pain?

Do you agree with that, teaching the patient the Agree

correct breathing technique can relieve his/her pain?
308 Disagree

Do you encourage the patient by rewarding her/him Agree

verbally when he/ she feel pain?
309 Disagree

Do you think that encourage the patient to relax Agree

different parts of his/ her body can relieve the sensation
310 Disagree
of pain?

51
 Do you think that interior decoration of the unit affects Agree
patient‘s ability to manage pain?
311 Disagree

Are you willing to encouraging family members to Agree

bring some of the patient‘s belong to the unit?
312 Disagree

Section IV: practice questions

There are statements about practice of non- pharmacological pain management and each
statement has five alternatives with five-point scale. Read each item carefully and circle.

1= not at all

2 = very seldom

3= sometimes

4 = nearly always

5 = always

No. Non- pharmacological Pain management measuring Five point scale

items

401 I use thermal regulation as a method of pain relief 1 2 3 4 5

402 I use cold application to relive pain 1 2 3 4 5

403 I use heat application to relive pain 1 2 3 4 5

404 I use massage to relive pain 1 2 3 4 5

405 I spend time with the patient when s/he feels pain 1 2 3 4 5

406 I relieve the patient‘s pain by position changes 1 2 3 4 5

407 I use touching as a method of pain relief 1 2 3 4 5

408 I use breathing technique to relive pain 1 2 3 4 5

52
Section V: Questionnaire that assess barriers that prevent nurses from using non-
pharmacological methods.

After properly reading the following statements, identify barriers that hinder nurses from using
non-pharmacological pain management and put the right symbol in the provided box.

Barriers

501 Patient related barrier Patient unwilling

Family / patient need

Lack Patient/family Awareness

Others, what? Please list

502 Organizational related barrier Inadequate or absent of guideline

Nurse patient ratio/ workload

Lack of facilitation in service training

program

Lack of equipment

Others, what? Please list

53