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International Journal of Africa Nursing Sciences 2 (2015) 26–33
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International Journal of Africa Nursing Sciences
journal homepage: www.elsevier.com/locate/ijans
Developing a context appropriate clinical guideline for post-operative
pain management in Ghana: A participatory approach
Lydia Aziato a,⇑, Oluyinka Adejumo b
a
b
School of Nursing, University of Ghana, P.O. Box LG43, Legon, Ghana
School of Nursing, University of the Western Cape, Private Bag X17, Bellville 7535, South Africa
a r t i c l e
i n f o
Article history:
Received 6 May 2014
Received in revised form 21 November 2014
Accepted 10 March 2015
Available online 17 March 2015
Keywords:
Collaboration
Post-operative pain
Consensus
Stakeholder
Expert review
a b s t r a c t
Clinical guidelines involve statements that guide clinicians to provide effective care to patients. However,
there are no context appropriate clinical guidelines for post-operative pain (POP) management in Ghana.
This study sought to develop such a clinical guideline. The study adopted a participatory approach drawing from the existing literature to develop the guideline with the involvement of 27 experts and stakeholders including nurses, doctors, anaesthetists, pharmacists, patients, and patients’ relatives. Also, the
guideline statements were discussed and finalised at a multidisciplinary consensus forum made up of
29 members. Consensus was achieved by employing procedures similar to a modified nominal group
technique. Purposive sampling was employed. The guideline was made up of four dimensions described
in a conceptual Radial Venn which emphasised inter-relationships among patient and family education,
team work, monitoring and input by hospital leadership, and application of appropriate scientific recommendations for POP management. The effective collaboration with stakeholders resulted in the adoption
of the clinical guideline by the Ghana Health Service for use within the Ghanaian health system.
Ó 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Background
Clinical guidelines are defined as statements that are developed
systematically to help health care providers and patients make
appropriate decisions about specific clinical issues (Hewitt-Taylor,
2004). The statements of a clinical guideline are based on the best
available evidence relating to the specific aspect of care or procedure. The process of guideline development involves establishing
the scope or parameters of the guideline. This forms the foundation
of the clinical guideline, whereby specific limits of the guideline are
clearly stated, such as the objective of the guideline, the target
patient group and the specific procedure or patient care activity
involved (Hewitt-Taylor, 2004; National Institute for Health and
Clinical Excellence (NICE), 2014; Scottish Intercollegiate Guideline
Network (SIGN), 2013; The Appraisal of Guidelines Research and
Evaluation in Europe (AGREE) Collaboration, 2013).
The development of a clinical guideline also involves identification of a multidisciplinary team or stakeholders to ensure that all
relevant areas are incorporated. It is recommended that the team
should have a balance of disciplines and that the membership
should be kept at a manageable size to ensure effectiveness
⇑ Corresponding author. Tel.: +233 244719686.
(Hewitt-Taylor, 2004; Keeley, 2003). Another hallmark of clinical
guideline development is a systematic review of the evidence for
which the clinical guideline is developed (National Institute for
Health and Clinical Excellence (NICE), 2014). Thus, a systematic
review was conducted as part of the doctoral study from which this
paper was derived (Aziato, 2012) to ensure that guideline statements included evidence-based recommendations for POP
management.
Clinical practice guidelines may be procedure-based, unitbased, institution-based or for national use. (Haljamäe &
Stomberg, 2003; Lindenfeld & Kelly, 2010; Rolley, Salamonson,
Wensley, Dennison, & Davidson, 2011). Therefore, it is necessary
for the limits of a particular clinical guideline to be well demarcated to avoid ambiguity and confusion regarding its use, as this
could have negative repercussions Thus, the development of clinical guidelines follows standard processes stipulated by recognised
bodies such as the National Institute for Clinical Excellence in
the UK, the Scottish Intercollegiate Guidelines Network, and The
Appraisal of Guidelines Research and Evaluation in Europe
Collaboration. This study drew from these standard processes to
develop a contextual clinical guideline for post-operative pain
(POP) management in Ghana.
Guideline development institutes most often develop guidelines for specific conditions and procedures at the national
E-mail address: aziatol@yahoo.com (L. Aziato).
http://dx.doi.org/10.1016/j.ijans.2015.03.001
2214-1391/Ó 2015 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
L. Aziato, O. Adejumo / International Journal of Africa Nursing Sciences 2 (2015) 26–33
level, and therefore such guidelines have a wider spectrum
(Hewitt-Taylor, 2004). However, this paper describes the
development of a clinical guideline for a specific clinical issue
(post-operative pain management on a surgical ward). On a surgical ward, there may be different guidelines for various procedures
that guide the health professional to provide the best possible care.
For example, there are guidelines for the administration of drugs
such as opioids, for the nursing care of a patient receiving
patient-controlled analgesia or epidural analgesia, and intravenous
fluids (Rolley et al., 2011). Generally, such guidelines reflect
current evidence-based standards and are reviewed periodically.
However, within resource constrained countries, the authors were
not aware of any clinical guideline for POP management at the
time of the study.
Many patients continue to experience moderate to severe postoperative pain globally and researchers over the years have
devoted attention to many aspects of pain (Abdalrahim, Majali, &
Bergbom, 2010; Qu, Sherwood, McNeill, & Zheng, 2008).
Although pain is a personal phenomenon, patients respond to
POP differently (Aziato & Adejumo, 2014c). Also, the socio-cultural
background of the patient influences pain response (Lovering,
2006). In view of this, individual and contextual factors are to be
incorporated in the planning and delivery of care. Therefore, the
guideline developed for a resource-limited clinical context is
necessary as it is suitable to address the uniqueness of such context. Lack of understanding of context factors could lead to inappropriate guideline statements. The inappropriate statements
will result in difficulties in the use of the clinical guidelines
(Ploeg, Davies, Edwards, Gifford, & Miller, 2007; Taba et al., 2012).
In this study, a resource-limited clinical context is defined as a
situation/scenario where there is limited staff education, equipment and non-use of methods such as patient controlled analgesia
[PCA]). Thus, the scope and limits of the clinical guideline were
derived from in-depth understanding of contextual factors that
influenced post-operative pain management and a systematic
review of the literature. For example, patients and nurses in
Ghana do not have adequate knowledge on POP management
due to inadequate education and training (Aziato & Adejumo
2014a; Aziato & Adejumo 2014b; Aziato & Adejumo 2014c; there
are no advanced techniques for pain management such as PCA.
Nurses fear patients will be addicted to opioids such as pethidine
and hence do not administer adequate opioids (Aziato &
Adejumo 2014a). There was also inadequate knowledge on pain
management, team work, and supervision. Post-operative pain
management is seen as inadequate in Ghana (Aziato & Adejumo,
2014a; Clegg-Lamptey & Hodasi, 2005). Incorporating systematic
reviews in clinical guideline development is recommended by
accredited guideline development agencies such as The Cochrane
Collaboration, Scottish Intercollegiate Guideline Network (SIGN),
National Institute for Health and Clinical Excellence (NICE), and
The Appraisal of Guidelines Research and Evaluation in Europe
(AGREE) Collaboration (Hewitt-Taylor, 2004). It is necessary to
appraise included studies based on an established hierarchy of
the evidence. The hierarchical order of the scientific evidence is
systematic reviews and meta-analysis, randomized controlled trials (RCT), cohort studies, case-controlled studies, cross sectional
surveys, case reports, expert opinion, and anecdotal evidence
(Keeley, 2003). The method used for appraisal of the evidence is
determined by the type of studies involved in a particular systematic review.
This article provides a detailed account of a participatory process undertaken to develop a clinical guideline for POP management in Ghana. The participatory process employed ensured that
relevant stakeholders were actively involved and their views incorporated in the clinical guideline developed. Participatory processes
have been adopted by community-based projects and this
27
approach has been demonstrated to be effective (Kraemer Diaz,
Spears Johnson, & Arcury, 2013; Ritchie et al., 2013). The approach
has been employed successfully for promoting environmental
health (Liu et al., 2011). The report is derived from a multi-stage
doctoral study by the first author.
2. Methods
The study was approved by the Ethics Committee at the
University of the Western Cape (South Africa) and the Ghana
Health Service Ethics Committee. Steps were taken to ensure anonymity and confidentiality of participants, through the use of identification codes. Participation was voluntary and individual
informed consent was obtained by signing the informed consent
form. The study was conducted in two hospitals in Accra, Ghana.
A systematic review was attempted in January to April, 2012.
The aim of the review was to answer the question: ‘What measures
ensure effective POP management among adult general surgical
patients in a resource limited environment?’ The review adopted
an exploratory approach targeting both quantitative and qualitative literature with a comparable group or control group. Data
sources searched included several online databases, books, and
non-electronic journals. The selection of articles was done with
focus on the study (intervention for POP management) and not
the author, particular journal or the author affiliation. Both authors
independently selected the relevant article to avoid selection bias.
A critical independent review of the abstracts resulted in exclusion
of eight (8) of the selected studies because findings were not
applicable to the Ghanaian clinical setting (Arya, Abdollahi,
Golalipour, Kazemnezhad, & Mohammadi, 2007; Bardiau,
Taviaux, Albert, Boogaerts, & Stadler, 2003; Closs, Briggs, &
Everitt, 1999; Good et al., 1999; Good et al., 2001; Roykulcharoen
& Good, 2004; Seers, Crichton, Carroll, Richards, & Saunders,
2004; Wong, Chan, & Chair, 2010); and only one study included
(Mac Lellan, 2004) based on a nurse-led intervention rather than
the use of advanced pain management technique (Table 1).
Subsequently, a focused review was undertaken as a remedial
review to identify studies applicable to a resource-limited context.
Identified studies emphasised effective leadership and team work,
pre-emptive analgesia, regular around-the-clock analgesia, multimodal analgesia, and patient education (Table 2). The focused review
was necessary because of paucity of evaluative research for pain
management in resource-limited clinical environment. The studies
identified were appraised for quality and applicability to resourcelimited clinical context and not the level of scientific evidence. The
identification of studies during the focused review was based on an
in-depth understanding of context factors (Aziato, 2012).
Subsequently, two participatory approaches were adopted and
included participant/expert review and the conduct of a consensus
forum oriented towards a modified nominal group technique to
achieve consensus (Jackson, Hettinga, Mead, & Mercer, 2009). A full
understanding of the contextual factors influencing POP management in Ghana (Aziato & Adejumo, 2014a,b,c), a systematic review
(Aziato, 2012), and a review of existing clinical guidelines on acute
pain management in other countries such as the USA, Australia,
New Zealand, Canada, UK and South Africa (American Society of
Anaesthesiologists (ASA), 2012; Australian and New Zealand
College of Anaesthetists (ANZCA), 2010; European Association of
Urology, 2010; The British Pain Society, 2007; The South African
Society of Anaesthesiologists (SASA), 2009), indicated that the
existing guidelines could not be applied in a resource-limited clinical context as occurs in Ghana. The reason for this assertion is that
the existing guidelines included statements for PCA and epidural
techniques which were not available in resource-limited clinical
context at the time of study. Thus, the authors developed initial
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L. Aziato, O. Adejumo / International Journal of Africa Nursing Sciences 2 (2015) 26–33
Table 1
Included study.
Author and
year
Objective (s) of study
Design and
sampling
Participants (no./age)
Setting
Interventions
Findings
Conclusions
Mac Lellan
(2004)
To introduce a
nurse-led intervention
to improve pain
management after
surgery and evaluate
its effectiveness by
measuring patients’
pain scores
Experimental
(pretest-post-test);
conducted in three
(3) phases.
Sampling:
Convenient
sampling
800 male and female
patients – 200
pre-intervention and
200 post-intervention
in each hospital.
Patients had different
surgeries such as
urological,
gynaecologic,
orthopaedic, and
general surgery
Two (2)
teaching
hospitals in
Ireland; the 2
hospitals
were studied
prospectively
Education for
nurses in the form
of short pain
courses.
Introduction of
regular pain
assessment.
Profiling of pain at
hospital level
Pain score reduction in
the order of 0.73 cm
(7.3%) on a visual
analog scale (VAS) 0 to
10 cm, was statistically
significant for day of
surgery and 2 days
postop (q = 0.05) in the
intervention hospital. A
reduction was not seen
in the control hospital
Introduction
of nurse-led
intervention
reduced
patients’ pain
scores
guideline statements following an insight into the contextual factors and the systematic review of the literature. These statements
were subjected to participant and expert review. Experts in this
study were individuals with expert knowledge or experience (personal or clinical) in post-operative pain. Expert knowledge was
recognised through publications on pain and clinical expertise
involved at least 5 years post qualification clinical experience.
2.1. Participant/expert review
According to Rycroft-Malone (2001), the processes for
incorporating input from experts and participants should be
clearly described by guideline developers. Thus, the authors sought
a review of the initial draft guideline statements from external
experts and experts in the two hospitals, as well as patients and
patients’ relatives. Purposive sampling was used to recruit reviewers to ensure that all relevant reviewers were involved. The expert
reviewers included nurses, doctors, anaesthetists, hospital leaders,
patients’ relatives, patients, nurse educators and an international
reviewer.
The draft statements and summary of the contextual findings
and literature review were disseminated through electronic mail
(e-mail) and personal delivery. The heads of surgery (nursing and
medical) at each hospital helped to identify ‘experts’ to review
the statements. The summary of the contextual findings and literature review was to help reviewers relate the guideline statements
to the ‘local’ context. A form was designed for feedback. The
reviews were done in private and it focused on the structure,
Table 2
Studies identified from ‘focused review’.
Author (s)/year
Aim
Findings/conclusion
Contemporary measure recommended
Joshi, Rawal,
Kehlet, and The
PROSPECT
collaboration
(2011)
Systematic review (SR) to evaluate the
available literature on the management of pain
after open hernia surgery
Field block with or without wound infiltration, either
as a sole anaesthetic/analgesic technique or as
adjunct to general anaesthesia is recommended to
reduce post-operative pain (POP)
Pre-emptive analgesia reduces POP
Fredericks et al.
(2010)
SR to examine who would most benefit from
postop education, type or approach, and dose
of education
Delivery of postop patient education through the
individualisation of content, use of combined media
for delivery, provision of education on a one-on-one
basis, and in multiple sessions is associated with
improvement in educational or health outcomes
Patient education improves health/
education outcomes such as better POP
management
Cummings et al.
(2010)
SR to examine the relationships between
various styles of leadership outcomes for the
nursing workforce and their work environment
Leadership styles that focused on people and
relationships (transformational, resonant,
supportive, and consideration) were associated with
nurse job satisfaction and leadership styles focused
on task (dissonant, instrumental, and management
by exception) were associated with lower nurse job
satisfaction
Emphasises effective leadership
improves workforce
Jirarattanaphochai
and Jung (2008)
SR to assess the efficacy and safety of nonsteroidal anti-inflammatory drugs (NSAIDS) in
addition to analgesics on POP management in
lumber surgery
Meta-analysis provides evidence that the addition of
NSAIDS to opioid analgesic in lumber surgery
provided better pain control than opioid analgesics
alone
Combination or multimodal analgesic
is better than single analgesic therapy
Paice et al. (2005)
Quality improvement study to determine the
efficacy and safety of scheduled dosing of
opioid analgesics among patients on the
medical unit
Scheduled doing was associated with decreased pain
intensity ratings; there is no difference in adverse
events between the scheduled and the PRN groups.
Thus, scheduled dosing of opioids provides improved
analgesia with no increased risk of adverse events
among inpatient medical patients
Scheduled dosing of opioids provides
more stable plasma levels of the opioid
administered rather than a PRN
administration
Meterko et al.
(2004)
Quantitative study to investigate the
relationship between team work culture of
hospitals and patients’ satisfaction with care
received
Team work culture for hospitals is positively
associated with patients’ satisfaction. Thus, health
care organisations should develop a culture that
emphasises team work and limit aspects of
bureaucracy that do not assure efficiency and quality
care
Highlights the relevance of team work
in health care
L. Aziato, O. Adejumo / International Journal of Africa Nursing Sciences 2 (2015) 26–33
content, format, and applicability of the guideline statements.
Feedback was obtained within two weeks after administration by
e-mail, telephone, and face-to-face interaction.
The feedback was synthesised and incorporated in a revised
version (Draft 2). The process drew from previous authors regarding clinical guideline development (National Institute for Health
and Clinical Excellence (NICE), 2014; Rolls & Elliott, 2008;
Scottish Intercollegiate Guideline Network (SIGN), 2013; The
Appraisal of Guidelines Research and Evaluation in Europe
(AGREE) Collaboration, 2013). The synthesis of the feedback
resulted in the re-structuring of statements, modification of sentences, re-ordering of statements, and modification of headings.
The reviewed clinical guideline (Draft 2) was then subjected to a
multidisciplinary stakeholders’ consensus forum.
2.2. Consensus forum
Formal consensus method involves a process of group decisionmaking that ensures that decisions made are representative of the
group’s ideas or concerns. The process ensures that each member is
given an opportunity to make a comment (Rolls & Elliott, 2008).
The emphasis on group decisions in a consensus process is to
enhance ‘ownership’ of research outcome. The context-appropriate
consensus process adapted for this study was drawn from the work
of previous researchers leaning towards a modified group technique (Fig. 1) (Berry, Davidson, Nicholson, Pasqualotto, & Rolls,
2011; Jackson et al., 2009; Nair, Aggarwal, & Khanna, 2011;
Rolley et al., 2011; Rolls & Elliott, 2008).
The authors liaised with the Director of the Institutional Care
Division (ICD) of the Ghana Health Service (GHS) to identify all of
the relevant stakeholders for the consensus forum. These included
one representative each from the GHS, the West African College of
Nursing, Ghana Anaesthetists’ Society, Ghana College of Physicians
and Surgeons, Pharmacy Council, the Commission on Human
Rights and Administrative Justice, and the WHO. Others were
tutors from the Peri-Operative Nursing School, the Diploma
General Nursing School, the Graduate Nursing Programme;
Nurses, Surgeons, Pharmacists, Anaesthetists, Hospital leaders,
and patients. The authors discussed the list of stakeholders to
ensure that all relevant members were invited. On the day of the
forum, only two stakeholders could not attend.
Dra 1
Expert Review
Final
consensus
statement
Group
modificaon
Dra 2
Group Discussion
Independent
Decisions
Modify/Maintain
(Group level) - integrate, split,
re-word, collapse, add a
statement
Maintain/Modify
All Panel Discussion
Fig. 1. Consensus forum process for development clinical guideline.
29
Letters of invitation signed by the Director General of the GHS
at the time of study was sent to stakeholders and it was emphasised that appropriate individuals who could make meaningful
contributions on the guideline should be nominated. The authors
believed that the collaboration with the GHS was necessary to
ensure adequate participation. Also, the nomination of individual
stakeholder by individual organisations helped to minimise selection bias on the part of the authors. The attachments to the invitation letter were the reviewed guideline (Draft 2), a summary of the
contextual findings, a summary literature review and a feedback
form. These were dispatched to stakeholders at least two weeks
before the day of the forum.
The date, time and venue of the forum were decided in consultation with the hospital authorities, the Director (ICD), and
heads of surgical departments of the two hospitals. A conference
room was identified at the tertiary health facility to ensure proximity for most of the participants and enhance attendance.
The authors identified a facilitator and two research assistants
for the forum. The facilitator was an experienced researcher and
was not directly affiliated with any of the stakeholders. The first
author met with the facilitator and the two research assistants
prior to the day of the forum to discuss and explain the formal consensus process and the roles of the facilitator and the research
assistants, as well as a draft programme. One research assistant
served as a recorder and a time-keeper and the other research
assistant was at the registration desk and ensured that participants
were comfortable.
On the day of the forum, there was a brief opening ceremony
after which the first author presented an overview of the study
and highlighted the contextual findings and the findings from a
systematic review that informed the draft clinical guideline. Also,
a summary report of the participant/expert review on the initial
draft was given.
Thereafter, the research team assigned participants purposively
to four groups guided by the four dimensions of the guideline as
follows:
(1) Patient and family require adequate information and education on POP management.
(2) Effective team work is required between nurses, doctors and
other health team members regarding POP management.
(3) Input and monitoring from hospital management and
departmental leadership is required to achieve effective pain
management.
(4) Evidence-based contemporary recommendations for POP
management should be employed (Aziato, 2014).
Assignment to groups was also according to the background of
each participant and the ability to offer meaningful contributions.
Each group discussed and reviewed statements as necessary.
Inspite of the fact that participants had access to the guideline
document two weeks in advance, the group discussion afforded
them (especially those who could not read the guideline before
the forum) an opportunity to review the statements. The facilitator
ensured that groups were well-coordinated.
After the group discussion, group leaders made presentations
on statements. Some statements were rearranged and separated
(adding 2 statements). Further comments on statements were
invited from the larger group for discussion, review and adoption.
Subsequently, when there were no further comments on the statements, the facilitator explained the decision process with an
emphasis on independent individual decisions. Independent
anonymous decisions (individual private decisions without names
on decision forms) were taken on individual statements as follows:
A = Agree (maintain statement); B = Modify statement; C = Abstain
(will go by decision of others); D = Delete/remove statement. End-
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L. Aziato, O. Adejumo / International Journal of Africa Nursing Sciences 2 (2015) 26–33
points of decisions such as ‘Abstain’ were included to allow flexibility in decisions, so that non-technical participants such as
patients would not be forced to make a decision on a technical
area. The independent or private decisions were adopted for the
study based on the heterogeneous nature of the participants. The
end-point decisions adopted were denoted A, B, C, and D to ensure
ease of decision making. Decisions A (Agree) and C (Abstain) meant
final end-points; and decisions B (modify statement) and D (delete)
attracted further discussions and another round of decisions on
those specific statements.
Thus, after the first round of decisions, five statements were
modified and second round decisions were taken. The independent
and anonymous individual decisions ensured that participants
made decisions without coercion or intimidation. No participant
wrote a D; so no statement was deleted. The facilitator read the
consensus statements of the guideline maintained. At the end of
the consensus forum, two statements were added (Table 3 indicates the number of statements at each phase).
2.3. Findings – Outcome of the participatory process
The participatory process culminated in a context appropriate
clinical guideline for POP management for Ghana which has been
adopted by the GHS. The clinical guideline developed had specific
consensus statements that supported the four dimensions of the
guideline (Table 4). The statements did not indicate the levels of
evidence as pertains to other clinical guidelines because statements focused largely on the contextual evidence rather than the
wider literature. Thus, for consistency and ease of use, the four
statements derived from literature did not indicate levels of
evidence.
The four dimensions of the guideline were described with a
framework that demonstrated the linkages and inter-relationships
between the statements. It was realised that effective management
of POP in a resource-limited clinical context depends on the use of
all the statements within the four dimensions depicted in Fig. 1.
The conceptual Radial Venn relates to the interconnectedness of
the four dimensions of the guideline emphasising that none of
the components should be ignored by pain management personnel. The diagram for the framework was adapted from designs of
Microsoft Office 2010 called Radial Venn. The central concept of
the Radial Venn is congruent with the concept of inter-relationship
of the four dimensions of the clinical guideline developed. The
Radial Venn is used for both overlapping relationships and their
relationship to a central idea in a cycle. Hence, the diagram was
appropriate for the framework of a POP management guideline.
(See Fig. 2)
Table 3
Number of guideline statements for the four guideline components.
Number of statements
Components
Draft
1
Draft
2
Final
Patient and family require adequate information and
education on POP management
Effective team work is required between nurses,
doctors and other health team members
regarding POP management
Input and monitoring from hospital management
and departmental leadership is required to
achieve effective pain management
Evidence-based contemporary recommendations for
POP management should be employed
10
12
10
15
15
15
8
7
9
3
3
4
3. Discussion
The statements supporting the four dimensions are simple and
address specific context findings. For example patients lack knowledge on POP and are reluctant to ask health professionals questions
on POP management (Aziato & Adejumo, 2014c). Therefore, statements on the patient domain give specific instructions and education on POP. Patient education has been confirmed to enhance POP
management outcomes (Fredericks, Guruge, Sidani, & Wan, 2010).
Also, ineffective team work has been reported from the context of
the study (Aziato & Adejumo, 2014a) and statements on team work
address all specific areas that could enhance effective team work.
Team work that creates a positive environment could lead to
improved pain management and improve patient satisfaction
(Meterko, Mohr, & Young, 2004).
Nurses report ineffective leadership and lack of monitoring
which results in lapses in clinical practice such as inadequate analgesic administration (Aziato & Adejumo, 2014a). Adherence to
specifications of statements of leadership could enhance work output and indirectly lead to effective pain management as supported
by previous authors (Cummings et al., 2010). Nurses in Ghana do
not administer regular analgesics post-operatively and analgesics
are not administered pre-emptively (Aziato & Adejumo, 2014a).
Clear specific statements on contemporary recommendations for
POP such as regular administration of analgesic, using more than
one form of analgesic for POP, and giving the drug before patient
experiences pain have been found to improve POP management
(Jirarattanaphochai & Jung, 2008; Joshi, Rawal, Kehlet, & The
PROSPECT collaboration, 2011; Paice, Noskin, Vanagunas, & Shott,
2005). The authors reflect on the approach used for this study.
It pre-supposes that researchers should develop appropriate
ways of involving stakeholders as appropriate (Mason et al.,
2013). The participatory process should be non-threatening to participants and respect the culture within which the study is undertaken. Other authors have demonstrated that groups where
members feel threatened or do not respect each other’s opinions
result in ineffective discussions and findings from such groups
are biased or skewed (Wibowo & Deng, 2013). In this regard,
researchers are admonished to understand the context and culture
of the research setting so that groups will be constituted according
to the cultural ethos of the setting (Liu et al., 2011).
Participant commitment and understanding of the research
process also enhances effective responses and participation.
Timely and effective comments were received and this could mean
that the participants had full understanding of the processes in this
study. The effective cooperation or involvement of research participants in a given study has been noted to enhance the outcome of
the study (Liu et al., 2011). The high response for the consensus
forum could be because the GHS hosted the forum. Although the
first author was actively involved in the planning of the forum,
the GHS was recognised as the official host. However, the consensus forum was coordinated by the research team.
Further, the specific consensus guideline statements were
developed systematically following standard processes of guideline development (National Institute for Health and Clinical
Excellence (NICE), 2014; Scottish Intercollegiate Guideline
Network (SIGN), 2013; The Appraisal of Guidelines Research and
Evaluation in Europe (AGREE) Collaboration, 2013; The Cochrane
Collaboration, 2011). Thus, there was incorporation of an international pain consultant and all relevant stakeholders. Independent
private decision ensured that guideline statements were not
skewed in favour of a dominant group or individuals.
A guideline for resource-limited clinical environment is of relevance to other similar context. It is realised that most African countries are deficient in terms of contemporary gadgets for post-
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Table 4
Guideline statements supporting four broad areas.
Patient and family information
and education
1. Pain is a personal and individual experience, and it is important to tell the nurses or doctors about the severity and duration
of your pain to ensure the best treatment is given
2. Your nurses and doctors are committed to providing you with the safest and most effective post-operative pain management available. Do not think that reporting your pain is a bother to the nurses and doctors
3. Talk about your pain management with the nurses or doctors so that whatever concerns or questions you have about pain
will be answered. Always report before your pain is severe, because severe pain can delay recovery and affect other aspects
of your health
4. Ask the nurses or doctors what kind of pain medicine you will be given and how often you can take each of them so that
you can help keep your pain under control by asking for the pain medicine on time. Also ask about the possible side-effects
of your pain medicines
5. Remember that it is important to ask everything you can about your pain medicine because taking the right pain medicine
in the right amount and in regular doses will help you feel more comfortable so that you can heal and recover faster
6. You may not be able to eat or drink right after surgery, so you may be given pain medicine in the form of an injection
(needle) or inserted in the anus; but as your condition improves, your pain medicines may be given by mouth (swallowed)
7. It is important to take your pain medicine so that you can be comfortable enough to deep breathe, turn, and walk. Tell the
nurses or doctors if you have a problem with pain medicine that is provided so that an alternative may be given
8. Ensure that if prescriptions for pain-medicines are given to you, the drugs are made available so that the nurses can give
you at the right time. Pain after an operation is best treated with pain medicines
9. Family members who notice relations are in pain should report to the nurses or doctors and to do so before pain becomes
severe
10. Do not allow anyone other than the nurses and doctors to give you any medicines while you are in the hospitalIf you
require more information about post-operative pain management contact your nurses and doctors
Team work
1. Unrelieved pain produces many adverse effects and can negatively impact patient outcomes. It is important that nurses and
doctors work together to ensure that patients’ pain management needs are met so that patients can deep breathe, cough,
turn, and walk safely after surgery
2. Pain is a subjective and individual experience, and the patient is the best judge of his or her own pain. Nurses and doctors
should encourage patients to promptly report pain so that appropriate or individualised actions can be taken to relieve it
3. The doctor and other health personnel (as allowed by the institution) are responsible for prescribing appropriate analgesics
in the patients’ folder, on the treatment chart, prescription form, or the National Health Insurance (NHI) medication form as
necessary
4. Doctors and nurses share the responsibility for providing the patient and family with adequate information about how
post-operative pain will be managed and to involve them in pain management decisions to enhance their co-operation
5. Doctors, clinical pharmacists and ward in-charges should follow-up on prescribed analgesics and ensure that the patient
receives the prescribed dosage of analgesics. Deficits (missed-dose or under-dose) should be promptly investigated and
corrected
6. Anaesthetist and clinical pharmacist should be actively involved in the management of patients’ pain
7. Although the patient’s report of pain is the gold standard of pain assessment, there may be non-verbal cues of pain (e.g.,
grimacing, bracing, moaning, and change in activity) that nurses and doctors may observe. These non-verbal pain cues
should be looked out for and investigated and addressed
8. Opioid analgesics should never be withheld because of fear of addiction. The risk of addiction when opioids are taken for
post-operative pain relief is extremely rare. If pain persists beyond expected duration and severity depending on the type
of surgery, then it should be investigated
9. It is important to keep pain at the level that will allow patients to participate in recovery activities with relative ease. Waiting for patients to report severe pain is strongly discouraged; severe pain can be avoided by ensuring that all post-operative
patients are given the right analgesic at the right time
10. Pain is often worse at night. A doctor should be available or easily accessible during the night to enhance effective pain
management during this time. Nurses should ensure at all times that patients are given all their prescribed analgesics
and patients are monitored for pain and the safety of the prescribed analgesics
11. Nurses should effectively document and inform the other team members about their patients’ pain reports and other pain
management concerns raised by patients and their families to afford continuity of care
12. Nurses and other team members should regularly up-date their knowledge on pain management (e.g., pain assessment and
analgesics) so that they will be more confident in their pain management activities. The team should also regularly evaluate their patient care objectives or goals
13. Uncontrolled pain requires immediate attention. Pain management protocol should be established to enhance patients’
pain management
14. If a patient refuses an analgesic by a particular route, an alternative route of administration should be prescribed and given
so that the patient will not suffer unduly. Pain management education should be reinforced in such cases
15. Non-pharmacologic measures may be helpful and encouraged to supplement but not replace analgesic administration in
the management of post-operative pain
Leadership
1. Leadership should recognise that effective and safe post-operative pain management will improve patient outcomes.
There should be pain management policies in all healthcare institutions. The necessary equipment should also be provided to enhance the management of post-operative pain
2. Leadership should be responsible for providing pain management education for the team (i.e. Doctors, nurses, pharmacists, physiotherapists, etc.) This is accomplished through organisation of initial and regular up-dates
3. Leadership should ensure that all policies are strictly adhered to and all violations sanctioned appropriately
4. Leadership should ensure regular audit/evaluation of pain management and dissemination of results to all concerned
5. Leadership should ensure regular departmental clinical meetings on pain management
6. Leadership should institute award schemes to deserving health teams/individuals in pain management
7. Leadership should ensure the proper storage and documentation of use of narcotic drugs in all units/departments
8. There should be hospital-based research committees to facilitate research at the hospitals. Findings from research should
be implemented into practice, e.g., the use of a validated and reliable self-report pain assessment tool
9. Leadership should establish a complaints system and information/education unit in all Units/departments to encourage
feedback from clients on pain management
(continued on next page)
32
L. Aziato, O. Adejumo / International Journal of Africa Nursing Sciences 2 (2015) 26–33
Evidence-based
recommendations
1. Pre-emptive analgesia (analgesic given before a painful stimulus) – the anaesthetist should ensure patient receives appropriate
analgesic whiles in the operating theatre by the best recommended route such as rectal, intrathecal, or intravenous and should
suggest the surgeon infiltrate the surgical site with appropriate analgesic or local anaesthetic
2. Multi-modal analgesia (using two or more forms of analgesic concurrently, e.g., non-opioid + opioid + local anaesthetic) is the
recommended approach to the management of post-operative pain. Surgeons should ensure that different forms of analgesics
are prescribed to enhance their synergistic effect. Pharmacists should supply the correctly prescribed medication and nurses
should administer all of the analgesics as prescribed
3. Time-scheduled analgesic administration (giving the analgesics according to the time prescribed regularly) is recommended.
Surgeons should prescribe the regular administration of analgesics, clinical pharmacists should ensure the availability of prescribed analgesics, and nurses should administer analgesic at regular intervals around-the-clock as prescribed
4. Non pharmacological methods of relieving pain such as early mobilisation, passive mobilisation, positioning, and other appropriate measures should be used as adjuncts to analgesic administration for post-operative pain management
guidelines for different clinical setting such as emergency wards
regarding pain management.
Paent and
family
informaon and
educaon
Input and
monitoring by
Hospital and
Departmental
leadership
Effecve
POP
Management
4. Conclusion
Effecve
teamwork
among health
professionals
Evidence-based
contemporary
recommendaons
of POP
management
The study employed a participatory approach for the development of a context appropriate clinical guideline for the management of POP. The authors realised that the effective collaboration
of relevant stakeholders contributes to effective guideline development as stipulated by recognised guideline development bodies.
Researchers should be conversant with their context and adapt
appropriate measures to effectively involve relevant stakeholders.
The conceptual framework for the clinical guideline emphasises
the inter-relationship of the four dimensions as appropriate for
POP management in a resource-limited clinical environment.
Hence, it is highlighted that patient and family education, effective
team work, monitoring by leadership, and the use of evidencebased recommendations for POP management are necessary to
enhance POP management.
Fig. 2. Framework for clinical guideline for post-operative pain management.
Funding
operative pain management such as PCA. An extensive literature
review to explore the use of such gadgets in Africa identified the
use of PCA in South Africa (Shipton, Beeton, & Minkowitz, 1993;
Upton, Beeton, Minkowitz, & Shipton, 1992). It could pre-suppose
that some pilot modern gadgets are being used in other countries
but studies have not reported their use for POP management.
Indeed, a systematic review conducted as part of the doctoral from
which this paper was drawn confirmed paucity of evaluative
research in post-operative pain management in resource limited
environment (Aziato, 2012). Thus, most of the studies were explorative and reported the persistence of moderate to severe POP
among post-operative patients (Clegg-Lamptey & Hodasi, 2005;
Finnström & Söderhamn, 2006; Klopper, Andersson, Minkkinen,
Ohlsson, & Sjöström, 2006; Ohene-Yeboah, 2006). The persistence
of pain is a wake-up call for further research on POP within
resource-limited clinical context.
The study was supported by Centre of Teaching and Learning
Scholarship (CENTALS) at the University of the Western Cape.
Conflict of interest
The authors report no conflict of interest in this study.
Acknowledgements
The authors are grateful to the GHS for hosting the consensus
forum, Chris Pasero, Prof. Clegg-Lamptey, Prof. Slyvester Achio,
for review of the guideline, and all the experts who contributed
in the development of the clinical guideline for POP management
in Ghana.
References
3.1. Limitations of the study
Although this study did not develop a clinical guideline with a
wide spectrum of applicability, it is possible to apply the clinical
guideline developed and conceptualised with a framework of a
Radial Venn in resource-limited clinical contexts. The active
involvement of the GHS could have covertly influenced some participants during the consensus forum. However, it is reiterated that
the GHS did not coordinate the forum.
The guideline in this study was developed for patients who can
self-report post-operative pain. Future studies could develop
guidelines for other types of pain and for patients with limitations
regarding self-report of pain. Also, future studies could develop
Abdalrahim, M. S., Majali, S. A., & Bergbom, I. (2010). Jordanian surgical nurses’
experiences in caring for patients with postoperative pain. Applied Nursing
Research, 23(3), 164–170.
American Society of Anaesthesiologists (ASA) (2012). Practice guidelines for acute
pain management in the perioperative setting: An updated report by the
American Society of Anaesthesiologists Task Force on Acute Pain Management.
Anaesthesiology, 116 (2 P 248–73).
Arya, B., Abdollahi, A.-A., Golalipour, M.-J., Kazemnezhad, K., & Mohammadi, M. R.
(2007). Evaluation of post-operative analgesic efficacy of intramuscular
pethidine, compared to indometacin and diclofenac Na suppositories in
unilateral inguinal hernioplasty patients. Journal of Medical Sciences, 7(2),
311–314.
Australian and New Zealand College of Anaesthetists (ANZCA) (2010). Acute Pain
Management: Scientific Evidence. Retrieved from <http://sydney.edu.au/
medicine/pmri/pdf/Acute-pain-management-scientific-evidence-third-edition.
pdf>.
L. Aziato, O. Adejumo / International Journal of Africa Nursing Sciences 2 (2015) 26–33
Aziato, L. (2012). Development of clinical guidelines for the management of
post-operative pain within the medico-socio-cultural context of Ghana (Ph.D. thesis).
South Africa: University of the Western Cape.
Aziato, L., & Adejumo, O. (2014a). The Ghanaian surgical nurse and postoperative
pain management: A clinical ethnographic insight. Pain Management Nursing,
15(1), 265–272.
Aziato, L., & Adejumo, O. (2014b). Determinants of nurses’ knowledge gap on pain
management in Ghana. Nurse Education in Practice, 14(2), 195–199.
Aziato, L., & Adejumo, O. (2014c). An ethnographic exploration of postoperative
pain experiences among Ghanaian surgical patients. Journal of Transcultural
Nursing. http://dx.doi.org/10.1177/1043659614526246.
Aziato, L. (2014). The concept of pain and trends in post-operative pain
management: Implications for nursing practice in Ghana. In L. Aziato, A.
Kwashie, K. A. Korsah, & F. Naab (Eds.), Footprints of the nursing profession:
Current trends and emerging issues in Ghana (pp. 56–74). Accra: Sub-Saharan
Publishers.
Bardiau, F. M., Taviaux, N. F., Albert, A., Boogaerts, J. G., & Stadler, M. (2003). An
intervention study to enhance postoperative pain management. Anaesthesia and
Analgesia, 96, 179–185.
Berry, A. M., Davidson, P. M., Nicholson, L., Pasqualotto, C., & Rolls, K. (2011).
Consensus based clinical guideline for oral hygiene in the critically ill. Intensive
and Critical Care Nursing, 27(4), 180–185.
Clegg-Lamptey, J. N. A., & Hodasi, W. M. (2005). An audit of aspects of informed
consent and pain relief in general surgical units of Korle-Bu Teaching Hospital.
Ghana Medical Journal, 39(2), 63–67.
Closs, S. J., Briggs, M., & Everitt, V. E. (1999). Implementation of research findings to
reduce postoperative pain at night. International Journal of Nursing Studies, 36(1),
21–31.
Cummings, G. G., MacGregor, T., Davey, M., Lee, H., Wong, C. A., Lo, E., et al. (2010).
Leadership styles and outcome patterns for the nursing workforce and work
environment: A systematic review. International Journal of Nursing Studies,
47(3), 363–385.
European Association of Urology (2010). Guidelines on Pain Management. Retrieved
from <http://www.uroweb.org/gls/pdf/Pain%20Management%202010.pdf>.
Finnström, B., & Söderhamn, O. (2006). Conceptions of pain among Somali women.
Journal of Advanced Nursing, 54(4), 418–425.
Fredericks, S., Guruge, S., Sidani, S., & Wan, T. (2010). Postoperative patient
education: A systematic review. Clinical Nursing Research, 19(2), 144–164.
Good, M., Stanton-Hicks, M., Grass, J. A., Anderson, G. C., Lai, H.-L., Roykulcharoen,
V., et al. (2001). Relaxation and music to reduce postsurgical pain. Journal of
Advanced Nursing, 33(2), 208–215.
Good, M., Stanton-Hicks, M., Grass, J. A., Cranston Anderson, G., Choi, C.,
Schoolmeesters, L. J., et al. (1999). Relief of postoperative pain with jaw
relaxation, music and their combination. Pain, 81(1–2), 163–172.
Haljamäe, H., & Stomberg, M. W. (2003). Postoperative pain management – Practice
guidelines. Current Anaesthesia & Critical Care, 14, 203–206.
Hewitt-Taylor, J. (2004). Clinical guidelines and care protocols. Intensive and Critical
Care Nursing, 20(1), 45–52.
Jackson, A., Hettinga, D. M., Mead, J., & Mercer, C. (2009). Using consensus methods
in developing clinical guidelines for exercise in managing persistent low back
pain. Physiotherapy, 95(4), 302–311.
Jirarattanaphochai, K., & Jung, S. (2008). Nonsteroidal anti-inflammatory drugs
for postoperative pain management after lumbar spine surgery: A metaanalysis of randomized controlled trials. Journal of Neurosurgery: Spine, 9,
22–31.
Joshi, G. P., Rawal, N., Kehlet, H., & The PROSPECT collaboration (2011). Evidencebased management of postoperative pain in adults undergoing open inguinal
hernia surgery. British Journal of Surgery, 99(2), 168–185.
Keeley, P. W. (2003). Clinical guidelines. Palliative Medicine, 17, 368–374.
Klopper, H., Andersson, H., Minkkinen, M., Ohlsson, C., & Sjöström, B. (2006).
Strategies in assessing post-operative pain – A South African Study. Intensive
and Critical Care Nursing, 22, 12–21.
Kraemer Diaz, A. E., Spears Johnson, C. R., & Arcury, T. A. (2013). Variation in the
interpretation of scientific integrity in community-based participatory health
research. Social Science & Medicine, 97, 134–142.
Lindenfeld, J., & Kelly, P. A. (2010). Developing a cardiology–oncology clinical
practice guideline. Progress in Cardiovascular Diseases, 53(2), 173–179.
Liu, J., McCauley, L., Leung, P., Wang, B., Needleman, H., & Pinto-Martin, J. (2011).
Community-based participatory research (CBPR) approach to study children’s
health in China: Experiences and reflections. International Journal of Nursing
Studies, 48(7), 904–913.
Lovering, S. (2006). Cultural attitudes and beliefs about pain. Journal of Transcultural
Nursing, 17(4), 389–395.
33
Mac Lellan, K. (2004). Postoperative pain: Strategy for improving patient
experiences. Journal of Advanced Nursing, 46(2), 179–185.
Mason, M. J., Tanner, J. F., Piacentini, M., Freeman, D., Anastasia, T., Batat, W., et al.
(2013). Advancing a participatory approach for youth risk behavior:
Foundations, distinctions, and research directions. Journal of Business Research,
66(8), 1235–1241.
Meterko, M., Mohr, D. C., & Young, G. J. (2004). Teamwork culture and patient
satisfaction in hospitals. Medical Care, 42(5), 492–498.
Nair, R., Aggarwal, R., & Khanna, D. (2011). Methods of formal consensus in
classification/diagnostic criteria and guideline development. Seminars in
Arthritis and Rheumatism, 41(2), 95–105.
National Institute for Health and Clinical Excellence (NICE) (2014). Developing NICE
clinical guidelines. Journal. Retrieved from <http://www.nice.org.uk/>.
Ohene-Yeboah, M. (2006). Acute surgical admissions for abdominal pain in adults in
Kumasi, Ghana. ANZ Journal of Surgery, 76(10).
Paice, J. A., Noskin, G. A., Vanagunas, A., & Shott, S. (2005). Efficacy and safety of
scheduled dosing of opioid analgesics: A quality improvement study. The
Journal of Pain, 6(10), 639–643.
Ploeg, J., Davies, B., Edwards, N., Gifford, W., & Miller, P. E. (2007). Factors
influencing best-practice guideline implementation: Lessons learned from
administrators, nursing staff, and project leaders. Worldviews on Evidence
Based Nursing, 4(4), 210–219.
Qu, S., Sherwood, G. D., McNeill, J. A., & Zheng, L. (2008). Postoperative pain
management outcome in Chinese inpatients. Western Journal of Nursing
Research, 30(8), 975–990.
Ritchie, S. D., Jo Wabano, M., Beardy, J., Curran, J., Orkin, A., VanderBurgh, D., et al.
(2013).
Community-based
participatory
research
with
Indigenous
communities: The proximity paradox. Health & Place, 24, 183–189.
Rolley, J. X., Salamonson, Y., Wensley, C., Dennison, C. R., & Davidson, P. M. (2011).
Nursing clinical practice guidelines to improve care for people undergoing
percutaneous coronary interventions. Australian Critical Care, 24(1), 18–38.
Rolls, K. D., & Elliott, D. (2008). Using consensus methods to develop clinical
practice guidelines for intensive care: The Intensive Care Collaborative project.
Australian Critical Care, 21(4), 200–215.
Roykulcharoen, V., & Good, M. (2004). Systematic relaxation to relieve
postoperative pain. Journal of Advanced Nursing, 48(2), 140–148.
Rycroft-Malone, J. (2001). Formal consensus: The development of a national clinical
guideline. Quality in Health Care, 10, 238–244.
Scottish Intercollegiate Guideline Network (SIGN) (2013). SIGN 50: A Guideline for
Developer’s Handbook. Retrieved from http://sign.ac.uk/guidelines/fulltext/50/
index.html.
Seers, K., Crichton, N., Carroll, D., Richards, S., & Saunders, T. (2004). Evidence-based
postoperative pain management in nursing: Is a randomized-controlled trial
the most appropriate design? Journal of Nursing Management, 12(3), 183–193.
Shipton, E. A., Beeton, A. G., & Minkowitz, H. S. (1993). Introducing a patientcontrolled analgesia-based acute pain relief service into southern Africa–the
first 10 months. South African Medical Journal = Suid-Afrikaanse Tydskrif Vir
Geneeskunde, 83(7), 501–505.
Taba, P., Rosenthal, M., Habicht, J., Tarien, H., Mathiesen, M., Hill, S., et al. (2012).
Barriers and facilitators to the implementation of clinical practice guidelines: A
cross-sectional survey among physicians in Estonia. BMC Health Services
Research, 12(455), 1–7.
The Appraisal of Guidelines Research and Evaluation in Europe (AGREE)
Collaboration (2013). Electronic Library for Guideline Developers. Journal.
Retrieved from <http://www.agreecollaboration.org>.
The British Pain Society (2007). Recommended guidelines for Pain Management
Programmes for adults: A consensus statement prepared on behalf of the British
Pain Society. Retrieved from <http://www.anaesthesiauk.com/documents/pmp_
0306_v9.pdf>.
The Cochrane Collaboration (2011). Cochrane Handbook for Systematic Reviews of
Interventions. Retrieved from The Cochrane Collaboration <http://
www.cochrane-handbook.org/>.
The South African Society of Anaesthesiologists (SASA) (2009). South African acute
pain guidelines. Retrieved from <http://www.sasaweb.com/content/images/
SASA_Pain_Guidelines.pdf>.
Upton, P. M., Beeton, A. G., Minkowitz, H. S., & Shipton, E. A. (1992). Patientcontrolled analgesia. Its South African debut in a provincial hospital. South
African Medical Journal = Suid-Afrikaanse Tydskrif Vir Geneeskunde, 81(2), 74–76.
Wibowo, S., & Deng, H. (2013). Consensus-based decision support for multicriteria
group decision making. Computers & Industrial Engineering, 66(4), 625–633.
Wong, E. M.-L., Chan, S. W.-C., & Chair, S.-Y. (2010). The effect of educational
intervention on pain beliefs and postoperative pain relief among Chinese
patients with fractured limbs. Journal of Clinical Nursing, 19(17/18), 2652–2655.