Description
Please view and use the sample paper attached for this paper. The reference and article you will use are also attached because you wont be able to access my school library.
For this assessment, Create a 3-5 page annotated bibliography and summary based on your research related to best practices addressing Limited Access to Healthcare .
Side note: To explore your chosen topic, you should use the first two steps of the Socratic Problem-Solving Approach to aid your critical thinking.
1) a brief overview of Limited Access to Healthcare problem. In your overview:
Summarize the health care problem or issue.
Describe the professional relevance of this topic.
Describe any professional experience you have with this topic.
2) Identify peer-reviewed articles relevant to this health care issue or problem..
Conduct a search for scholarly or academic peer-reviewed literature related to the topic and describe the criteria you used to search for articles, including the names of the databases you used. You will select four current scholarly or academic peer-reviewed journal articles published during the past 3–5 years that relate to your topic.
Use the information in below to form a paragraph for number 2 question;
I used the search engine called Summon from the Capella University Library. Summon looks through almost all of the library’s materials. I refined my search for my peer review article and full text online. I search for keywords like “barriers in accessing health services” and “limited access to healthcare” I also chose a Journal article for the content type. I chose Nursing and medicine as the discipline filter. Also I chose article published within five years.
3) Assess the credibility and explain relevance of the information sources you find.
Determine if the source is from an academic peer-reviewed journal.
Determine if the publication is current.
Determine if information in the academic peer-reviewed journal article is still relevant.
4) Analyze academic peer-reviewed journal articles using the annotated bibliography organizational format. Provide a rationale for inclusion of each selected article. The purpose of an annotated bibliography is to document a list of references along with key information about each one. The detail about the reference is the annotation. Developing this annotated bibliography will create a foundation of knowledge about the selected topic. In your annotated bibliography:
a. Identify the purpose of the article.
b. Summarize the information.
c. Provide rationale for inclusion of each article.
d. Include the conclusions and findings of the article.
e. Write your annotated bibliography in a paragraph form. The annotated bibliography should be approximately 150 words (1–3 paragraphs) in length.
f. List the full reference for the source in APA format (author, date, title, publisher, et cetera) and use APA format for the annotated bibliography.
g. Make sure the references are listed in alphabetical order, are double-spaced, and use hanging indents.
5) Summarize what you have learned while developing an annotated bibliography.
a. Summarize what you learned from your research in a separate paragraph or two at the end of the paper.
b. List the main points you learned from your research.
c. Summarize the main contributions of the sources you chose and how they enhanced your knowledge about the topic.
Your assessment should also meet the following requirements:
Length: 3–5 typed, double-spaced pages, not including the title page and reference page.
Font and font size: Times New Roman, 12 point.
Written communication: Write clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics.
Content: Provide a title page and reference page following APA style.
References: Use at least four scholarly or academic peer-reviewed journal articles.
APA format: Follow current APA guidelines for in-text citation of outside sources in the body of your paper and also on the reference page.
Unformatted Attachment Preview
Marseille, B. R., Kolawole, J., Thorpe‐Williams, J., Francis, L., Delva, S., Foronda, C. L., Bivins, B., Owusu,
B., Josiah, N., & Baptiste, D. (2023). Addressing hypertension among haitian adults with insufficient
access to quality healthcare: A discursive review. Journal of Advanced Nursing, 79(5), 1691‐1698.
https://doi.org/10.1111/jan.15633
Omerov, P., Craftman, Å. G., Mattsson, E., & Klarare, A. (2020). Homeless persons’ experiences of health‐
and social care: A systematic integrative review. Health & Social Care in the Community, 28(1), 1‐11.
https://doi.org/10.1111/hsc.12857
Ahinkorah, B. O., Budu, E., Seidu, A., Agbaglo, E., Adu, C., Ameyaw, E. K., Ampomah, I. G., Archer, A. G.,
Kissah‐Korsah, K., & Yaya, S. (2021). Barriers to healthcare access and healthcare seeking for childhood
illnesses among childbearing women in sub‐saharan africa: A multilevel modelling of demographic and
health surveys. PloS One, 16(2), e0244395‐e0244395. https://doi.org/10.1371/journal.pone.0244395
Eshete, M. T., Baeumler, P. I., Siebeck, M., Tesfaye, M., Wonde, D., Haileamlak, A., Michael, G. G., Ayele,
Y., & Irnich, D. (2019). The views of patients, healthcare professionals and hospital officials on barriers to
and facilitators of quality pain management in ethiopian hospitals: A qualitative study. PloS One, 14(3),
e0213644‐e0213644. https://doi.org/10.1371/journal.pone.0213644
RESEARCH ARTICLE
The views of patients, healthcare
professionals and hospital officials on barriers
to and facilitators of quality pain management
in Ethiopian hospitals: A qualitative study
Million Tesfaye Eshete ID1,2*, Petra I. Baeumler3, Matthias Siebeck2,4, Markos Tesfaye5,
Dereje Wonde6, Abraham Haileamlak7, Girma G. Michael1, Yemane Ayele1, Dominik Irnich3
a1111111111
a1111111111
a1111111111
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1 Department of Anesthesiology, Institute of Health, Faculty of Medicine, Jimma University, Jimma, Ethiopia,
2 Centre for International Health, Ludwig-Maximilians-Universität Munich, Munich, Germany,
3 Multidisciplinary Pain Center, Department of Anaesthesiology, University Hospital Ludwig Maximilians
University Munich, Munich, Germany, 4 Department of General, Visceral, Vascular and Transplantation
Surgery, Hospital of the University of Munich (LMU), Munich, Germany, 5 Department of Psychiatry,
St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia, 6 Department of Sociology, College of
Social Sciences and Humanity, Jimma, University, Ethiopia, 7 Department of Pediatrics and Child Health,
Institute of Health, Faculty of Medicine, Jimma University, Jimma, Ethiopia
* mtesfaye1@gmail.com
OPEN ACCESS
Citation: Eshete MT, Baeumler PI, Siebeck M,
Tesfaye M, Wonde D, Haileamlak A, et al. (2019)
The views of patients, healthcare professionals and
hospital officials on barriers to and facilitators of
quality pain management in Ethiopian hospitals: A
qualitative study. PLoS ONE 14(3): e0213644.
https://doi.org/10.1371/journal.pone.0213644
Editor: Alexandra Sawyer, University of Brighton,
UNITED KINGDOM
Received: May 10, 2018
Accepted: February 26, 2019
Published: March 14, 2019
Copyright: © 2019 Eshete et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: Due to ethical
restrictions related to protecting patient, healthcare
professional and hospital official confidentiality, all
relevant and anonymized data are available upon
request after ethical approval of the Jimma
University Institutional Review Board, Jimma,
Ethiopia. Requests can be sent to the board
Chairman of the IRB of the Jimma University Dr.
Daniel Yilma (daniel.yilma@ju.edu.et) or the
corresponding author.
Abstract
Background
Postoperative pain remains a challenge in the developed world, but the consequences of
inadequately treated postoperative pain are particularly severe in low- and middle-income
countries. Since 2011, reports have drawn attention to the poor quality of postoperative pain
management in Ethiopia; however, our multicenter qualitative study was the first to attempt
to understand the factors that are barriers to and facilitators of quality pain managment in
the country. To this aim, the study explored the perspectives of patients, healthcare professionals, and hospital officials. We expected that the results of this study would inform strategies to improve the provision of quality pain management in Ethiopia and perhaps even in
other low- and middle-income countries.
Methods
This study used a qualitative, descriptive approach in which nine healthcare professionals,
nine patients, and six hospital officials (i.e. executives in a managerial or leadership position
in administration, nursing, or education) participated in face-to-face, semi-structured interviews. Thematic data analysis was conducted, and patterns were explained with the help of
a theoretical framework.
Findings
The barriers identified ranged from healthcare professionals’ lack of empathy to a positive
social appraisal of patients’ ability to cope with pain. They also included a lack of emphasis
on pain and its management during early medical education, together with the absence of
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Barriers to and facilitators of quality pain management in Ethiopian hospitals
Funding: This study was supported by the Jimma
University and CIHLMU Center for International
Health, Ludwig-Maximilians-Universität, Munich,
Germany.
available resources. Enhancing the ability of healthcare professionals to create favorable
rapport with patients and increasing the cultural competence of professionals are essential
ingredients of future pain education interventions.
Competing interests: The authors have declared
that no competing interests exist.
Conclusions
Barriers to and facilitators of postoperative pain management do not exist independently but
are reciprocally linked. This finding calls for holistic and inclusive interventions targeting
healthcare professionals, patients, and hospital officials. The current situation is unlikely to
improve if only healthcare professionals are educated about pain physiology, pharmacology, and management. Patients should also be educated, and the hospital environment
should be modified to provide high-quality postoperative pain management.
Introduction
The number of patients undergoing surgery is rising worldwide [1]. However, pain treatment
after surgical procedures remains unsatisfactory [2], and up to 40% of patients experience
severe pain after surgery [3]. Estimates of the proportion of patients who develop persistent
postoperative pain vary from 5% up to 85% [4]. Globally, about 22% of chronic pain is related
to previous surgery, but this rate can be reduced by adequate postoperative pain management
[5]. Untreated postoperative pain has also been linked to extended hospital stays, atelectasis,
respiratory infection, myocardial infarction [6,7], and even death [8]. In the developed world,
awareness of the impact of postoperative pain has grown, but endeavors to improve its management remain challenging [3]. Patients in low- and middle-income countries (LMIC) are at
greater risk of the severe consequences of untreated postoperative pain [7,9]. This is partly
because pain management is not a priority in low-resource settings, where the health care systems are focused on achieving the United Nations Millennium Development Goals, such as
eradicating poverty and reducing maternal and child death [10]. Other reasons why health policy in LMIC pays little or no attention to postoperative pain management, despite its importance for the prevention of disability, remain unclear. To improve the care of surgical patients
in LMIC, we have to explore barriers to and facilitators of quality pain management (QPM).
Although it is difficult to define and measure the quality of pain management, QPM is defined
as a characteristic that encompasses the structure, process, and outcomes of care [11]. It has
specific characteristics, including appropriate ongoing assessment (both before and after the
administration of analgesics) and multidisciplinary, safe, efficacious, cost-effective, and culturally and developmentally appropriate care [12]. Furthermore, experts around the world currently recommend the use of multimodal regimens in many situations, although the exact
ingredients can vary, depending on the patient, setting, and surgical procedure [13].
Surprisingly, at the time of writing this manuscript no qualitative data were available about
the quality of postoperative pain management in Ethiopia, indicating that little or no attention
is being paid to this topic. A decade ago, a nationwide study in Ethiopia reported that healthcare professionals (HCPs) believed that pain was undertreated because pain management was
not standardized and analgesics, trained healthcare providers, and non-pharmacological treatment options were lacking [14]. A study from one of the hospitals participating in this study
(Jimma University Medical Center) reported that the prevalence of undertreated postoperative
pain was as high as 80.1%; this finding was not surprising because Ethiopia has nil morphine
per capita [15,16]. A lack of strong opioids, no use of non-pharmacological pain management
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Barriers to and facilitators of quality pain management in Ethiopian hospitals
techniques, and poor anesthesia and surgical infrastructure are the typical characteristics of
hospital settings in Ethiopia [17,18].
We decided to conduct the current study to find solutions for the above mentioned and
other problems (e.g. the need to design and implement an effective intervention for QPM).
The known barriers to and facilitators of postoperative pain management were mainly identified in studies conducted in the developed world and may not apply to low-resource settings
or to other populations from different cultural backgrounds. Here, we present the views of
patients, HCPs, and hospital officials interviewed at three hospitals in Ethiopia.
Interview data were analyzed according to the theory of reciprocal determinism, a tenet of
social cognitive theory (SCT). Reciprocal determinism has been recommended for pain management-related topics [19]. It defines behavior as a triadic, dynamic, and reciprocal interaction of personal factors, behavior, and the environment [20]. The “person” in this theory refers
to the individual’s unique personality, set of experiences, personal values, cognition, thinking,
etc. Environmental factors are anything outside the person, such as physical things, resources,
equipment, facilities, policies, and the like. The environment also includes social factors, such
as family, friends, and community [21]. Behavior is the outcome of interest, which in the current study was the “practice of postoperative pain management.” The individual, bi-directional
relationship between both the personal and environmental factors and the actual behavior
(current practice) is shown in Fig 1. Thus, this study used a qualitative descriptive strategy
Fig 1. List of emergent themes that influence quality pain management.
https://doi.org/10.1371/journal.pone.0213644.g001
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Barriers to and facilitators of quality pain management in Ethiopian hospitals
[22,23] to attempt to answer the research question of what Ethiopian patients, HCPs, and hospital officials perceive as barriers to and facilitators of quality postoperative pain management.
Methods
Setting
Our study was conducted as part of an ongoing quasi-experimental study to evaluate the effectiveness of an educational intervention for HCPs, patients, and hospital officials at three hospitals in Ethiopia: Yekatit 12 Medical College Hospital (Yk 12 MCH), Zewditu Memorial
Hospital (ZMH), and Jimma University Medical Center (JUMC). ZMH and YK 12 MC are
located in the capital city, Addis Ababa, which has more than 3.3 million inhabitants [24].
JUMC is located 355 km south-west of the capital, in Jimma Zone, which has an estimated
total population of 2.4 million [25]. The participating hospitals are comparable regarding years
in operation, postoperative settings, and infrastructure (S1 Table).
Design
We used a qualitative description design [22,23] to explore barriers to and facilitators of QPM
in the postsurgical patients. The perspectives of HCPs, patients, and hospital officials were
recorded in face-to-face, semi-structured interviews, conducted from October 4, 2016 to
December 8, 2016. The method of qualitative description has been used widely in qualitative
health research [22], including research on pain management practices [26].
Sampling and recruitment
The hospitals participating in the main longitudinal, quantitative, quasi-experimental study
were also selected for this qualitative study. Purposive sampling with the maximum variation
technique was used to select participants. The framework for maximum variation was based
on baseline pain intensity (patients with mild, moderate, and severe pain), type of surgery
(patients who had undergone orthopedic, gynecologic, and general surgical procedures), and
sex. For instance, if one female gynecologic patient with mild pain, one female orthopedic
patient with moderate pain, and one male patient with moderate pain who had undergone
general surgery were selected from one of the hospitals, two orthopedic male patients with
severe pain were selected from the other hospital, and so on. This was continued until the predetermined a priori sample of nine patients was obtained. In the same manner, first we defined
a minimum of nine HCPs a priori (including at least two nurses, two surgeons, two gynecologists, and two anesthetists) with as even a representation as possible of men and women and
number of service years (see Table 1 in results section). Nurses, surgeons, gynecologists, and
anesthetists were included because these HCPs routinely participate in the perioperative pain
management of surgical patients in Ethiopia. We also determined that each hospital should
contribute at least two HCPs to the sample. To select hospital officials, we considered individuals from two groups, i.e. those who were in charge of the overall administration of the hospitals
and those who were in charge of the surgical wards. We then identified potential participants
(at least two officials from each hospital). Primarily, researcher (MTE) screened clinical record
files to identify eligible patients. Then, patients were approached, and when agreed to be part
of the study they completed a brief questionnaire that included demographic information,
type of surgery and pain intensity. To recruit HCPs the researcher was present in the surgical
wards at office hours and approached surgeons, gynecologists and nurses happen to be caring
for the surgical patient. However, anesthetists were approached during their lunch break in
the operation theatre’s cafeteria. HCPs who fulfil the selection criteria and agreed to be part of
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Barriers to and facilitators of quality pain management in Ethiopian hospitals
Table 1. Sociodemographic and clinical characteristics of participants.
Type of surgery
Pain intensity‡
Hospital
Duration of interview�
Female
Orthopedic
1
1
13
Female
Gynecologic
5
3
14
36
Male
General
8
2
17
4
50
Female
General
7
1
17
5
50
Male
General
5
1
14
6
61
Male
Orthopedic
9
2
16
7
23
Male
Orthopedic
9
2
15
8
35
Female
Gynecologic
4
3
13
9
33
Female
Gynecologic
6
3
16
HCP ID
Age
Sex
Profession
Years of service
Hospital
Duration of interview�
91
57
Male
Anesthetist
25
2
29
21
37
Female
Nurse
7
3
28
31
44
Male
Nurse
9
1
29
14
43
Male
Nurse
10
2
28
51
35
Female
Surgeon
3
3
25
16
40
Female
Surgeon
7
1
27
17
45
Male
Anesthetist
12
3
22
81
36
Female
Gynecologist
5
1
32
19
44
Male
Gynecologist
8
2
20
Official ID
Age
Gender
Position
Year of service
Hospital
Duration of interview�
21
48
Male
Nursing unit director director
6
1
27
22
33
Male
Medical director
4
3
25
32
35
Male
Clinical director
3
1
26
24
33
Male
General Provost
4
2
32
52
36
Female
Matrons office head
4
2
23
26
34
Male
General Dean
3
2
33
Patient ID
Age
Sex
1
32
2
44
3
†
Healthcare professional
‡measured on a numeric rating scale (0–10)
Numbers are rounded
�
https://doi.org/10.1371/journal.pone.0213644.t001
the study completed demographics, background profession, and year of service. To recruit
officials the researcher visited them at their office, and scheduled an appointment through the
secretary by explaining the purpose of the study. The researcher was then contacted back by
the secretary of the officials thorough mobile phone to conduct the interview. The officials also
completed an information sheet that included position title, year of service and demographics.
Everyone (patients, HCPs and hospital officials) who was invited to participate in the study
agreed to do so, and before commencing the semi-structured interview a signed informed
conscent was obtained. Table 1 (see results section) presents the demographic and professional
characteristics of the participants. After completing the interviews of the initial sample defined
above (24 participants), we started to analyze the data to obtain more information on the gathered data to help us select the next participants. However, this analysis showed that the completed interviews had reached data saturation, i.e. the interviews no longer provided new
information or voices [27], so that further interviews were deemed unnecessary. The aim of
our sampling approach was to help us reach data saturation, which should be considered a priori [27]; a large sample size does not necessarily ensure data saturation [27,28].
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Barriers to and facilitators of quality pain management in Ethiopian hospitals
Data collection
We collected data during individual, face-to-face semi-structured interviews that lasted on average 15 to 30 minutes. All patient interviews were conducted at the place of their preferences, that
is, the bedside, on the hospital wards 24 hours after surgery. Some patients’ were inevitably
immobile (e.g, orthopedic patients). Before the interview was started HCPs were informed that
the ward door will remain locked for the duration of the interview. Family members were also
agreed to leave the room for the duration of the interview. In cases where more than one patient
was available in the patient wards, care has been taken to make sure the conversation remained
laudable only for the patient and the interviewer. HCPs and hospital officials were interviewed in
their respective offices. Interviews were conducted by the first author (MTE), a male lecturer and
anesthetist with experience of working with postoperative patients; MTE received the necessary
training in qualitative research as part of his PhD curriculum. The interviews were conducted in
the local language, Amharic, and were audio recorded. We developed a semi-structured interview guide (S1 File) on the basis of a literature review [29,30] and the study objectives to standardize the interviews [31]. The guide for the patient interviews covered the following areas:
patients’ experience of pain after surgery, the perception of pain treatment options, coping
mechanisms, perceived barriers to QPM, and an evaluation of the HCPs’ help in alleviating pain.
The guide for the interviews with the HCPs and hospital officials included the perceived quality
of pain management and barriers to and facilitators of QPM. In addition, the interview guide for
hospital officials also included questions about monitoring pain management practices, the availability of the necessary drugs and human resources for pain management, and the policy or standards on how HCPs should manage postoperative pain. The interview guide served only as an
outline with the aim to generate a discussion that would help to address the research question,
i.e. what are the barriers to and facilitators of quality pain management in surgical patients from
the perspectives of patients, healthcare professionals, and hospital officials. The interviewer
asked probing questions, such as “What do you mean by that?” and “Can you elaborate more on
that, please?” At the end of each interview, the researcher asked the participants to discuss anything else they considered relevant. In line with the proper practice of semi-structured interviewing [31], the interviewer attempted to remain as objective as possible during the interview
process. He maintained a good rapport (trust and respect) throughout the interview.
Ethical considerations
The study was approved by the Jimma University Institutional Review Board, the Medical Ethics Committee of the Ludwig-Maximilians-Universität Munich, and by all participating hospitals. Before conducting the interviews, the interviewer briefly explained the study, including
the risks and benefits of participation. The interview continued only after written informed
consent was obtained, and participation was voluntary. The interviewer had no prior relationship with any of the participants. The study was performed in accordance with the established
ethical standards in the Declaration of Helsinki (1964).
Data analysis
Upon completion of each interview, a complete transcript was produced in Amharic. The
interviewer read and reviewed the transcribed data to ensure that they were clear and compared the transcriptions with the original audio recordings for accuracy. Data were analyzed
manually by Braun and Clarke’s six-step process of thematic analysis [32]. We used a “bottomup” approach (inductively) to ensure that important aspects were not missed. Line-by-line
coding was performed independently by two authors (MTE, DW), one of whom was a medical
sociologist with previous experience in qualitative research (DW). Once duplicate codes had
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Barriers to and facilitators of quality pain management in Ethiopian hospitals
Fig 2. Theoretical framework. Adapted from Wood and Bandura’s Triadic Reciprocal Determinism (Wood and
Bandura [54]).
https://doi.org/10.1371/journal.pone.0213644.g002
been removed and relevant data extracted, we started searching for themes. In line with the
research question, themes were constructed from the codes. Similar themes were collapsed,
and some were split, if necessary. The results of the data analysis are presented in Fig 2. Emerging concepts and categories were translated into English by two independent translators. The
final English version was established after a discussion between MTE and DW. A third person
(an anesthetist) translated the final English version back into Amharic. Finally, a committee of
four individuals, consisting of an expert in English (not a co-author of the paper), an anesthetist (not a co-author of the paper), an expert qualitative researcher (DE), and the first author
(MTE) settled issues of conceptual and semantic equivalence between the Amharic and the
final English versions. The two coders ultimately agreed that, according to the final analysis,
the data had reached saturation and no new data or themes were being generated, making
additional interviews unnecessary. To increase the dependability of the results, we prepared a
detailed study protocol and used two independent coders with different professional backgrounds (MTE and DW) [33]. To further strengthen the confirmability and credibility of the
results, we applied the data source triangulation technique in which we used several groups of
surgical ward staff working in different hospitals and performing different roles [34] The application of stratified purposive sampling and maximum variation sampling also enhanced the
transferability of the results [35].
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Barriers to and facilitators of quality pain management in Ethiopian hospitals
Findings
Study participants
Twenty-four participants were interviewed. The sociodemographic and clinical characteristics
and interview durations are summarized in Table 1.
Emerging themes were classified as barriers and facilitators related to HCPs, patients, and
the health care system. These themes and respective subthemes are presented below, together
with example quotes.
Barriers related to healthcare professionals
All participants identified HCPs’ lack of empathy and lack of education as barriers to QPM.
From the perspective of the HCPs and hospital officials, QPM was hindered by the failure to
use pain rating scales to assess patients’ pain intensity and by the fear of side effects and
dependence.
Lack of empathy. The feeling that “I am on my own” was the thought most commonly
shared by patients in the interviews. Patients frequently expressed how they felt neglected by
the HCPs, who paid no attention to their level of pain after surgery. In the patients’ view, the
HCPs seemed to have little interest in the patients’ wellbeing and not be willing to listen to the
patients or treat pain after surgery.
“Professionals should put themselves in our shoes. Whether the wound is big or small, it does
not matter, the pain is the same to us. They [professionals] always say it’s ok, this is small.
Doctors should be able to communicate with us. . .you know. . .we should be close to them.
Professionals should have the attitude of servants, not masters. They [professionals] have to
show us compassion.” (Hospital 1, patient [prostatectomy], male, 50)
Also, HCPs and hospital officials admitted a lack of empathy with patients in pain after surgery, and most HCPs had not yet undergone surgical interventions themselves.
“Because we (professionals) never went through the operation, most of us have no idea what it
is like to be in pain. What can you do? You cannot cut and suture them [professionals]? It is
the way it is. Pain is related to experience; they don’t have the experience, so they will not cope
with it.” (Hospital 2, HCP [anesthetist], male, 57)
Lack of information about pain and its management during medical education. Most
professionals said that the topic of pain was neglected in undergraduate medical education,
which strongly emphasized infections and other medical problems.
“If one patient does not receive proper pain treatment, they [professionals] don’t understand
the consequences. Then the patient suffers, develops chronic pain and is discharged with the
pain. He will eventually return with pain as a complaint. Nobody will find the pain because
you cannot find it in the laboratory. So, most likely he will end up in the psychiatric wards.”
(Hospital 2, HCP [gynecologist], male, 44)
The duration of and access to in-service training were also not perceived as being
satisfactory.
“For example, there are 500 nurses, and only 50 are selected for the training. Then, it is
declared that the training has been given to all professionals. Moreover, the trained
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Barriers to and facilitators of quality pain management in Ethiopian hospitals
professional does not share what he or she learned from the training with the rest of the team.
It is much better if the training includes all the nurses who are part of the care team” (Hospital
2, HCP [nurse], male, 44)
No use of pain rating scales in clinical practice. HCPs and hospital officials frequently
mentioned that pain rating scales were not used. They stated that most of them measured pain
subjectively, instead of using a standard pain rating scale. HCPs mentioned using patients’
facial expressions and “general condition,” as they put it, to evaluate patients’ level of pain and
make a decision about administering analgesics.
“We take into consideration the type of surgery when giving analgesics. Most of the time, if the
patient underwent thoracic surgery or had a bone fracture, we will use strong analgesics, if
available. If it is an abdominal surgery, these are less painful, so we use weaker analgesics. We
then follow the patients to see if they are complaining about pain. This is critical.. . .. . ..this is
to identify whether the pain is from the surgery itself or whether it is something else. . .. . … . .
like infection development or wound healing. . .. . .. . .you just have to take patients’ general
condition and facial expressions into consideration to decide how severe their pain is. This
what we use to measure pain in our setting.” (Hospital 3, HCP [surgeon], male, 35)
The way in which the patient asks for pain medication is also crucial in HCPs’ decision
whether or not the patient is in pain.
“The way the patient asks for analgesics matters. Some exaggerate the smallest pain, while
others bear the unbearable. . .If the patient nags you the whole day and complains a lot,
we then ask his surgeon and senior physicians to respond.” (Hospital 3, HCP [nurse], female,
37)
Fear of side effects and dependence. HCPs were afraid of opioid-related side effects, in
particular with respect to legal issues. To be on the “safe side” and avoid accountability, they
mainly relied on nonsteroidal anti-inflammatory drugs (NSAIDs), despite the knowledge
about their limited efficacy.
“Narcotics are not available like other analgesics, but even if they are available, there is a
worry. This worry concerns respiratory depression, because of the drugs. Professionals have to
be on the safe side and avoid legal consequences, so they intentionally avoid them. Also,
because these drugs are prone to abuse (addiction) the chance of these drugs reaching the
hand of the professional is also rare.” (Hospital 3, HCP [anesthetist], male, 45)
Also, independent of the HCPs attitude towards opioids, most of them believed that it was
not wise to give analgesics to the patient every time he or she complained because of the risk of
side effects.
“The surgery is part of the care, so there will always be pain. Even when the wound starts to
heal, and the skin begins to close naturally, there is pain. So, every time the patient complains
about pain I don’t think it is appropriate to give analgesics. Otherwise, there will be adverse
effects.” (Hospital 1, hospital official [nursing unit director], 48, male)
PLOS ONE | https://doi.org/10.1371/journal.pone.0213644 March 14, 2019
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Barriers to and facilitators of quality pain management in Ethiopian hospitals
Facilitators related to healthcare professionals
Continuing education for HCPs was identified as a facilitator of QPM after surgery. HCPs
stressed that the education should be carefully designed to improve their communication
skills, cultural competency, and ethical norms to help them provide respectful, compassionate
care.
Provide in-house/on-the-job training for healthcare professionals. HCPs and hospital
officials argued that the lack of emphasis on pain (or ignorance about it) and its management
in undergraduate medical and nursing education can be addressed by the hospitals themselves
when training young HCPs.
“If possible, we need to intervene in the pre-service education. In the same way that we teach
them to give anti-malarial drugs for malaria patients, they should be able to manage a
patient’s pain after an operation. Especially during their internship period, a lot can be done.
We need to start regarding pain as a disease.” (Hospital 1, hospital official [clinical director],
male 35)
Enhance the ability of healthcare professionals to create positive rapport with
patients. Patients and some HCPs felt that the lack of a harmonious relationship between
HCPs and patients affected patients’ mood and emotions. HCPs and hospital officials believed
that, in order to create a favorable caring environment for the patient, HCPs should receive
training in ethics and psychology, in addition to training in the physiology and pharmacology
of pain.
“Patients are not mere bone and flesh. They have moods and emotions. I think pain management should start with this attitude. They are in pain. You don’t have to be an additional
cause. You need to be considerate, and the best way to achieve this is to teach medical professionals about ethics, norms and compassionate care in addition to the usual anatomy and
physiology.” (Hospital 2, HCP [anesthetist], male, 57)
Increase the cultural competence of professional
