Influences on Nurses’ Approaches to Preoperative Pain Management in the East Regional Hospital, Bolgatanga, Ghana

Influences on Nurses’ Approaches to Preoperative Pain Management in the East Regional Hospital, Bolgatanga, Ghana

*Rachael Konadu Kyei¹, Lydia Aziato², David Tenkorang Twum³

¹Department of Surgery, Regional Hospital Bolgatanga, Bolgatanga, Ghana

²University of Health and Allied Sciences, Ho, Ghana

³University of Ghana, School of Nursing and Midwifery, Department of Adult Health, Accra, Ghana

*Corresponding Author

DOI: https://doi.org/10.51244/IJRSI.2025.12040111

Received: 08 April 2025; Accepted: 14 April 2025; Published: 17 May 2025

ABSTRACT

Pain has multiple dimensions, which are psychological, physical, emotional, and spiritual, and to manage pain effectively, a holistic assessment and management is required. However, the factors affecting preoperative pain assessment and management practices are poorly understood in Ghana.  This study explored the knowledge, attitude and practices on nurses’ approaches to the implementation pain management in the Regional Hospital Bolgatanga in the Upper East Region, Ghana. An exploratory descriptive qualitative research design was used the observation to identify and quantify for analysis that reached the results during this study. A non-parametric purposive sampling technique was used to selecting the 15 participants for the study.  A semi-structured interview guide was used to collect data through face-to-face in-depth interviews. The interviews were audio recorded, transcribed verbatim and analysed using thematic content analysis. The observation during study the study presented findings that indicated that nurses were aware of the need to assess and manage pain.  The study also revealed a lack of preoperative pain management protocols for nurses, a limited supply of consumables and equipment, and preoperative education guidelines. The study identified that cultural beliefs, societal perceptions, and financial constraints influenced pain management.  The study showed that nurses who manage surgical patients preoperatively use both pharmacological and non-pharmacological pain management strategies to manage pain.  Pain management is influenced or affected by sociocultural beliefs and financial constraints. Facility-based factors affect the assessment and management of preoperative pain in the study context. The nurses employed posture, the application of cold compresses, and massage to help lower patients’ degree of pain

Keywords: pain management, pain assessment, preoperative pain, pain

INTRODUCTION

Pain is a common experience among patients undergoing surgery worldwide. Effective preoperative pain assessment and management are crucial in ensuring patients’ comfort, and well-being and improve clients’ outcomes (Liu et al., 2023). Pain assessment and management play a crucial role in the overall care of patients undergoing surgery. Nurses’ understanding and management of preoperative pain are vital to patients’ pain experiences and recovery. Preoperative pain assessment helps to determine the intensity and the nature of pain experienced by the patient, which in turn aids in devising appropriate pain management strategies (Executive summary best practices pain management best practices inter-agency task force report, 2019).

Pain management aims to understand the pain better and improve efforts to prevent, assess, and treat pain (Kehlet, 2020). Despite pain research and how pain can be relieved, preoperative pain remains unmanaged in the population as a whole, especially in specific populations that include ethnic minorities and women (Taylor et al., 2020). Consequently, healthcare professionals, government agencies, health policymakers, and privately funded researchers are encouraged to lead this transformation that aims to reach the vast number of individuals with information on preoperative pain (Raja et al., 2020).

Risk Assessment Threshold and PQRST Implementation

To ensure a comprehensive preoperative pain evaluation, a structured risk assessment threshold has been established that incorporates the PQRST tool. This tool provides a systematic approach for pain assessment, enabling nurses to effectively evaluate and manage pain while aligning with continuous quality improvement and standardized operating protocols. The PQRST framework is defined as follows:

Risk Assessment Chart

The following character map (see Table 1) outlines the risk assessment threshold based on the PQRST tool. This chart is designed to guide clinical decision-making, ensuring that each element is consistently evaluated and recorded in line with the best practice guidelines, including those recommended by the Inter-Agency Task Force Report (Executive Summary on Best Practices in Pain Management, 2019).

Table: Risk Assessment Threshold

PQRST Component	Definition	Assessment Criteria/Threshold	Quality Improvement Indicator
Provocation/ Palliation	Factors that trigger or alleviate pain	Identify and document specific triggers and interventions; threshold based on patient response consistency	Regular audits of documented triggers and intervention outcomes
Quality	Description of the pain sensation	Use standardized descriptors (e.g., sharp, throbbing, burning) with patient input	Consistency in descriptive terminology across records
Region/ Radiation	Location and spread of the pain	Map the primary pain location and any radiation; threshold if pain spreads beyond the primary site	Periodic reviews of pain mapping accuracy
Severity	Intensity of pain measured on a numerical scale (0–10)	Threshold: Pain score ≥ 4 triggers escalation of intervention protocols	Monitoring frequency of pain score documentation
Timing	Duration, onset, and frequency of pain	Document onset time, duration, and frequency; continuous monitoring if pain is chronic	Regular assessment and timely re-evaluation protocols

Source: (Executive Summary on Best Practices in Pain Management, 2019).

According to O’Donnell (2015), pain management continues to be a challenge for healthcare professionals, especially in developing countries even though research shows improvements in some aspects. Despite an enhanced appreciation of the anatomy and neurophysiology of pain as well as the treatment improvements, evidence suggests that adequate pain management remains a challenge to many health practitioners (Chou et al., 2016; Turk, 2017; O’Donnell 2015).  A study in India on the prevalence of acute postoperative pain in adults undergoing in client’s abdominal surgery, and the relationship between pain intensity and satisfaction with analgesic management, revealed that the majority of clients experienced mild to extreme pain within the preoperative period before abdominal operation (Singh et al., 2016).  Mędrzycka-Dąbrowska et al. (2015) in their study found that 80% of the population experiences inadequate pain management globally, which affects diverse people. Such people are the elderly, breastfeeding mothers, pregnant women, mentally ill clients and children, compromising standard of health practice which affects pain management in various countries (Mędrzycka-Dąbrowska et al., 2015).

However, the highest achievable “standard of health” is enshrined as a fundamental right of every human being in the 1948 Universal Declaration of Human Rights document (WHO, 2012). This contains pain relief as part of the fundamental human right to health (Brennan et al., 2016).

Pain is still undertreated, particularly in low-income countries (Garcia et al., 2021). To contribute to a comprehensive model of pain management, it is prudent to draw attention to the graphic elements that influence the assessment and management of pain.

Studies are marginal in exploring the factors influencing preoperative pain assessment and management, especially in the Ghanaian context.  The few available studies on surgical pain are mostly on postoperative pain (Aziato & Adejumo, 2015; Aziato & Adejumo, 2014; Aziato et al., 2015).  As a result, empirical studies including literature relative to Ghanaian surgical clients’ preoperative experiences are lacking. This implies that preoperative pain management issues specific to the Ghanaian context may not have been sufficiently investigated (Aziato & Adejumo, 2014). Also, it has been established that each individual’s pain experience is influenced by the dynamic interaction of physical (physiological), psychological, and social factors (Craig & MacKenzie, 2021).

To manage pain effectively, an accurate diagnosis is paramount through a thorough medical history, which does not focus on the nature of pain but the past and present medical and social history. This will guide the healthcare provider to make an informed decision (Hooten et al., 2017).

Research suggests that various factors can influence nurses’ practices, in general.  However, an understanding of these factors in the light of preoperative pain assessment and management is important to improvements in the quality of care provided to clients, especially where there is limited empirical research exploring these factors from the perspective of nurses in Ghana. This understanding is better achieved through a qualitative study, to thoroughly explore these factors from the perspectives of nurses who work in the preoperative setting.

Over the past nine years at the Bolgatanga Regional Hospital of Ghana, clients present acute pain to the hospital that is sometimes culminate in surgical diagnosis. Various surgeries are performed after the diagnosis, and no pre-emptive analgesia is administered, especially to nontrauma surgical clients. These surgeries are done on in-patients and out-patients clients. It is, however, unclear how such preoperative pains are assessed and managed (Regional Hospital Annual Report, 2018). It is against this background that this study explored the factors influencing preoperative pain assessment and management among nurses in the surgical wards at the Regional Hospital in Bolgatanga Municipality in the Upper East Region of Ghana.

METHODOLOGY

Study design.

An exploratory descriptive qualitative research design was used. This research design is very appropriate when the topic being investigated has received little previous attention (Hunter et al., 2019). This is a hospital-based exploratory descriptive study and the social communication model of pain by Craig (2009) served as a theoretical guide. This qualitative research design helped to explore the factors influencing preoperative pain management practices among nurses. The in-depth interviews conducted with nurses working in the preoperative setting assisted in gaining insights into the experiences, beliefs and attitudes that impact nurses’ practices in this area (Nesengani et al., 2019).

Study Area

There are sixteen regions in Ghana but currently, it has ten regional hospitals. The study was conducted in one of the ten regional hospitals, which is the Upper East Regional Hospital. This hospital is sometimes referred to as Bolgatanga Regional Hospital and it is the region’s largest hospital, which functions as a referral center, and a public health institution for other hospitals in the area. The hospital has a total nursing population of approximately one hundred, and fiftyeight (158) registered general nurses, with two hundred and twenty-five (225) as its total bed capacity. The Regional Hospital has a surgical section, which is attached to the operating theatre. It handles fifty (50) surgical procedures on average every week. This primarily influenced the facility’s selection as the study centre, so that a broader perspective of preoperative pain assessment and management would be investigated.  The study population consisted of all nurses who managed clients with acute pain at the Regional Hospital, Bolgatanga.

Inclusion and exclusion criteria   

To aid the selection of participants, some inclusion and exclusion criteria were outlined. The inclusion criteria included nurses who have worked in the surgical wards for at least one-year post-national service and are involved in the care of clients before surgery. The exclusion criteria were nurses who had worked in the surgical ward for less than a year after finishing their national service, students, and national service personnel due to their inexperience in pain management. Also, nurses on annual leave, maternity leave, or study leave were all excluded from the study because they were unavailable at the time of the study.

Sampling and sample size

A total of fifteen (15) nurses were purposively chosen from the total number of nurses who fell within the inclusion criteria. This consisted of ten (10) females and five (5) males.

Trustworthiness

To ensure credibility, the authors ensured that the individual interviews conducted adhered to all qualitative interview protocols. The audio recordings were subsequently transcribed verbatim with peer debriefing done for the study to resonate with people other than the investigators. Transferability was ensured by providing a thick description of the context of the study and the participants. Confirmability was ensured by following up with participants to clarify issues that cropped up during transcription to prevent the researchers from projecting their imaginations. Dependability was ensured by the researchers through conducting an external audit of the findings.

Data collection

A semi-structured interview guide was used to solicit relevant information from the study participants. The researchers created the interview guide using the constructs of the conceptual framework and the study’s objectives as a reference. This data collection instrument was used because it was not a fixed type and provided a sequence for data processing, allowing the researcher to analyse relevant material in an interview and identify areas of interest (Taherdoost, 2021). The interview guide was pretested at the emergency unit using two participants who shared the same characteristics. The modified interview guide was used for the data collection.  The open-ended questions of the interview guide allowed for follow-up questions to get the relevant data from participants.

The interviews were conducted through face-to-face interaction, which allowed the participants to share their lived experiences. The COVID-19 protocols, including using a face mask, at least one-meter physical distancing, and using a hand sanitiser were observed during data collection.

All the interviews were conducted at hospital premises and it lasted between 30 to 45 minutes. All the interviews were conducted in English, audio recorded and transcribed verbatim for data analysis.

Data Analysis

The recordings on the recording device were transcribed verbatim after each interview before the next one. The simultaneous data collection and transcription enabled the researchers to refine the following interviews while keeping track of evolving codes. Thematic content analysis guided by Graneheim and Lundman (2004), and Naeem et al. (2023) were used.  According to Naeem et al. (2023), thematic analysis of qualitative data is a sort of analysis guided by theory, principles, or models based on preconceived themes that guide the study. The researchers looked for similar statements during the data analysis by comparing each interviewee’s statements and identifying the commonalities. Codes were created by grouping similar words and expressions in each transcribed data set. Similar codes were grouped or classified into themes based on the framework’s structures. Common themes were grouped and sub-themes were determined based on the constructs of the Social Communication Model of Pain (Craig, 2009). The process continued until the data were exhausted. Two main themes and sub-themes emerged. The themes were institutional factors influencing preoperative pain assessment and management and Preoperative pain assessment and management practices. Some sub-themes were protocol, logistics, accessibility to medicine, and health personnel factors.

Ethical Considerations

The ethical aspects of this study were drawn for regulatory approvals, informed consent, voluntary participation, confidentiality, and plagiarism.  Approval of the research was sought through protocol number. A subsequent authorization by the teaching and research direction of the institution of research was developed. An introductory letter and request for approval to conduct the research were presented to the management of the facility.

FINDINGS

Profile of participants in the study

Participants included in this study were between the age group of 26 to 38 years old. The participants consisted of fifteen (15) nurses, ten (10) of whom were females (67%), and the remaining five (5) were males (33%). All the participants were registered general nurses aged 26 to 38 years and had their education at the tertiary level. Regarding work experience, the minimum work experience was one (1) year and the maximum work experience was 13 years. Eight (8) of the participants, representing 53%, had gained 1-5 years of working experience, four (4) participants representing 27% had 6-10 years, and three (3) participants, representing 20% had 11-15 years of working experience. Three (3) of the participants were Staff Nurses, two (2) Senior Staff Nurses, seven (7) Nursing Officers, and three (3) Senior Nursing Officers. To proceed with the data analysis, data categorization resulted in the thematic categories as presented in Table 1.

Table 2: Synthesis of Themes and Sub-Themes

Themes	Subthemes
Preoperative pain assessment and management practices	Observation and history taking Pharmacological Management Non-Pharmacological Management
Institutional factors influencing preoperative pain assessment and management	Protocols Logistics Accessibility to medicines Health personnel factors

Preoperative pain assessment and management practices among nurses

Most of the participant nurses utilized preoperative pain assessment and management practices. They stated that they manage preoperative pain using medications and other forms of non-pharmacological pain management and how health personnel and clients affect preoperative pain management practice.

Observation and History-taking

The participants were aware that a physical examination of preoperative clients aids in determining the type of pain they experienced. It also helped to identify the location and triggers or causes, particularly in patients who employed non-verbal pain expression through observation.

“Usually what happens is that when they come, you will do a physical assessment of the client. Just like I cited earlier about the hernias when you observe, and then you see maybe there is swelling somewhere, you will ask the client maybe probably how long it’s been there” (P1).

“…. also, you check vital signs there will be increased BP and increased pulse this can let you know that there is pain somewhere” (P15).

 Pharmacological management

Most participant nurses stated that pharmacological management of pain depends on the severity of the patient’s pain based on the pain assessment.

“…you have to give a pain medication which is normally the case because preoperative clients, most of them are usually in severe pain especially the emergencies” (P5).

“It depends on the severity, we have paracetamol for the low pain, but we have brufen, tramadol, pethidine and more, so sometimes we can also combine them depending on the severity” (P4).

The participants stated that they used opioids, Non-Steroidal Anti-Inflammatory Drugs

(NSAIDs), and antipyretics in managing a preoperative client’s pain in some cases in collaboration with the ward doctors, sometimes on a mobile phone.

“We give the opiates, preferably morphine, but where the respiration is compromised, we do not go in for morphine. Because it has a respiratory depressive effect so do not go in for morphine straight away. Sometimes we combine the NSAIDs with para, preferably IV paracetamol, because the tablet obviously would not work effectively. So normally, we go in for the IV (intravenous), and we add an NSAIDs like diclofenac injection and then when these two are combined it gives a good effect” (P3)

“…. when we get there, we realize that maybe when you assess and realize that client is in severe pain, then we go in for Morphine and then Tramadol. Mostly that is what we give, but when we see that the pain is not severe, we can even give diclo injection to relieve the pain” (P1)

Non-pharmacological management Some participants described several non-pharmacological approaches that were used to comfort a preoperative patient in pain. Most of these included positioning, application of cold or warm compress, massage and reassurance. They expressed these statements to emphasize.

Positioning

“As a nurse, when a client comes to me, and the patient is in pain, the mechanisms I will use, I will either make the client assume a position that is less painful or apply a warm or cold compress to help alleviate the pain” (P5).

“Frequently positioning or by repositioning the client too will help in relieving the patient’s pain, so sometimes may be the position the client is being put by repositioning or putting the patient in a comfortable position will also help to relieve the pain” (P11)

Application of cold compress and massage  

With regards to the application of cold or warm compress, some participants stated:

 “Sometimes, we apply cold compresses; for instance, a patient with scrotal hernia or swelling at the scrotum sometimes we apply the ice pack on it” (P10).  

Interestingly, a participant indicated that they massage some preoperative clients in pain, which gives the patients some relief for a short period.

“Mostly what we do is prepare warm water then we soak a towel or any material that can soak water then we apply it on the site. When we apply it on the site, the blood supply will increase to that site, so with the aid of our fingers, and we massage over there (where the pain is located). Most of the clients always tell us there is some amount of relief they get from that. Nevertheless, mostly because the (the pain is visceral) is still within, the pain comes back, so we do that one and add the pharmacological aspect to it. It can take the pain off for a while before it comes again” (P6).

Abdominal decompression and urethral catheterization

“We also pass your NG tube to decompress the client’s abdomen, for instance, if he or she has a distended abdomen. With the passing of the NG tube and then the draining of the abdominal content, the patient can be relieved of his or her pain. You could also pass ureteral catheter if the bladder is distended and probably the patient has bladder pain, so with the draining of the urine the client’s pain is relieved” (P9).

Reassurance

Some of the nurses stated that reassuring preoperative clients help to calm them down and feel safe in the facility.

“….. okay, so you can also reassure your clients, here we do the reassurance a lot. At least speak with your patient, psyche your patient’s mind, and that could at least alleviate the patient of his or her pain” (P9).

“…. you have to reassure the client; you let the person know that he is in good hands. Because you can have the best team, but the first impression is something so if the person does not have a good perception about you whatever you do, you can do all your best, but the person will never appreciate it, so your reassurance” (P4).

A few participants indicated that health workers pose as a barrier to pain management.

Sometimes the health professionals’ cultural background like a female nurse should not undress/see a male nakedness until a relative is available. Also, if they do not have the required knowledge of pain management, it affects care delivery. The patient can be under-dosed due to fear of the patient becoming addicted to a particular drug.

“Sometimes too, the prescriber will prescribe the drug as it is supposed to, but the Nurse refuses to give it, because she is afraid if she gives it, the client is going to develop tolerance against the drug” (P4). 

“Some too, its culturally inclined, some people see pain to be normal, so for the person due to cultural practices and all those things, to respond to your pains that means would have reached the worst severe pain before the person will act” (P9).

Institutional barriers determining nurses’ assessment and management of preoperative pain

Another main theme identified is institutional barriers determining nurses’ assessment and management of preoperative pain. This is to find out the hitches that hinder the influence of preoperative pain assessment and management by the nurses. What are the institutional barriers that influence nurses’ assessment and management of preoperative pain? This theme contained five (3) subthemes including protocols, logistics access to medications, and health personnelrelated factors.

Protocol 

Based on the participants’ statements, half of the participating nurses stated that the hospital does not have a standardized preoperative pain protocol for preoperative pain assessment and management.

“We do not have a specific standard for pain management in those conditions but we have guidelines as to how to manage the conditions” (P15)

 “We have a preoperative protocol in preparation but it does not dwell more on pain, so preoperative pain we do not have laid down protocol to take care of the client’s pain. Most of the time you use your past experiences to take care of the pain of the patient” (P6) 

The nurses who participated in the study expressed concerns about the inadequate supply of items needed to work with, which makes pain management of a preoperative clients challenging. These include appropriate pain assessment tools, inadequate ice packs, hot water bottles, unfavourable patient beds, and also delayed access to drugs, as a result, delaying the intervention to relieve pain. Some participants stated:

“Our beds, they are not friendly so sometimes you want to position the patient in a way that will help relieve the patient pain but because the bed is not friendly, we are unable to position the client well. They are not in good shape” (P4)  

“Sometimes the beds that we need to do the elevations are broken down, the adjustable parts are not there, the sandbags might not be available, icepacks are not enough, not simply enough to attend to clients. Clients have to go and buy or the relative has to go and buy ice block then you wrap with something then use as ice pack” (P14)  

“We do not get the required tools to help us assess the pain” (P5)

“… also, another obstacle which I have not mentioned is the pain assessment tool; we do not have any pain assessment tool to use on the client for the patient to understand or for you to be able to assess pain very well in the ward. So, all the time we go around clients’, rate your pain from 1-10 using verbal means” (P13)

Health personnel and patient factors

Although the nurses indicated that the health personnel sometimes affect preoperative pain assessment and management. A few participants mentioned that the clients also sometimes hinder preoperative pain assessment and management due to their cultural beliefs that pain is a normal thing and a person is perceived as weak when she or he expresses pain. As a result, they are not able to express pain because of what society will say about them.

“In few cases, people think expressing pain is weakness, so they will not even tell you at all, they will want to endure it” (P8)  

“The cultural beliefs pose a challenge to us, because a patient might be in pain and per his or her cultural beliefs he or she is not able to verbalize or tell you I am in pain. So, per their cultural beliefs, people can endure pain. So, this also is a challenge because you could see clients who are in pain and then you ask them and they will tell you no I am not in pain because other people may see them as weak in society” (P9)  

One of the participants also mentioned that patients’ adherence to treatment had an impact on nurses’ duties.  

“Sometimes client’s compliance is one of them sometimes with that one you finish serving medications I know some patients who hide medications on them, you do not know about it, you finish serving your medication and then by the time you get there you see them taking another one someone recommended from the house” (P15) 

A participant mentioned that some clients are uncooperative, which makes it difficult to assess their pain and evaluate it.

“One of the barriers is that if you want to assess the pain and the client is not cooperating, this is one of the barriers, you will find it difficult to do what you are supposed to do and you will not be able to manage the pain” (P7)

Some participants indicated that some clients complained about the inability to afford the pain medications due to their financial burden.

“When it comes to the client, sometimes our patients or clients’ relatives complain of finances. For instance, if you have a non-insured client who will always have to be buying his or her medications it is really a challenge for that particular patient” (P9)

“Also with the pain medications, certain times they are not available in the hospital or you need to write for the clients to go and buy. Some don’t have the money even to buy the drug others too when you give them the drugs for them to go and search for it and come, by then the client has been in pain for a long time” (P13) 

Accessibility to Medicines (Opioids)  

The participants indicated that there is a challenge in accessing opioids in the facility. This affects care delivery hence they are not able to administer pain medications in time.

“Okay with the medications, the NSAIDS and paracetamol the pharmacy they have them but with the narcotics sometimes we are constrained, we write and it’s not available or you are to pay cash up-front and take it. So sometimes, when it comes to the narcotics, it is difficult getting it even when you get it, the duration before you get it makes it a bit frustrating” (P6)

Also, participants stated that sometimes the families of the clients are involved in acquiring medications for their relatives to aid in the timely management of patient pain.

“Sometimes the opioids will not be available, even though you need them and you will need to write for relatives to go to town and buy it or we wait for the medication to be bought, and in the worst case the relatives do not even have the money to buy it” (P8)

The findings were based on data generated from the narration of nurses who work at the surgical wards of the Regional Hospital, Bolgatanga. The findings revealed the complex nature of the factors influencing preoperative pain assessment and management practices among nurses. Knowledge in preoperative pain assessment and management, nurses’ personal pain experience, and how their pain has influenced them in pain management, health personnel related factors client -related factors were identified to influence preoperative pain assessment and management among nurses. The key findings in the study revealed that the nurses use pharmacological and non-pharmacological methods to manage preoperative patient pain. Even though some participants shared their knowledge of the pain rating, they knew about the numeric pain rating scale the other participants had limited knowledge of the rating scales. The nurses were aware of analgesics and other activities such as positioning, diversional therapy, application of a warm or cold compress and massage that are not related to drugs to treat or reduce pain. However, the nurses had limited access to pain medications, especially opioids.  Cultural beliefs that pain is normal, and so if one expresses pain, it is assumed that the person is a weak and societal perception. Financial constraints among some clients and relatives also influenced pain management.  The study also revealed a lack of preoperative pain management protocols for nurses, a limited supply of consumables and equipment, and preoperative education guidelines at the Regional Hospital studied.

DISCUSSION

Preoperative Pain Assessment and Management Practices among Nurses

The present study’s findings were the practices of preoperative pain assessment and management. Regarding preoperative pain assessment and management practices among nurses, most of the participants indicated verbal and non-verbal observation and the use of a pain assessment scale (1 – 10) to assess client pain. Physiological changes such as alteration in some vital signs were identified in the present study to indicate pain presence among preoperative patients. A few participants reported that pain brings about physiological changes in the body. Sometimes, abnormal vital signs readings can be associated with pain on observation. This manifested in the form of elevated blood pressure and increased temperature. This current study finding is similar to previous studies by Horgas, (2017) who stated that pain management is affected. However, another study submitted that an increase in physiological changes may not signify the presence of pain but can suggest the need for pain assessment (Herr et al., 2011). Some participants of this study indicated awareness of physiological changes in response to the presence of pain, and participants mainly used verbal and nonverbal expressions of pain.

Most of the nurses employed both pharmacological and non-pharmacological approaches to managing the pain of preoperative clients. Mostly, nurses used intramuscular diclofenac, intravenous tramadol, and pethidine to manage pain. Management of pain wherever there is a client in pain (emergency, operating room, and ward), anticipate their post-surgery and discharge pain management needs (Hyland et al., 2021).

The findings revealed that some participants required knowledge in critical areas of preoperative pain management, such as pharmacology. This could be because pharmacology is not adequately covered at the diploma level and most of the participants were diploma holders, who had little pain management training, they had insufficient pharmacological knowledge. This finding was supported by Lewthwaite et al. (2011) who conducted a descriptive study in an urban tertiary care hospital to investigate registered nurses’ knowledge and practice of pain management.  Lewthwaite et al. (2011) discovered that nurses had limited pharmacology understanding when it came to preoperative pain treatment. When it comes to immediate preoperative pain, aspirin and other nonsteroidal anti-inflammatory medicines are inefficient analgesics, according to the insights from the pharmacology questions as analgesia with 1-2 mg morphine IV typically lasts 4-5 hours.

Clients with a history of substance misuse should not be given opioids. Gabapentin (Neurontin) and other anticonvulsant medications provide optimum pain relief after a single dose. In this current study, it was indicated that the participants alleviated pain by using pain medicines. A study by Snyder et al. (2018) affirms that pain treatment with opioids, nonsteroidal anti-inflammatory medications, and acetaminophen should be prioritized so that intervention is not delayed. The study supports a study, which stated it was common practice to treat pain with drugs (Gai et al., 2020). Some of the participants indicated they delay administering pain medication to a preoperative patient if the prescriber has not done his/her assessment to finalize the diagnosis because they think pain medication will mask pain, which is likely to affect the diagnosis. Most nurses reported that managing pain using medication was the norm, especially in the first 24 hours after surgery (Mahama & Ninnoni, 2019)

However, one study in Nigeria found that using analgesia before surgery in clients with acute abdomen does not mask clinical signs while relieving pain. Instead, it may improve the collection of clinical signs, which may aid decision-making (Agodirin et al., 2013)

The participants’ non-pharmacological pain management approaches were positioning, application of cold and warm compresses, reassurance, diversional therapy, and psychological support. These pain management approaches help reduce preoperative pain as they relieve muscle pain and tension and reduce anxiety. Non-pharmacological pain treatments for preoperative pain management, including relaxation techniques, psychological support, acupuncture, and music therapy, were found to be effective in a study conducted in China by Wang et al. (2022) .  Hyland et al. (2021), asserted that not only do non-pharmacological strategies reduce anxiety and side effects associated with analgesics and opioids, but they are also safe, relatively inexpensive, and readily available as long as nurses are on duty.

Moreover, proper positioning with an elevation of the affected part of the body decreases preoperative pain. A study revealed that cold and warm compresses are effective and can reduce preoperative pain compared to some pain medication such as paracetamol (Geziry et al., 2018). Some participants reported that with an acute abdomen, they passed an NG tube to decompress the abdomen and a urethral catheter to relieve pain from the bladder. Vadivelu et al., (2023) stated that, when necessary, nasogastric intubation should be used for decompression in most clients to relieve pain from abdominal pressure. Anxiety among family members about a pain-control strategy should be addressed and factored in when making postoperative pain management decisions (Ayaz & Sherman, 2022). Some participants stated that they give preoperative education to patients, but it is not standardized because they only focus on what will be done for the clients without concentrating much on pain management. According to Horn et al. (2020) pain prevention is to promote recovery. Psychoeducation focusing on preoperative pain management should be considered part of a multimodal strategy to address patients’ preoperative psychological state.

Institutional factors influencing preoperative pain assessment and management 

This current study revealed that medicines and other equipment were not readily available for nurses to work with to alleviate the preoperative pain of clients. These included inadequate access to opioids. It was indicated in the WHO report (2010) that over 150 countries do not have access to morphine and some potent opioids. Limited access to opioids renders the treatment of preoperative pain of patients somehow ineffective. The inaccessibility of opioids in the facility affects care delivery; hence, nurses cannot administer pain medications in time. Equipment such as the bed and its accessories, are critical in preoperative pain management. However, the participants reported that the beds in the facility are not in good working order, which has a negative impact on their ability to make their patients comfortable.

Participants of the study reiterated how some sociocultural norms about pain affected their responses to preoperative pain in terms of assessment and management. Some participants indicated that their interactions with the patients either modulated their pain-responsive behaviour or shaped pain management. Some participants indicated that some socio-cultural outlook determined whether or not one should cry, frown, groan or remain mute in response to preoperative pain. They again reported that adults openly expressing pain by crying among other patients could be viewed as culturally unacceptable behaviour. Some of them also indicated that gender was an influential factor in pain expression as women are more culturally allowed to show pain than men. According to Ayaz and Sherman (2022), pain response behaviour and its management are both said to be linked with the experiencing person’s cultural background and social orientation to preoperative pain. The most common institutional barrier to assessing and managing preoperative pain, on the other hand, was system-related; that is, inconsistent availability or a lack of appropriate logistics for the nurse to work effectively.

CONCLUSIONS

Preoperative pain assessment and management by nurses is a critical component of surgical patient nursing care. The researchers discovered that the participant nurses only knew of the numeric (1-10) pain assessment scale.  Direct observation, proper history taking, vital sign monitoring, and personal experience were used by the nurses to intervene effectively in pain management utilizing pharmaceutical and non-pharmacological approaches. Some facility based factors affected the assessment and management of preoperative pain. These include inadequate supplies of logistics; improper equipment (non-adjustable beds) and challenges in obtaining access to opioids. Despite this, the nurses employed posture, the application of cold compresses, and massage to help lower clients’ degree of pain. Also, they provided clients with psychological assistance through preoperative instruction, diversionary treatment, and reassurance. Additionally, it was shown that some clients and healthcare professionals’ cultural and social perceptions affected preoperative pain assessment and management. Social ideas about how people should respond to pain and their cultural attitude that pain is normal. The study found that the health personnel sometimes affect preoperative pain assessment and management with the fear that the client can become addicted to pain medication. It was discovered that some health personnel and clients influence preoperative pain assessment and management due to their cultural belief that pain is normal and societal perceptions about the reaction to pain. The clients also hinder preoperative pain assessment and management because they believe that if one expresses pain it means he is a weak person, noncompliance from clients and financial constrain. The nurses help to reduce patients’ pain level using positioning and application of cold compresses and massage. They also support the patient psychologically using reassurance, diversional therapy, and preoperative education.

Strengths and Limitations

The social communication model of pain by Craig was the theoretical framework, with emphasis on the caregiver’s concepts guided the study. This made the researchers appreciate the challenges that influenced preoperative pain assessment and management practices. However, the study had limitations because it was conducted in a regional hospital in Ghana with a modest surgical bed capacity, even though there are other regional and tertiary hospitals in Ghana with larger bed capacities and additional surgical specializations. The conclusions were based on subjective reactions from participants, which may have been partly influenced by prior knowledge rather than actual clinical experience.

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