https://doi.org/10.15218/ejnm.2023.12 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov. 2023 Original Article Non-pharmacologic Pain management Knowledge and Barriers among Nurses in Erbil Hospitals ABSTRACT Aim of the study: Pain management is a multidisciplinary approach for easing suffering and improving the patients’ quality of life and nurses play a significant role in providing pain assessment and treatment. Non-pharmacological pain management is any interven- tion intended to improve health or well-being that does not involve the use of any drugs or medicine. This study aimed to assess the nurses’ knowledge and their barriers regard- ing non-pharmacologic pain management. Methods: A descriptive cross-sectional study was carried out at Hawler, Rizgary and Nanakaly teaching hospitals in medical and oncology wards on a non-probability purpos- ive sample of 100 nurses who worked in the above wards. The data was collected from the end of December to the end of February 2020 through self-reports by nurses using a constructive single choice questionnaire. Each correctly answered item was recorded as 1 and the incorrect one as 0. Results: The higher percentages of nurses, including males aged between (30-39) years, institute graduates, and experienced in jobs between (1-10) years. 69% of nurses have a moderate level of non-pharmacologic pain management, and, 47% of nurses have not applied non-pharmacological pain management in hospitals. Only 16% of them applied, and 37% sometimes applied, psychological and physical methods of non-pharmacologic pain management were more applied by 29% and 23% respectively by nurses than other methods. Nurses had many barriers to using non-pharmacological pain management, like nursing workload and lake of protocol for pain management. Conclusion: This study concluded that the majority of nurses have a fair (moderate) level of knowledge about non-pharmacological pain management and applied by only 16 % of nurses. Nurses have many barriers to using non-pharmacological pain management. Keywords: Pain management; Non-pharmacologic pain management; Knowledge; Barriers. Ronak Nematala Hussain; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Kurdistan Region, Iraq (Correspondence: ronak.hussain@hmu.edu.krd). 106 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Received: 31/03/2023 Accepted: 12/07/2023 Published: 30/11/2023 mailto:ronak.hussain@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov. 2023 Original Article Pain is an unpleasant sensory and emo- tional experience associated with actual or potential tissue damage the International Association for the Study of Pain (IASP) [1, 2]. Pain is a responsive mechanism to pro- tect from damage. Many studies describe pain as the fifth vital sign that health pro- fessionals monitor and manage when car- ing for patients [3, 4]. Pain is feeling, and only a person without pain is a happy per- son. In physiotherapy, more physical mo- dalities are used for the treatment of sub- acute and chronic pain [5].Non- pharmacological therapy as any interven- tion intended to improve health or well- being that does not involve the use of any drugs or medicine [6]. These therapies help the standard pharmacologic treat- ment in pain management. While medica- tions are being used for treating the so- matic (physiological and emotional) dimen- sion of the pain, non-pharmacologic thera- pies aim to treat the affective, cognitive, behavioral and socio-cultural dimensions of the pain [7]. Non-pharmacologic manage- ment is a number of effective interventions for pain. These may be used alone for mild to moderate pain, or in combination with drug therapy for more severe pain [8]. The use of non-pharmacological pain relief techniques has been found to be effective with fewer side effects and complications associated with them also diminishes pain perception by reducing intensity and in- creasing pain tolerance, reduces pain- related distress, strengthens coping abili- ties, and gives the patient and family a sense of control over pain [9].Non- pharmacologic interventions include cogni- tive behavioral therapy, relaxation therapy, biofeedback, patient education, self- management, and social support interven- tions. These types of interventions aim to change behavior, cognitions, and emotions by targeting the psychosocial processes that are implicated in the perceptions and responses to pain. Here, good nursing care plays a pivotal or central role. Nurses are not the only healthcare workers who are responsible for relieving patients’ pain; they also play a key role in managing pa- tients’ pain [10, 11].Because of the exten- sive prevalence of chronic pain, the major impact it has on quality of life and the many benefits of non-pharmacologic methods of pain management in relieving pain, therefore this method needs to be explored further. The barriers keeping nurses from using them need to be ex- plored. Nurses' knowledge of non- pharmacological pain management needs to be assessed, and any deficits identified need to be corrected, so patients have ac- cess to other options to manage their pain more effectively. The study aimed to as- sess non-pharmacologic pain management knowledge among nurses and potential barriers related to management. A quantitative descriptive cross-sectional study design was used to assess nurses’ knowledge about non-pharmacologic pain management in Hawler, Rizgary and Nanakaly Teaching Hospitals in Erbil city. The sample study included a non- probability purposive sample, including all nurses who worked in medical wards during the period of data collection from 21 December 2020 to the end of February 2020. Data were collected through the nurses’ self-report method by using a constructed questionnaire that was based on an extensive review of relevant literature. The questionnaire consisted of three parts, which included part I: socio- demographic characteristics of the nurses, which include setting, gender, age, level of education, and experience in the job. Part II consisted of the nurse's knowledge of non-pharmacologic pain management. 107 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov. 2023 Original Article Part III included the barriers to the appli- cation of non-pharmacologic pain man- agement. Prior to data collection, formal permission was obtained from the ethical approval of the ethical committee at the College of Nursing and official permission was obtained from the Erbil Directorate of Health. Nurses’ using a constructive single choice questionnaire, each correctly an- swered item was recoded as 1 and the in- correct one as 0. Data were analyzed through the SPSS (Statistical Package for Science Service) for Windows V.21 for sta- tistical data analysis, which includes de- scriptive statistical analysis (frequency, percentage, mean of percentage, which is calculated by the sum of percentages di- vided by a number of items and chi-square to find out the association between nurs- es’ non-pharmacologic pain management and some of the sociodemographic varia- bles like setting, age, level of education. The P value of each test ≤ 0.05 is consid- ered statistically significant. Table 1 represents socio-demographic characteristics of nurses’ distribution: 41% of nurses were within the age group (30- 39) years, 33% of them within (20-29) years, 51% of nurses were males and 49% of them females. Concerning level of edu- cation, 57% of nurses were institute grad- uates, and bachelor was 23%. About setting, 38% of nurses were from Rizgary teaching hospital, 36% were from Hawler teaching hospital and 26% were from Nanakaly teaching hospital. Regarding ex- perience in the job, 51% of nurses were between (1-9) years of experience, and 30% were between (11-19) years. 108 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULTS Table-1. Socio-demographic characteris- tics of the nurses (n.100) Socio-demographic characteristics of nurses F. (%) 1. Age of nurses 20-29 33 (33) 30-39 41 (41) 40-49 17 (17) 50-59 9 (9) 2. Gender of nurses Male 51 (51) Female 49 (49) 3. Level of education Preparatory- nurse 20 (20) Institute 57 (57) Bachelor 23 (23) 4. Setting of nurses Hawler Teaching Hospital 36 (36) Rizgary Teaching Hospital 38 (38) 5. Nanakaly Teaching Hospital 26 (26) 6. Experience in job years 1 – 9 51 (51) 10-19 30 (30) 20 – 29 15 (15) 30-40 4 (4) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov. 2023 Original Article Table 2 shows from Q1 to Q6, regarding nurses' knowledge about pain assessment. The results show that 44.83 of nurses de- fine pain and assess it correctly and % 72 of nurses answer correctly to the question about the knowledge of the signs and symptoms of pain. Regarding nurses' knowledge of non-pharmacologic pain management from Q7-Q18, it shows the Table 3 reveals to overall levels of nurses' knowledge. Most nurses, 69% have moder- ate. overall mean of percentages, and % 57.3 of nurses answered correctly and % 42.7 an- swered incorrectly. For most of the nurses, 83% correctly answered on massaging as a pain reliever, with 17% incorrect. The low- est percentages of knowledge about on non-pharmacologic pain management (TENS) were 0.30 and 0.15, respectively. knowledge, 22% have poor knowledge and 9% of nurses have good knowledge. 109 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2 : Nurse’s knowledge about non-pharmacologic pain management (No.100) Nurse knowledge about pain and non-pharmacologic pain management Incorrect answer Correct answer F. F. Definition of pain 44 56 Nurses have the right to assess the pain of the patients. 47 53 Ideal time for pain assessment 76 24 The frequency of use of the pain assessment in the 24-hour tool is. 89 11 Sign and symptom of pain 28 72 According to nursing process pain assessment is provided in which steps? 47 53 Overall mean of percentages 55.17 44.83 Pain can be managed without drug 25 75 Chronic pain can be managed without drug 56 44 By pharmacologic and non-pharmacologic can manage or relief pain 33 67 Having idea about non-pharmacologic pain management 37 63 Social method is non-pharmacologic pain management 53 47 Transcutaneous electrical nerve stimulation (TENS) a method of non-pharmacologic pain management 70 30 Definition of TENS 85 15 Deep breath exercise is relaxation technique for pain management 29 71 According to situation (cold or heat application-massage) is more effective non- pharmacologic pain management 29 71 massage is the most effective method to getting the attention away from the pain 49 51 Massaging use method of stroking, kneading, and rubbing can relieve pain 17 83 The benefits of using non-pharmacological pain management is 29 71 Over all mean of percentages 0.42.7 0.57.3 Table 3: Overall Nurses’ levels of Knowledge about non-pharmacologic pain management Overall Nurses’ levels of Knowledge F. (%) Poor Knowledge 22 (22) Moderate Knowledge 69 (69) Good Knowledge 9 (9) Total 100 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov. 2023 Original Article 110 of 47% of nurses did not apply, 37% of them with some times applied, and 16% always applied. while the other 20% used none pharma- cologic methods of pain management, while cognitive behavior method is used by 8% of nurses. having a nursing workload and 14% of having a lack of protocol of pain manage- ment barriers. Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 4 shows the implementation of non -pharmacologic pain management by nurses in the hospitals. A high percentage Table 5 shows that a higher percentage% 29 of the nurses used the psychological method, 23% used the physical method, 20% of them used all of the methods of none pharmacologic pain management, Table 6 shows that the higher percent- ages, 47% of nurses' barriers, are within all the above barriers, followed by 17% Table 4 Non pharmacologic pain management method applied in the hospitals Applied of non-pharmacologic pain management by nurses F. (%) No 47 (47) Some time 37 (37) Yes 16 (16) Table 5: Methods of none pharmacologic pain management applied by the nurses Methods of none pharmacologic pain management that apply by the nurses F. (%) Physical method 23 (23) Psychological method 29 (29) Cognitive behavior method 8 (8) All above 20 (20) None of above 20 (20) Table 6: Barriers to using non-pharmacological pain management. Barriers to using non-pharmacological pain management F. (%) 1 . Lack of the protocol of pain management 14 (14) 2 . Nurses' unwillingness and patient instability 8 (8) 3 . Inadequate motivation 8 (8) 5 . Nursing workload 17 (17) 6 . Nurses' lack of knowledge 6 (6) 7 . All the above barriers 47 (47) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov. 2023 Original Article 111 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 6.1 shows the nurses' opinion about providing actions that minimize the barri- ers of applying non-pharmacologic pain management in hospitals. 49% of nurses minimize those barriers through item of Table 7 Shows that there were significant associations between the setting and age of nurses with applying non-pharmacologic pain management in the hospital at p.value 0.046, 0.048 respectively. Manag- ing pain without drug were applied more by nurses from Hawler teaching hospital than Nanakaly and Rizgary teaching hospi- applying all of the above actions, fol- lowed by 16% of them within caregiver training to minimize barriers and 15% by enhancing patient by staff and family. elder. Also, there is a significant associa- tion between nurses’ knowledge of non- pharmacologic pain management with their educational level; the higher their level of education (bachelor), the more knowledgeable they are about non- pharmacologic pain management at P-value 0.003, respectively. Table 6.1: Actions that provide to minimize the barriers. The following actions to minimize the barriers F. (%) Enhance patient by staff and family 15 (15) Enhance patient by himself 4 (4) Provide good environment 9 (9) Caregiver training 16 (16) Caring according to hospital policy 7 (7) All of the above way 49 (49) Table 7 :Association between some of the nurses’ sociodemographic characteristics with their non- pharmacologic pain management Setting of nurses Hawler Teaching Hospital Rizgary Teaching Hospital Nanakaly Teaching Hospital Total 1. Appling non-pharmacologic pain man- agement in the hospitals No 12 21 14 47 Some time 19 13 5 37 Yes 5 4 7 16 Total 36 38 26 P. 0.046 Nurses’ age (years) 20-29 30-39 40-49 50-90 2. Appling non-pharmacologic pain management No 8 23 11 5 47 Some time 1 8 11 4 4 37 Yes 7 7 2 0 16 Total 3 3 41 17 9 P.0.048 3. Nurses’ level of education Prep-nurse Institute Bachelor Total Knowledge about non-pharmacologic pain management Un known 8 16 2 26 Poor 4 6 1 11 Good 16 13 11 40 Very good 8 3 12 23 Total 36 38 26 P. 0.003 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov. 2023 Original Article management methods. However, the cur- rent study finding is lower compared with the result of the study [15] in Zimbabwe Bindura Hospital, which had a mean knowledge score of 64.5%.In current study, 69% of nurses had a fair level of overall nurse's knowledge about non- pharmacologic pain management; this is due to the fact that more than half of nurs- es have within medium level of education. This result, along with results of Bindura Hospital and United States studies [15, 16] and Nigerian study [17], revealed that nurses have adequate knowledge about non-pharmacological methods for pain control. However, lower, compared with another study of the western part of Ethio- pia, 78.1% correctly answered the item [18].The present result disagree with the result of a previous study [19] conducted in Bangladesh they indicated that nurses with poor level of knowledge and whereas the level of practice was moderate In the current study near than half of nurses not apply non-pharmacological method of pain management this may be related to the hospitals system and inadequate facilities to use non-pharmacological methods and excess workload this result in consistent with the results of the Turkey article study [20] that reviewed about 35 Turkish and English studies which included 13 of these studies were master’s thesis and 11 of these were doctoral thesis and research articles the most research was done in 2016 and 2017. They stated that nurses have never used or limited used non- pharmacological methods in pain manage- ment. In addition the current result disa- gree with the results of Turkey study [4] and study [21] in Egypt they mentioned that majority of nurses were restricted or didn’t apply non-pharmacological pain management practices for their patients. Furthermore the result of the study [12] in Jordan supported current study result they It is the first study done in Erbil, even in Iraq, on the nurses' knowledge regarding non-pharmacological pain management; therefore, the goal of this study is to as- sess nurses' knowledge of non- pharmacological pain management and their barriers among chronic disease pa- tients in Erbil. In this study, the results show that the higher percentage of nurses were from Rizgary teaching hospitals, males, aged from 30-39 years, married, medical institute graduates, having less than ten years of experience; this result disagrees with the result of the previous study [12] done on Jordanian nurses which revealed that the majority of the nurses were females, more than half of the re- spondents belonged to the age group of 26-30 years old, majority of the respond- ents had professional experiences be- tween 6 - 10 years and (86.8%) of re- spondents had a bachelor degree. The cur- rent study findings regarding non- pharmacological pain assessment and management sub-items revealed that nearly half (%44.83) of the nurses an- swered the questions correctly. It may be related to a need for more protocols for pain management and nurses' workload in the hospitals. This finding is consistent with the Egypt study [13], which revealed that nurses' pain assessment and manage- ment among critically ill patients needed a better level of practice. Regarding nurses’ knowledge of non-pharmacological pain management, results of this study show that 57.3 % of the overall mean percent- ages of nurses had correctly answered; this may relate to the fact that the majori- ty of nurses institute graduate within mid- dle level of education. This result is con- sistent with the results of Ethiopian stud- ies [14, 2] which revealed that 53.3% and 51.2% of nurses, respectively, had good knowledge of non-pharmacological pain 112 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. DISCUSSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov. 2023 Original Article non-pharmacological pain management were lack of time (54.2%), excessive work- load (51.2%), and lack of knowledge of some of the various alternative measures (38.9%). Furthermore the most common barriers that prevents nurses using non- pharmacological pain management for pa- tients in the three Saudian hospitals (1, 2& 3) supported the current result by stated their barriers were the lack of time (55%, 62.5%, 15% respectively), then followed by unwillingness of patients (5%, 25%, 7.5% respectively) [ 23]. Regarding association between applying of non-pharmacologic pain management with setting and age of nurses there was significant association at P.value 0.046, 0.048 respectively. Nanakaly Teaching Hospital more applying of non- pharmacologic pain management than Hawler and Rizgary Teaching Hospitals, and the younger nurses more applied non- pharmacologic pain management than or- ders; this may relate to younger nurses more familiar and beneficiary about using internet and mass media than older. There were a positively relationship between nurses’ knowledge on non-pharmacologic pain management with their educational level at P.value 0.003, this result supported by Nigerian and Saudian studies [17, 23] which finds that there is significant rela- tionship between the nurses’ knowledge with their educational level and years of practice regarding use of alternative pain relief measures. While the results disagree with the Egypt study which stated that there is no significant relationship between nurses’ knowledge as well as practices with their age, years of experience [13]. Also current results disagree with the result from Tehran, Iran [24].They stated that nurse’s educational level, and their work experiences were not significantly associ- ated with the non-pharmacological pain management. stated nurses tended to have a moderate practices of pain management (Mean = 4.968; standard deviation = 1.310). Con- cerning the methods of non- pharmacological pain management that were applied by nurses in this study, the results show that nurses mostly applied the psychological and physical methods. This result is supported by the result of the Nigerian study [17], which found that nurses were more aware (85.7%) of the physical methods of non-pharmacological pain control when compared to psycho- logical (49.8%) methods. Furthermore re- garding using methods of non- pharmacological pain management in cur- rent study the results congruent with the results of Brazil review article study [22] in 2017 they revealed that from the non- pharmacological measures that can be employed by nurses are patient orienta- tions with regard to emotional support, and massage, relaxing massage, heat or cold application, measures that can be implemented by nurses. In relating to bar- riers of non-pharmacological pain man- agement in this study the present result show that nurses have many barriers such as lack of protocol of pain management, nursing workload, nurses unwilling and patient instability, lack of motivation to use non-pharmacology pain management methods and poor nurses knowledge, this results supported by the result of Ethiopi- an study [14] which stated that based on nurses response barriers were around 121 (71.6%) of nurses were had fatigue, 121 (71.6%) nurses in adequate motivation, about three fourth 125(74.0%) within heavy nurses’ workload, 122(72.2%) con- flict and unwillingness to use non- pharmacological pain management,125 (74.0%) multiple responsibility of nurses. In addition the current result agree with the results of Nigerian study [17] which indicated their barriers of 113 Copyright ©2022 The Author(s). 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