Pain assessment in Unconscious patients

NURSES’ KNOWLEDGE AND PRACTICES OF PAIN ASSESSMENT IN UNCONSCIOUS
PATIENTS; EVALUATION OF EDUCATIONAL INTERVENTION:
A CASE STUDY OF MBARARA REGIONAL REFERRAL HOSPITAL
BY
VALENCE MFITUMUKIZA
REG NO. 2014/MNS/040/PS
A DISSERTATION SUBMITTED TO THE DEPARTMENT OF NURSING IN
PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF
A MASTERS DEGREE IN CRITICAL CARE NURSING
OF MBARARA UNIVERSITY OF
SCIENCE AND TECHNOLOGY
DECEMBER, 2016

Nurses’ knowledge about pain assessment in unconscious patients
ii
DECLARATION
I, Valence Mfitumukiza, declare that this research report is my original work and is submitted to
Mbarara University of Science and Technology for the award of Masters Degree in Critical Care
Nursing and further state that it has never been presented to this university or any other institution
for any award.
Signature
……………………………………… ………….day of ………………2016
Mfitumukiza Valence
2014/MNS/040/PS

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APPROVAL
This is to certify that this research report has been produced under our guidance and is being
submitted with our approval.
………………………………………. ………….. day of ………….. 2016
Dr. Sara Groves (PHD, MPH, MSN, BNS, RN)
Senior Lecturer, Mbarara University of Science and Technology
Associate Professor, John Hopkins University, USA
………………………………………. ………….. day of ………….. 2016
Sr. Betty Kinkuhaire (MNS, BNS, RN)
Lecturer, Mbarara University of Science and Technology

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DEDICATION
This work is dedicated to my family, friends who supported me throughout this academic
pursuit. It is also dedicated to those nurses who work tirelessly to restore patients’ health amidst
several challenges in our health care system.

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ACKNOWLEDGEMENT
I thank the almighty God for having protected me till now.
I extend my sincere gratitude to my family for their endless support in all spheres of life
My deepest appreciation goes to Massachusetts General Hospital who offered me a scholarship
that enabled me to pursue this course of study. May God bless the sponsors abundantly and
continue to live for many years.
My heartfelt thanks go to my supervisors; Dr. Sara Groves and Sr. Betty Kinkuhaire. Your
technical guidance and support has enabled me accomplish this work.
I am deeply indebted to Dr. Laura Brennman and Dr. Grace Nambozi who accepted to read
through my work and guided me accordingly, your inputs are invaluable. May God bless you!
I also wish to thank all lecturers from the department, faculty of medicine, faculty of Science and
Peace Corps Volunteers who taught me.
Sincere thanks also go to Micheal Kanyesigye guided me during data analysis.
To my colleagues; Tamu, Oshabe Salongo, Grace, Adrian and Vital. You provided a shoulder to
lean on when in need. Thank you for the support and cooperation throughout the course.
Finally to participants who took their time despite tight schedules to participate in this study; it is
because of you that this research has taken shape. Your contributions are invaluable! Thank You

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Contents
DECLARATION ............................................................................................................ ii
APPROVAL...................................................................................................................iii
DEDICATION ............................................................................................................... iv
ACKNOWLEDGEMENT .............................................................................................. v
OPERATIONAL DEFINITIONS.................................................................................. xi
LIST OF ACRONYMS................................................................................................. xii
ABSTRACT.................................................................................................................xiii
CHAPTER ONE ............................................................................................................. 1
1.0 Introduction............................................................................................................. 1
1.1 Background ............................................................................................................... 1
1.3 Objectives.................................................................................................................. 3
1.3.1 Broad Objective...................................................................................................... 3
1.3.2 Specific Objectives................................................................................................. 3
1.4 Hypothesis................................................................................................................. 4
1.5 Significance of the study........................................................................................... 4
1.6 Study scope ............................................................................................................... 4
CHAPTER TWO............................................................................................................. 5
LITERATURE REVIEW............................................................................................. 5

vii
2.0 Introduction............................................................................................................... 5
2.1 Pain in unconscious patients ..................................................................................... 5
2.2 Pain Assessment in Unconscious patients................................................................. 6
2.3 Pain assessment tools ................................................................................................ 7
2.4 Practices of pain assessment in unconscious patients ............................................... 9
2.5 Knowledge of pain assessment in unconscious patients ......................................... 10
2.8 Conceptual framework............................................................................................ 12
CHAPTER THREE .................................................................................................... 16
METHODOLOGY...................................................................................................... 16
3.0 Introduction............................................................................................................. 16
3.1 Study area................................................................................................................ 16
3.2 Study population ..................................................................................................... 16
3.3 Research design....................................................................................................... 16
3.4 Sample size.............................................................................................................. 17
3.5 Sampling Method .................................................................................................... 17
3.6 Inclusion criteria...................................................................................................... 17
3.7 Exclusion criteria..................................................................................................... 17
3.8 Data collection methods.......................................................................................... 18
3.10 Quality Control...................................................................................................... 19
3.11 Data Analysis ........................................................................................................ 19
3.13 Dissemination........................................................................................................ 20

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CHAPTER FOUR......................................................................................................... 21
RESULTS...................................................................................................................... 21
4.0 Introduction............................................................................................................. 21
4.2 Participants’ demographic characteristics............................................................... 21
4.3 Participants’ knowledge about pain assessment in unconscious patients (pre and post
educational intervention)............................................................................................... 22
4.4 Comparison between nurses’ knowledge of pain assessment in unconscious patients before
and after the education intervention.............................................................................. 25
4.5 Nurses practice of pain assessment in unconscious patients................................... 26
4.6 Comparison between nurses’ practice of pain assessment in unconscious patients pre and
post educational intervention ........................................................................................ 28
CHAPTER FIVE........................................................................................................... 29
DISCUSSION, CONCLUSION, RECOMENDATIONS ............................................ 29
5.0 Introduction............................................................................................................. 29
5.1 Nurses’ knowledge of pain assessment in unconscious patients pre-education intervention
....................................................................................................................................... 29
5.2 Nurses knowledge of pain assessment in unconscious patients post-education intervention
....................................................................................................................................... 31
5.3 Nurses’ practice of pain assessment in unconscious patients pre-intervention....... 32
5.4 Nurses’ practices of pain assessment in unconscious patients post education intervention
....................................................................................................................................... 33
5.5 Study limitations ..................................................................................................... 34

ix
5.6 Conclusion............................................................................................................... 34
5.7 Recommendations................................................................................................... 34
5.8 Nursing Implications............................................................................................... 35
5.9 Areas for future research......................................................................................... 35
REFERENCES.............................................................................................................. 37
APPENDIX I: CONSENT FORM................................................................................ 44
APPENDIX I I: QUESTIONNAIRE............................................................................ 49
APPENDIX III: MUST REC APPROVAL LETTER.................................................. 52
APPENDIX IV: APPROVAL LETTER FROM UGANDA NATIONAL COUNCIL FOR
SCIENCE AND TECHNOLOGY ................................................................................ 53
APPENDIX V: AMENDMENT LETTER FROM MUST-REC.................................. 54
APPENDIX V: MRRH APPROVAL LETTER ........................................................... 55
APPENDIX VI: TEACHING FORMAT FOR THE PAIN ASSESSMENT .............. 56

x
LIST OF FIGURES
Figure 1: Conceptual framework adopted and modified from theory of symptom management
(Doddo et al 2001)......................................................................................................... 15
LIST OF TABLES
Table 1: Demographic characteristics of 20 nurse participants .................................... 22
Table 2: Participants’ Knowledge pre and post educational intervention for each question.
....................................................................................................................................... 23
Table 3. Comparison of total scale score, pre-test vs. post-test (n = 20) ...................... 26
Table 4: Nurses practice of pain assessment in unconscious patients........................... 27
Table 5: Difference in nurses’ practice of pain assessment in unconscious patients’ pre and
post education intervention ........................................................................................... 28

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OPERATIONAL DEFINITIONS
ASSESSMENT: These are ways nurses use to ascertain whether a patient has pain or not.
KNOWLEDGE: Is the awareness of the nurse about the key principles related to pain
assessment among unconscious patients.
PAIN: It is unpleasant sensation felt by a patient secondary to inflammation or injury
PRACTICE: Is the performance of interventions based on principles related to pain assessment
in unconscious patients
UNCONSCIOUSNESS: A state of patient’s unresponsiveness due to pathological condition or
injury

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LIST OF ACRONYMS
ASP: International Association for the Study of Pain
BPS: Behavioral Pain Scale
CPOT: Critical care Pain Observation Tool
CPR: Cardio pulmonary Resuscitation
ICU: Intensive Care Unit
MUST: Mbarara University of Science and Technology
MRRH: Mbarara Regional Referral Hospital
PAIN: Pain Assessment Intervention and Notation algorithm
NRS: Numerical Rating Scale
IRB: Institutional Review Board

xiii
ABSTRACT
Unconscious patients feel pain but are unable to self-report pain. They often respond by
physiological and behavioral responses, therefore, nurses working in critical care units should be
equipped with knowledge to assess and manage patients’ pain to promote quick recovery.
The aim of the study was to assess nurses’ knowledge and practice about pain assessment in
unconscious patients and to evaluate whether education intervention improves knowledge. A
quasi-experimental pre-test, post-test design was employed on 20 nurses working on ICU,
Emergency and high dependence units at Medical and Surgical wards of Mbarara Regional
Referral Hospital.
The majority of the participants agreed that raised blood pressure and raised pulse but they
disagreed that temperature and pupillary dilation are indicators of pain in unconscious patients.
Most of participants also agreed that Agitation, Facial grimace, Sighing and crying are indicators
of pain in unconscious patients but disagreed on mechanical ventilation and abnormal limb
movements. The majority of the nurses (63.2%) had never assessed pain in unconscious patients.
Out of eight who had previously assessed pain, four (50%) had never used a pain assessment
tool. However, 70% of Participants reported that they assessed the need for analgesia
administration before performing procedures. Education intervention improved significantly
nurses’ knowledge and practice about pain assessment in unconscious patients (P<0.01).
The study recommends that the ministry of health and hospital administration may regularly
arrange in-service education, draft policies/guidelines about pain assessment in unconscious
patients. Pain assessment in unconscious patients may be included in curricula of nurses at
different levels of nursing training.

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CHAPTER ONE
1.0 Introduction
This chapter introduces the problem statement based on background information. The overall
objective of the research project is identified and specific objective for the research project
stated. The chapter includes the significance of the study and study scope.
1.1 Background
According to the International Association for the Study of Pain (IASP, 2012), pain is an
unpleasant sensory and emotional experience associated with actual or potential damage or
described in terms of such damage. Pain is an important stressor for critical care patients. Many
sources of pain have been identified, such as acute illness, surgery, trauma, invasive equipment,
nursing and medical interventions, and immobility (Gelinas et al. 2004).
Alderson and McKechnie (2013) reported that pain and its recognition could be a particular
problem to patients in the ICU. They further revealed that around 70% of patients in the ICU
have unrecognized and/or under treated pain. They noted that such pain would be problematic
because severe pain interferes with cardiovascular and respiratory physiology and therefore
impair patients’ recovery and discharge. Relatedly, severe pain can contribute to adverse
psychological outcomes in ICU patients including anxiety, depression and post-traumatic stress
disorder (Sessler, 2009).
Assessment of pain is a critical step to providing good pain management (Wells, Pasero, &
McCaffery 2008). Patients’ self-reports of pain are the most valid measure of pain and should be

2
obtained if at all possible (National Pharmacological Council, 2001). In critical care, many
factors may alter verbal communication with patients, such as administration of sedative agents,
mechanical ventilation, and patients’ changes in level of consciousness (Gelinas et al. 2004).
However, an individual’s inability to communicate verbally does not negate the possibility that
he is experiencing pain and is in need of appropriate pain-relieving treatment (IASP, 2012).
Although unconscious patients cannot speak, they do communicate with facial expressions, or
hand motions, or by seeking attention with other movements (Gelinas et al. 2004). The
observable indicators include those with physiological and behavioral pain components.
Healthcare professionals can use these indicators for pain assessment.
In Western developed nations, tools such as behavioral pain scale and critical care pain
observation tool have been developed and validated in assessing pain among unconscious
patients in any hospital setting (Alderson and McKechnie, 2013)
However, often pain assessment is not done worldwide and this results in under treatment. In
Uganda, there are no standard guidelines for pain assessment for the unconscious patient,
limiting even more the likelihood that the assessment will be completed.
1.2 Problem Statement
Critically ill patients often experience moderate to severe pain in the face of life-threatening
illness or injury but the health care team sometimes forgets or under-appreciates the treatment
(Gelinas, 2004). Whenever possible, the existence and intensity of pain should be measured by
the patient’s self-report because pain is subjective. However, some patients cannot provide a

3
self-report of pain verbally, in writing, or by any other means such as using their fingers or
blinking their eyes to answer yes or no questions (Pasero &McCaffery 2002). Therefore, nurses
who work in critical care units should possess knowledge to assess pain in patients who are
unable to talk using behavioral and physiological indicators.
Despite an ongoing acknowledgement in the literature that pain is a significant problem within
the critical care environment, this issue has not been adequately addressed by critical care nurses
(Shannon & Bucknall, 2003). A study in Hong Kong revealed that nurses had knowledge deficit
about pain assessment and management (Lui and Fong, 2008)
There is limited data about pain assessment in critical care units done in Uganda. Therefore,
based on this gap in knowledge it is compelling to carry out a study to assess nurses’ knowledge
of pain assessment in unconscious patients in critical care units and to examine the outcome of
an interventional education program of pain assessment.
1.3 Objectives
1.3.1 Broad Objective
To assess nurses’ knowledge and practices of pain assessment in unconscious patients in
critical care units of Mbarara Regional Referral Hospital.
1.3.2 Specific Objectives
I. To assess the current nurses’ knowledge related to pain assessment in
unconscious patients of Mbarara Regional Referral Hospital.
II. To determine nurses’ current practice of pain assessment in unconscious
patients

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III. To evaluate whether education intervention improves nurses’ knowledge and
practice of pain assessment in unconscious patients
1.4 Hypothesis
Education intervention to nurses about pain assessment in unconscious patients improves their
knowledge and practice significantly
1.5 Significance of the study
Assessment of pain is very important in critically ill patients to offer better care management and
facilitate better patient outcomes. The study will help to adapt a standard tool that could be used
in assessing and managing pain in non-verbal critically ill patients. All this information would be
useful to improve nursing practice and will reduce on hospital bed occupancy rate, morbidity and
mortality. It will also provide information for nurse educators to better prepare nursing students to
provide care to critically ill unconscious patient. It will also act as a baseline for further studies
related to pain in critical care units.
1.6 Study scope
The study assessed nurses’ knowledge and practices about pain assessment in unconscious patients
in critical care units. It was conducted in Mbarara Regional Referral Hospital (MRRH). The study
was conducted between June 2016 and November 2016.

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CHAPTER TWO
LITERATURE REVIEW
2.0 Introduction
This chapter highlights related literature about pain assessment from studies done elsewhere.
Related literature to underpin this study was retrieved from nursing journals, medical journals,
and textbooks. Literature search from databases like Google Scholar, PUBMED and Hinari
identified the related literature. The literature generated gap in knowledge about Nurses’
knowledge and practice of pain assessment in unconscious patients and this justified the need for
this study.
2.1 Pain in unconscious patients
Pain is an unpleasant sensory and emotional experience associated with actual or potential
damage or described in terms of such damage (ASP, 2012). Pain can either be acute or chronic.
Acute pain is caused by tissue damage or inflammation with duration of less than six months
(Leo, 2008).
Pain is an important stressor for critical care patients. Many sources of pain have been
identified, such as acute illness, surgery, trauma, invasive equipment, nursing and medical
interventions, and immobility (Glinas et al. 2004). Critically ill patients also have pain because
of their disease conditions and treatment interventions such as endotracheal suctioning,
physiotherapy, wound care and prolonged immobilization thus making pain management a major
concern in the ICU (Mularski 2004).

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2.2 Pain Assessment in Unconscious patients
Assessment of pain is a critical step to providing good pain management (Wells, Pasero, and
McCaffery, 2008). Assessment of acute pain refers to the comprehensive clinical process of
describing the pain and its effect on patient function in sufficient detail to assist in diagnosis and
determine the extent of injury or disease, to select the appropriate therapy, and to evaluate
response to therapy. It may require the practitioner to use a particular type of pain assessment
tool (Brown, 2008).
In 1996, the American Pain Society (APS) introduced the phrase “pain as the 5th vital sign.”
This initiative emphasizes that pain assessment is as important as assessment of the standard four
vital signs and that clinicians need to take action when patients report pain (American pain
society, 1996). The Veterans Health Administration recognized the value of such an approach
and included pain as the 5th Vital Sign in their national pain management strategy (Pusser
et.al.2014).
Pain assessment in the ICU should be performed regularly and consistently, not only to assess
the initial onset and severity of a patient’s pain, but also to assess a patient’s response to
treatment (Mosenthal, 2005). This helps in evaluating response to treatment and monitoring
progress of recovery. Patients’ self-reports of pain are the most valid measure of pain and
should be obtained when possible (National Pharmacological Council, 2001). In critical care,
many factors may alter verbal communication with patients, such as administration of sedative
agents, mechanical ventilation, and patients’ changes in level of consciousness (Gelinas et al.

7
2004). However, the patient’s inability to communicate verbally did not negate the possibility
that an individual was experiencing pain and in need of appropriate pain-relieving treatment
(IASP, 2012). The American Society for Pain has a hierarchy of pain assessment that includes:
a self-report when possible, identify causes of pain, observe patient behaviour; have surrogate
report pain; and use analgesics trial in anticipation of pain (Pasero and Macffery 2011).
2.3 Pain assessment tools
A number of new and reliable tools have been developed to try to assess pain in unconscious
patients. One pain assessment tool that could be used with the unconscious patients is the
examination of the patient’s vital signs (Abour and Gelinas, 2010). This assessment tool was
based on the body’s physiological responses to pain that includes tachycardia, tachypnoea, or
hypertension. These parameters are often used by anesthetists to guide analgesia in anaesthetized
patients in theatre.
It should be noted however that some studies have found that vital sign assessments of patient
pain in the ICU were not consistent with patient reports of pain. It may be difficult to assess
patient pain using vital signs because ICU patients are often very unwell, with many potential
causes for any change in their vital signs. Tachycardia may be due to pain, but could also be
caused by fever or hypovolaemia. Therefore, some of the assessments of pain measurements are
not always reliable (Alderson and Mckechnie 2013).
An assessment of pain in unconscious ICU patients could be made using the Behavioural Pain
Score (BPS) tool (Ahlers et al. 2010). The BPS is an observational scale of patient behaviour,
which allows an assessment of a patient’s pain to be made by health workers.

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The BPS has three categories of behavior: the patient’s facial expression, the movement of their
upper limbs, and their compliance with mechanical ventilation. The BPS provided descriptions
of different behaviors that could be observed and a score assigned to each one. Higher scores
were associated with greater pain. An overall pain score was then calculated, ranging from three
(no pain) to twelve (worst possible pain). Several studies have shown the BPS to be a reliable
and valid method of assessing pain in ICU patients. It was found to be particularly helpful for
recognizing pain caused by routine procedures in the ICU, such as turning or tracheal suctioning
(Aissaoui, Zeggwagh, Zekraoui, et al. 2005).
A similar behavioural scale called the Critical-Care Pain Observation Tool (CPOT) may also be
used (Tousignant-Laflamme, Bourgault, Gelinas, et al. 2010). This is very similar to the BPS,
but included vocalization as an additional category of behavior. CPOT can therefore also be
applied to patients who have been extubated after being mechanically ventilated. ICU nurses
using the CPOT in practice reported that it was helpful in their practice, provided them with a
common language, and standardized their assessments of pain (Gelinas, Fillion, Puntillo, et al.
2006).
Other methods of pain assessment have also been identified but with less validity testing. These
include the pain assessment intervention and notation algorithm (PAIN), and a pain behaviors
checklist (Pasero et al. 2009).
Nurses working with hospitalized patients with acute pain must select the appropriate elements
of assessment for their current clinical situation. According to one study, the most critical aspect
of pain assessment was that it was done on a regular basis (e.g., once a shift, every 2 hours) using

9
a standard format. The authors concluded that assessment parameters should be explicitly
directed by hospital or unit policies and procedures (Wells, Pasero, & McCaffery, 2008).
2.4 Practices of pain assessment in unconscious patients
In a study done in surgical trauma and medical ICU of Virginia Commonwealth University
Health System, researchers found that quality pain management begins with a thorough
assessment, reassessment and documentation to facilitate treatment and communication among
health care providers. In their study it was found out that the hindrance in pain management
began with a failure to recognize pain (Shugarman, et al. 2010). Good pain assessment required
conistent use of a valid and reliable instrument.
Gelinas et al. (2004), in their study in California, found that 42% of nurses and physicians did
not document pain assessment, assessment of non-observable indicators of pain was present in
29 percent of participants while on observable indicators of pain 15percent of episodes of
physiological indicators were recorded and 59percent of episodes of body movements, and 10
percent episodes of compliance with ventilator were recorded.
Kaasalainen et al. (2007) found that half of all nursing staff used informal screening approaches
rather than a Numerical Rating Scale (NRS) to assess patients’ pain. Similar findings have been
reported even in the presence of protocols (Shugarmann et al. 2010). A study done in Hong
Kong of 143 nurses working on medical units reported that the majority of participants (89%)
had either never or only seldom used objective tools for pain assessment, and only 19percent of
them had ever attended courses related to pain assessment and management (Lui, et al. 2008).

10
A study done in Canada found that critical care nurse reported better use of assessment tools. Of
the 140 participants, 98.6percent used one or more pain assessment tools for patients able to self-
report and 45.7percent for patients unable to self-report pain (Rose et al. 2011).
2.5 Knowledge of pain assessment in unconscious patients
Management of pain in unconscious patients depends on nurses’ knowledge of pain assessment.
However, Wang & Tsai (2010), found that ICU nurses lack knowledge in pain assessment and
management. Relatedly, critical care nurses may focus on other priorities of care that are obvious
by sight, such as respiratory management, thus compromising effective pain management
(Young et al. 2007).
In a study at the Moi Teaching and Referral Hospital in Kenya clinicians were asked about
knowledge and practices of management of post-operative pain. Of the 200 clinician participants
41percent of the nurse participants indicated that they had sufficient knowledge to recognize and
manage pain (Kituyi, et al 2011). In the same study 21percent of all the participants had
received no formal pain evaluation and management. In addition, findings showed that in the
post-operative care units the number of years of practice among all the health care providers did
not impact their knowledge and confidence in the evaluation and management of pain. Also in
line with the above, Tanabe and Buschman (2000) noted that 44percent of 305 nurses surveyed
felt that inadequate staff knowledge of pain management principles was a barrier that affected
their practice.
Conversely, a study done in Mulago Hospital, in Uganda found that 91.2percent of the
participants had adequate knowledge but almost half lacked knowledge on key pain assessment

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principles. The majority (90%) of participants reported that they did assess pain among critically
ill patients, but almost all of them (96%) did not use pain assessment tools (Kizza, 2012).
2.6 Educational Intervention
In general, the literature supports the importance of effective educational programs to improve
both knowledge and a positive attitude towards pain control among critically ill patients. In a
study done to evaluate the effectiveness of educational programme for surgical nursing staff the
researchers found that continuing education improved knowledge and attitudes toward pain
assessment and management (Chiang, Chiang and Cheng, 2008). McNamara, Harmon, &
Saunders (2012) in their study in Ireland noted the positive effects of educational intervention
and training on pain management. A study conducted among nurses (N=59) demonstrated a
significant improvement of nurses’ knowledge and attitude towards pain assessment after
attending an acute pain educational program.
Consistent with the above findings, Ho and colleagues (2013) conducted a study among nurses
(N=86) in Malaysia. The outcome of the study showed that nurses who have previously attended
a pain course had increased their knowledge and attitude towards pain management. It was noted
in the study that pain education and nurses’ knowledge on opioid pharmacology had improved
nurses’ ability to provide proper and adequate pain assessment and management.
A study done to examine the effect of an educational intervention on nurses’ management of
pain in an acute care setting found a 50% decrease in the mean difference between patients’
assessment of pain and nurses’ documentation (p <.04) post-intervention. However, there were
no signiﬁcant differences found on total knowledge or bias scores (Schreiber et.al, 2014)

12
A similar study done with instruction in small discussion groups about pain assessment and
management found that the intervention improved knowledge. These sessions were 45 minutes
in length, consisted of two to six nurses per group, and focused on effective pain management
strategies. Results indicated that mean knowledge scores differed significantly and in a positive
direction after intervention [pre intervention mean = 18.28, SD = 2.33; post intervention mean =
22.16, standard deviation =1.70; t (31) =-8.87, p <.001]. Post-bias scores (amount of time and
energy nurses would spend attending to patients’ pain) were significantly higher for 6 of 15
patient populations. The strongest bias against treating patients’ pain was for the unconscious
and mechanically ventilated individuals. After the implementation of professionally directed
small group discussions with critical care nurses, knowledge levels related to pain management
increased and biases toward specific patient populations decreased (Lewis etal, 2015).
2.7 Summary
. The literature indicates that pain assessment of the unconscious patients remain a challenge to
nurses having varying experience. Use of different tools has improved pain assessment in
unconscious patients, although the lack of availability of these tools makes it difficult for a
standardized pain assessment to be implemented in critical care units in Uganda. Different
studies have demonstrated that training of nurses to use pain assessment tools may improve pain
assessment in unconscious patients. Assessment of the current knowledge and practices of the
nurses will ascertain if the improvement strategies are needed at ICU and HDUs of Mbarara
Regional Referral Hospital.
2.8 Conceptual framework
Theory of symptom management was used to guide the study. This theory was developed by
lecturers of University of San Franscisco, California, Department of Nursing in early 2000

13
purposely to advance symptom management (Doddo et al. 2001). It was based on six
assumptions;
That the gold standard for the study of symptoms is based on the perception of the individual
experiencing the symptom and his/her self-report·
That the symptom does not have to be experienced by an individual to apply this model of
symptom management. The individual may be at risk for the development of the symptom
because of the influence (impact) of a context variable such as a work hazard. Intervention
strategies may be initiated before an individual experiences the symptom.
That nonverbal patients (infants, post-stroke aphasic persons, unconscious) may experience
symptoms and the interpretation by the parent or caregiver is assumed to be accurate for
purposes of intervening.
That all troublesome symptoms need to be managed.
That management strategy may be targeted at the individual, a group, a family, or the work
environment.
That symptom management is a dynamic process; that is, it is modified by individual outcomes
and the influences of the nursing domains of person, health/illness, or environment. (Doddo, et
al. 2001)

14
The theory entailed three core concepts: symptom experience, symptom management strategies
and symptom status outcomes. The symptom experience includes an individual's perception of a
symptom, evaluation of the meaning of a symptom and response to a symptom. Perception of
symptoms refers to whether an individual notices a change from the way he or she usually feels
or behaves. People evaluate their symptoms by making judgments about the severity, cause,
treatability and the effect of symptoms on their lives. Responses to symptoms include
physiological, psychological, sociocultural and behavioral components. Understanding the
interaction of these components of the symptom experience is essential if symptoms are to be
effectively managed. Therefore, responses to pain is an individual’s perception and can manifest
into physiological, psychological, and behavioral responses.
The goal of symptom management is to avert or delay a negative outcome through biomedical,
professional and self-care strategies. Management begins with assessment of the symptom
experience from the individual's perspective. Assessment is followed by identifying the focus for
intervention strategies. Pain assessment is the first step in management of pain. Outcomes
emerge from symptom management strategies (Doddo et al. 2001).

15
Figure 1: Conceptual framework adopted and modified from theory of symptom
management (Doddo et al 2001)
Demographic characteristics
 Educational level
 Level of experience
 Years in service
 Years spent working in
critical care units
Trainings attained/Policy beliefs
 Special training in critical care
 Continuing Nursing education
about pain assessment and
management
 Policy beliefs
 Institutional protocols
Nurses Knowledge
and practice of pain
assessment in
unconscious patients
Recognition of pain
manifestations in unconscious
patients
Failure to recognize pain
manifestations in unconscious
patients
 Early pain mgt
 Quick recovery
 Reduced hospital
stay/costs
 Reduced morbidity and
mortality
Increased Morbidity and
mortality

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CHAPTER THREE
METHODOLOGY
3.0 Introduction
This chapter explains the methods that were used in this study. It entails; study area, study
population, research design, sample size, sampling methods, quality control, data collection
methods, data analysis plan, ethical considerations, and the planned dissemination of research
findings.
3.1 Study area
The study was carried out in Mbarara Regional Hospital (MRRH) in western Uganda. MRRH
doubles both as a regional referral hospital and as a teaching hospital for Mbarara University of
Science and Technology and other institutions in the region. This hospital was selected because
it handles complicated cases, most of them referrals from lower facilities. It lies along Mbarara –
Kabale highway in Mbarara municipality. It is approximately 267 km from Kampala, the capital
city. The study was done in ICU, Accident and Emergency, Medical and Surgical wards
3.2 Study population
The study targeted nurses caring for critically ill patients in the study hospital. Nurses working in
ICU, Emergency ward, Surgical and Medical wards were included.
3.3 Research design
The study employed a quasi-experimental one group pretest and post-test quantitative design.
Participants’ knowledge and practices of pain assessment in unconscious patients were assessed
with a self-administered researcher designed questionnaire then subjected to intervention
(education about pain assessment in unconscious patients) and posttest was done after one month
using the same tool.

17
Participants Pretest Educational intervention Posttest
The pretest scores about knowledge and practices of pain assessment were compared with the
posttest scores to ascertain whether there was a change.
3.4 Sample size
The researcher targeted all the 24 nurses because the population was small. 20 nurses
participated in the study (87% of the target). The small sample Size made it easier for the
researcher to conduct the study in time but the findings may not be generalized.
3.5 Sampling Method
A convenient sampling was used to enroll twenty nurses who participated in the study. Those
who were in the hospital at time of data collection and particularly in the targeted wards and met
inclusion criteria were recruited.
3.6 Inclusion criteria
 Nurses employed by the study hospital providing direct care in the Emergency,
ICU, Surgical and Medical wards.
 Nurses who have been on these wards for a minimum of 6 months
 Nurses who have a minimum of a certificate
 Those who consented to participate
3.7 Exclusion criteria
 Nurses who were sick at time of data collection
 Nurses who were on leave at the time of the study
 Intern nurses

18
3.8 Data collection methods
The hospital administrators and nurses in charge were informed about the research. A time was
agreed upon for the instruction (Training). Each nurse selected consented before the program
begun. On the day of the instruction, a self-administered researcher designed pretest
questionnaire was issued to each respondent with explanations as necessary. The pretest included
semi structured questions (See appendix II). The survey included a Likert scale to assess nurses’
knowledge of pain assessment in unconscious patients containing 13 items based on the
Behavioural Pain Assement Scale (BPS), Critical Care Pain Observation Tool (CPOT) and Adult
Non Verbal Pain Scale (NVPS) used to measure the presence of pain in unconscious patients.
These tools were validated on 30 unconscious patients and showed internal consistency as
follows BPS and CPOT exhibited the best inter-rater reliability (weighted-κ 0.81 for BPS and
CPOT) and the best internal consistency (Cronbach-α 0.80 for BPS, 0.81 for CPOT), which were
higher than for NVPS (weighted-κ 0.71, P <0.05; Cronbach-α 0.76, P <0.01) (Chaques et.al.
(2014).The scale has a total score range possible from 13 to 50.
Each participant was required to complete the questionnaire lasting for 15-30 minutes. This was
followed by training on pain assessment. The content of the training included definition of pain,
classification of pain, pain manifestations, methods of pain assessment and tools in unconscious
patients used, and a brief summary of pain management. The training (education intervention)
lasted for one and hour. One month after the instruction (training) the same participants filled the
same questionnaire as a post assessment. After one month, it was believed that the participants
had synthesized knowledge and translated it into practice.

19
3. 9 Data collection tools
A self-administered questionnaire which was designed by the researcher based on literature
reviewed was used for data collection. Training materials such as pens, writing pads, handouts,
projector and laptop were available.
3.10 Quality Control
The questionnaire was pretested on nurses working in Kampala International University
Teaching Hospital. Ambiguous questions were corrected. Both questionnaire and teaching
materials were given to research experts for perusal and corrections were made as per advice.
The tests and instruction were given the same way in a similar situation for all the nurses to
increase the reliability of the tools. The data collection tool was tested for internal consistency
statistically using Cronbach’s alpha
3.11 Data Analysis
Data from the pre and posttest were entered in spreadsheets, cleaned and then exported to
STATA version 13 for statistical analysis. Descriptive statistics included frequencies, and
percentages. Inferential statistics were used in comparing the pre and post test scores to test the
hypothesis that educational intervention improves pain assessment in unconscious patients. A
non-parametric test (wilcoxon rank test) was used to compare knowledge scores while paired
student t-test compared the means of pre-test and post-test data for practice scores.

20
3.12 Ethical considerations
The research proposal was reviewed by the department of Nursing, then Faculty Research
Committee (FRC) of MUST, and ethical review was done by MUST REC which gave letter of
approval for the study. Letters of approval were presented to hospital administration to seek for
permission to conduct the study. Approval was given by Hospital Director to collect data. Ward
in charges were also contacted who gave permission to do the study.
Written Informed consent was sought from the study participants following a thorough explanation
of the purpose of the study. Participants were informed that they are free to opt out of the study at
any time without in any way affecting their working conditions/privileges. Privacy and anonymity
was maintained by coding the questionnaires with unique numbers. All individual data were kept
confidentially by the principal investigator and shall always be stored in lockable cupboard not
accessible to unauthorized person.
3.13 Dissemination
Copies of the dissertation will be presented to the Department of Nursing, the MUST main library,
and Mbarara Regional Referral Hospital. Findings will also be presented in conferences and
published in nursing/medical journals as relevant to the outcomes of the study.

21
CHAPTER FOUR
RESULTS
4.0 Introduction
Twenty nurses participated in the study during the data collection from September 2016 to
November 2016 by completing a pretest knowledge assessment, attending educational program
about pain in unconscious patients, and completing a post-test knowledge assessment. This was
intended to see whether education intervention improves nurses’ knowledge about pain
assessment in unconscious patients.
The knowledge assessment tool demonstrated strong internal consistency using the 40 paired
responses of the 20 participants with a Cronbach’s alpha of .86.
The results for both descriptive and inferential statistics were generated from STATA version 13
and are presented in tables. They are arranged as follows demographic characteristics, pre and
post education intervention knowledge, and practice of pain assessment in unconscious patients
and comparison of knowledge, practice of pain assessment pre and post intervention.
4.2 Participants’ demographic characteristics
The mean age of participants was 38.4 years, most participants were females (70%), and
majority were Registered Nurses (65%). Almost a third of the participants (30%) were working
in the ICU followed by a quarter from the Emergency ward. A third of the participants had spent
16-20 years in service (35%).

22
Table 1: Demographic characteristics of 20 nurse participants
Characteristic Frequency (n) Percentage (%)
Age (mean SD) 38.4(4.9)
Sex (n %)
Male
Female
6
14
30
70
Education level (n %)
Enrolled Nurse
Registered Nurse
Graduate Nurse
6
13
1
30
65
5
Ward (n %)
Medical ward
Emergency ward
ICU
Surgical ward
Other
4
5
6
3
2
20
25
30
15
10
Time on identified ward (n %)
<6 months
6-11 months
12-23 months
2-4 years
>5 years
6
3
2
6
3
30
15
10
30
15
Service Period as a nurse (n
%)
1-5 years
6-10 years
11-15 years
16-20 years
3
5
5
7
15
25
25
35
4.3 Participants’ knowledge about pain assessment in unconscious patients (pre and post
educational intervention)
The individual items on the scale also yield insight into the specific knowledge gained.
The majority of participants knew that vital signs (see table 2, qn 3-5) and behavioral changes
were indication of pain (table 2, qn. 7-11). In the pretest the majority knew that unconscious
patient did experience pain and that pain should be assessed (See Table 2). However, they were
less sure about how pain manifested itself and could be assessed in patients who could not

23
communicate. Education increased the knowledge in each physiologic area with an increase in
the mean scores from pre to post test (q. 4-13). The largest increase in knowledge was with
recognizing facial grimacing (q. 9), muscle rigidity (q. 10), intolerance to the ventilator (q. 11),
and abnormal limb movement (q. 13) indicated pain (see Table 2).
Table 2: Participants’ Knowledge pre and post educational intervention for each question.
Characteristics Pretest (n
%)
Posttest (n
%)
p-value
for
difference
in scores
pre and
post test
1.Pain is unpleasant sensory and emotional
experience
True
Not true
Not sure
None of the above
Mean
17(85)
2(10)
1(5)
0(00)
3.8
20(100)
0(00)
0(00)
0(00)
4
0.10
2.Patients who are unconscious experience pain
Strongly Agree
Agree
Disagree
mean
6(30)
12(60)
2(10)
3.2
11(55)
9(45)
0(00)
3.6
0.06
3.Nurse should Assess pain in unconscious patients
No
Yes
mean
5(25)
15(75)
0.75
20(100)
0(00)
0.0
0.02
4.Raised blood pressure is an indicator of pain
Strongly Agree
Agree
Disagree
Strongly disagree
Mean
4(20)
11(55)
4(20)
1(5)
2.9
10(50)
9(45)
1(5)
0(00)
3.5
0.02
5.Raised pulse is an indicator of pain unconscious
patients
Strongly Agree
Agree
7(35)
11(55)
14(70)
6(30) 0.02

24
Disagree
Strongly disagree
Mean
2(10)
0(00)
3.3
0(00)
0(00)
3.7
6.Raised temperature is an indicator of pain
Strongly Agree
Agree
Disagree
Strongly disagree
Mean
1(5)
5(25)
10(50)
4(20)
2.2
3(15)
11(55)
4(20)
2(10)
2.8
0.03
7.Is Agitation an indicator of pain unconscious
patients
Strongly Agree
Agree
Disagree
Strongly disagree
Mean
7(35)
9(45)
4(20)
0(00)
3.2
13(65)
7(35)
0(00)
0(00)
3.7
0.02
8.Pupillary dilatation is an indicator of pain
Strongly agree
Agree
Disagree
Strongly disagree
Mean
0(00)
5(25)
8(40)
4(35)
1.9
0(00)
6(30)
12(60)
2(10)
3.2
<0.01
9. Facial grimacing is an indicator of pain
Strongly Agree
Agree
Disagree
Strongly disagree
Mean
3(15)
8(40)
8(40)
1(5)
2.7
18(90)
2(10)
0(00)
0(00)
3.9
<0.01
10.Muscle rigidity is an indicator of pain unconscious
patients
Strongly Agree
Agree
Disagree
Strongly disagree
Mean
1(5)
6(30)
10(50)
3(15)
2.3
17(85)
2(10)
1(5)
0(00)
3.8
<0.01
11. Sighing, crying and moaning is an indicator of
pain unconscious patients
Strongly Agree
Agree
Disagree
12(60)
6(30)
2(10)
17(85)
3(15)
0(00)
0.05

25
Strongly disagree
Mean
0(00)
3.5
0(00)
3.9
12. Intolerance to mechanical ventilation is an
indicator of pain unconscious patients
Strongly Agree
Agree
Disagree
Strongly disagree
Mean
1(5)
5(25)
10(50)
4(20)
2.15
14(70)
6(30)
0(00)
0(00)
3.7
<0.01
13. Abnormal limb movement is an indicator of pain
Strongly Agree
Agree
Disagree
Strongly disagree
Mean
2(10)
7(35)
9(45)
2(10)
2.5
15(75)
5(25)
0(00)
0(00)
3.8 <0.01
14. Unconscious patients don't feel pain
Strongly Agree
Agree
Disagree
Strongly disagree
Mean
3(15)
2(10)
6(30)
9(45)
3.1
0(00)
0(00)
1(5)
19(95)
4.0
<0.01
*The mean was determined by numbering strongly agree=4, agree=3, disagree=2, strongly
disagree=1 except in the last question (q 14) where the direction was reversed. Dichotomous
question were scored differently, Answer yes =1, no= 0
4.4 Comparison between nurses’ knowledge of pain assessment in unconscious patients
before and after the education intervention
The overall scale score of nurses’ knowledge regarding pain assessment in unconscious patients
showed improvement following the educational intervention, see table III. Because the total scale
scores had a non-normal distribution the non-parametric Wilcoxon Signed-ranks test indicated
that knowledge was significantly higher following intervention (Mdn = 45) than the pre-
intervention knowledge assessment scores (Mdn = 37), Z = 3.84, p < .001.

26
Table 3. Comparison of total scale score, pre-test vs. post-test (n = 20)
Pre Test Scale Score Post Test Scale Score
Mean 35.00 45.25
Median 37.00 45.00
Std. Deviation 3.78 2.73
Variance 14.32 7.46
Minimum 27 39
Maximum 39 49
4.5 Nurses practice of pain assessment in unconscious patients
The majority of the nurses (60%) had never assessed pain in unconscious patients. However,
after the training 95% reported that they did assess pain. Out of eight who had previously
assessed pain, four (50%) had never used a pain assessment tool. After educational intervention,
58% reported that they used the Critical Care Pain Observation Tool (CPOT) and 37% used the
Behavioural Pain scale. The majority of the nurses (70%) reported that they assess the need for
analgesia administration before performing procedures prior to training; after the training, the
percentage increased to 95%. No participant had ever received training about pain assessment in
unconscious patients prior to this study

27
Table 4: Nurses practice of pain assessment in unconscious patients
Characteristics Prettest (n
%)
Posttest (n %)
1.Ever assessed pain in an unconscious patient
No
Yes
12(60)
8(40)
1(5)
19(95)
1.a Reasons for not assessing pain in unconscious patients
Knowledge deficit
It’s Doctors’ procedure
They don’t feel pain
Unable to talk
No encounter with unconscious patients
n=12
6(50%)
1(8.3%)
1(8.3%)
4(33.3%)
n=1
0(00)
0(00)
0(00)
0(00)
1(100%)
1.b Tools used for pain assessment in unconscious patients
Behavior Pain Scale(BPS)
Critical care Pain Observation Tool
Wong Baker Faces Rating Scale
No tools used
n =8
1(12.5)
1(12.5)
2(25)
4(50)
n = 19
7(36.8)
11(57.9)
00(00)
1(5.3)
1.c How else did you assess for pain
Vital signs
Sternal rub
Facial expression
n = 4
1(25%)
1(25%)
2(50%)
0(00)
0(00)
1(100)
2. How important is pain assessment tool
Not important
Minimally important
Moderately important
Extremely important
3(15)
2(10)
4(20)
11(55)
0(00)
0(00)
3(15)
17(85)
3.Did you assess the need for administration of analgesia
before procedures
No
Yes
6(30)
14(70)
1(5)
19(95)
4. Ever received training about pain assessment in
No
Yes
20(100)
00(00)
00(00)
20(100)
5. Current knowledge about pain assessment is adequate
No
Yes
20(100)
0(00)
3(15)
17(85)

28
4.6 Comparison between nurses’ practice of pain assessment in unconscious patients pre
and post educational intervention
A paired student t test was run on three questions of practice which were scored as follows;
dichotomous questions (required yes or no answer) were scored 1 and 0 respectively, question
that required responses like extremely important=3, moderately important =2 minimally
important =1 Not important=0. Pretest scores and posttest scores were compared. There was a
statistically significant mean increase in nurses’ practice of the pre and post training scores of
1.6 with SD 1.4, t (19) = -4.1, P < 0.01.
Table 5: Difference in nurses’ practice of pain assessment in unconscious patients’ pre and
post education intervention
Var Obsns Mean Std
Err
Std. Dev 95% Conf. interval T df P value
Practice pre
intervention
20 4.2 .36706
52
1.641565 3.431724 4.968276
-4.1 19 <0.01
Practice
post
intervention 20 5.75 .09933
99
.4442617 5.542079 5.957921

29
CHAPTER FIVE
DISCUSSION, CONCLUSION, RECOMENDATIONS
5.0 Introduction
This chapter presents a discussion of the results. It involves comparing the results from this study
with other study findings. It is arranged as follows: knowledge of pain assessment pre and post
education intervention, practice of pain assessment pre and post education intervention and
comparison of knowledge and practice pre and post intervention
5.1 Nurses’ knowledge of pain assessment in unconscious patients pre-education
intervention
The majority of nurses reported, even before the intervention, that unconscious patients did
experience pain and that it should be assessed by nurses for potential treatment. This concurs
with a study done in a public sector hospital in Johannesburg South Africa where the authors
found nurses were the most accurate assessors of pain levels in patients who could not self-report
(Onwong’a, 2014).
Majority of the participants knew that physiological responses (change in blood pressure, pulse,
temperature) at significant levels were indicators of pain. This is in line with Abour and Gelinas
(2010) who reported that one pain assessment tool that could be used with the unconscious
patients was the examination of the patient’s vital signs. This assessment tool was based on the
body’s physiological responses to pain that includes tachycardia, tachypnoea, or hypertension.
These parameters are often used by anesthetists to guide analgesia in patients in theatre. In line
with the above, a study done in Johannesburg South Africa reported that 84.8% of health care
respondents use elevated vital signs as physiological indicators of pain (Onwong’a, 2014).

30
Conversely, some studies have found that vital sign assessments of patient pain in the ICU were
not consistent with patient reports of pain. It may be difficult to assess patient pain using only
vital signs because ICU patients are often very unstable, with many potential causes for changes
in their vital signs. Tachycardia may be due to pain, but could also be caused by fever or
hypovolaemia. Therefore, some of the assessments of pain measurements using vital signs were
not always reliable (Alderson and Mckechnie 2013).
The majority of the participants (40%) in this study reported that pupillary dilation was not an
indicator of pain in unconscious patients, and even after the instructional intervention the
participants were the least likely to think this was a pain response. This is in contrast with a study
done by Puntillo and Miaskowski (2008) that reviewed pain measures for use with critical care
adult patients unable to self-report and found pupil dilation was a physiological indicator of pain.
Nurses had relatively good knowledge about three behavioural responses to pain in unconscious
patients. These included agitation, facial grimace, and sighing, moaning and crying. This is in
agreement with Gelinas et al, (2004) who found that significant behavioural responses to pain
included moving away from painful stimuli, grimacing, moaning, and crying, restlessness,
protecting the painful area and refusing to move.
Conversely, the study participants did not agree that two parameters: abnormal limb movements
and intolerance to mechanical ventilation (for patients intubated) were also indicators of pain in
unconscious patients. This differs from Gelinas (2007) who reported that body movements and
compliance with mechanical ventilation were among parameters to assess in ventilated adult
patients for pain. This lack of agreement could be attributed to some nurse participants had

31
limited experience with mechanical ventilation, but did not explain why they did not think
abnormal limb movement was a pain response.
Overall the nurses had some knowledge about pain assessment in unconscious patients though
they didn’t know that pupillary dilation, abnormal limb movements and intolerance to
mechanical ventilation for those who are on ventilation machines are parameters for pain
assessment.
5.2 Nurses knowledge of pain assessment in unconscious patients post-education
intervention
The results of the posttest showed a significant improvement in nurses’ knowledge about pain
assessment in unconscious patients. There was a statistically significant increase in knowledge
(P < 0.01). This concurs with a study done to assess whether education intervention improved
knowledge and attitudes of nurses’ post-operative pain management for improved patient
satisfaction. In a US Georgia plastic surgery unit, they found after intervention a statistically
significant increase in knowledge and attitudes on the nurses’ posttest (p ≤ .05) (Ellen and Beri
2015). Relatedly, de Rond et al. (2000) found education improved significantly the nurses’
assessment of patient’s pain, documentation about pain in nursing records, and more patients
appropriately received analgesics prescribed daily PRN. This also coincided with a quasi-
experimental study done to assess whether a theory-based educational intervention could change
nurses’ knowledge and attitudes concerning cancer pain management. The study found there was
a statistical significant (p<0.05) knowledge improvement of total mean score from baseline to
four weeks (Gustafsson and Borglin 2013).

32
5.3 Nurses’ practice of pain assessment in unconscious patients pre-intervention
Majority of the participants (63%) reported that they had never assessed pain in unconscious
patients. This is in agreement with a study done in Jordan looking at pain assessment and
management in critically ill intubated patients. The authors found that only 35% of the patients
had documented pain assessment in their medical records. They concluded that pain assessment
and management in criticall patients was inadequate (Shahnaz et al. 2014).
Among the participants in this study who had never assessed pain, 50% (n= 12) reported that
they lacked knowledge, 33.3% reported that unconscious patients are unable to talk and
communicate their pain. This is consistent with Wang & Tsai (2010) who found that ICU nurses
lacked knowledge in pain assessment and management. On the contrary, a study done at the Moi
Teaching and Referral Hospital in Kenya, clinicians were asked about knowledge and practices
of management of post-operative pain. Of the 200 clinician participants 41% of the nurse
participants indicated that they had sufficient knowledge to recognize and manage pain (Kituyi,
Imbayo, Wambami, Sisenda & Kuremu 2011)
The majority of the eight participants who reported that they did assess pain, did not use any pain
assessment tool, mainly relying on vital signs. This concurs with a study done in Hong Kong of
143 nurses working on medical units that reported the majority of participants (89%) had either
never or only seldom used objective tools for pain assessment (Lui etal. 2008).

33
Although a bigger percentage reported that they did not use pain assessment tools, they
considered pain assessment tools to be extremely important. This is in agreement with Onwong’a
(2014) in his study in Johannesburg who found that 70.9% of nurses took pain assessment tools
to be extremely important.
The majority of participants (70%) reported that they assessed the need for administration of
analgesia before performing procedures. This is in line with a study done in Johannesburg which
revealed nurses routinely (75% of the time) do pain assessment to determine need for pre
emptive analgesia prior to procedures (e.g. wound care , drain removal ,and invasive line
placement) (Onwong’a, 2014).
All participants reported that they had never received training about pain assessment with
unconscious patients. This concurs with several studies that reported lack of formal training
either pre or in service and this affected knowledge as well as practice (Lui & Fongo, 2008).
Mulago National Referral Hospital also found that 30.6% of nurses had never received training
on pain assessment and management (Kizza, 2012)
5.4 Nurses’ practices of pain assessment in unconscious patients post education
intervention
In comparison of pretest and posttest scores, there was a statistically significant increase in
nurses’ practice (SD 1.3, t (19) = -6.5, P< 0.05). Consistent with the above findings, Ho and
colleagues (2013) conducted a study among nurses in Malaysia and the findings showed that
nurses who had previously attended a pain course had increased their knowledge and attitude
towards pain management. It was noted in the study that pain education and nurses’ knowledge

34
on opioid pharmacology had improved nurses’ ability to provide proper and adequate pain
assessment and management.
5.5 Study limitations
 The researcher had wanted to use another study site (Masaka Regional Referral Hospital);
this was not possible because of delays in clearance and time constraints.
 Getting nurses who were on duty to allocate some time to answer questionnaire was a
difficult task since most of them would be busy and at times alone on the ward.
5.6 Conclusion
Majority of the participants agreed that raised blood pressure and raised pulse while they
disagreed that temperature and pupillary dilation are indicators of pain in unconscious patients.
Most of participants also agreed that Agitation, Facial grimace, Sighing and crying are indicators
of pain in unconscious patients but disagreed on mechanical ventilation and abnormal limb
movements. Although participants knew more than half of the parameters used in pain
assessment in unconscious patients, this did not translate into practice. The majority of the nurses
(63.2%) had never assessed pain in unconscious patients. Out of eight who had previously
assessed pain, four (50%) had never used a pain assessment tool. However, 70% of Participants
reported that they assessed the need for analgesia administration before performing procedures
Education intervention improved significantly nurses’ knowledge and practice about pain
assessment in unconscious patients (P<0.01)
5.7 Recommendations
Based on the outcome of this study the hospital administration should regularly arrange
continuous in service education for nurses about pain assessment in unconscious patients. This
will equip the staff with knowledge and skills to advance quality care to patients.

35
Ministry of health and hospital administration may draft guidelines/protocols for pain assessment
in unconscious patients, specifically adopting one of the validated pain assessment tools.
Pain assessment including pain assessment of unconscious patients may be included in the
curricula of nurses at different levels of nursing training.
Nurses in ICU, emergency and high dependence units should always assess pain and can choose
one of the validated observation tools to use in pain assessment in unconscious patients. This will
help in better management of pain and quality care.
5.8 Nursing Implications
The study generated information about pain assessment in unconscious patients and proved that
education intervention improves knowledge and practice of pain assessment in unconscious
patients. This information will help nurses also adopt a validated tool to use for pain assessment
in unconscious patients and this will improve clinical practice.
It will serve as an eye opener for nurses in education to always put more emphasis on pain
assessment while training students both in theory and clinical areas.
The study findings will act as a baseline for future studies about pain assessment in unconscious
patients for nurses in the research and clinical field.
5.9 Areas for future research
An exploratory descriptive research with a larger sample may done examining nurses’
knowledge about pain assessment of unconscious patients

36
A randomized controlled trial could be done to assess whether education intervention improves
nurses’ knowledge and practice about pain assessment in unconscious patient immediately and
over time
Studies would be useful to assess pain management practices among nurses/health workers in
critical care units.
A same study can be done with mixed design where observation can be included to ascertain
whether the nurses actually implements the assessment and documents pain pre and post
intervention.

37
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44
APPENDIX I: CONSENT FORM
MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY
RESEARCH ETHICS COMMITTEE
P.O. Box 1410, Mbarara, Uganda
Tel. 256-4854-33795 Fax: 256 4854 20782
Email: irc@must.ac.ug mustirb@gmail.com
Web site : www.must.ac.ug
-
INFORMED CONSENT DOCUMENT
This document outlines the research study and expectations for potential participants. It should be written in
layman terms and typed on MUST-REC letterhead. The wording should be directed to the potential participant NOT
to IRC. If a technical term must be used, define it the first time it is used. Also, any abbreviation should be spelled
out the first time it is used.
NB: All the sections of this document must be completed without any editing or deletions
Please use a typing font that is easily distinguishable from the questions of the form
Study Title: NURSES’ KNOWLEDGE PRACTICES OF PAIN ASSESSMENT IN UNCONSCIOUS
PATIENTS; EVALUATION OF EDUCATIONAL INTERVENTION
Principal Investigator(s): Valence Mfitumukiza, R.N., B.S.N., DHSM, MNS candidate
INTRODUCTION
What you should know about this study:
 You are being asked to join a research study.
 This consent form explains the research study and your part in the study
 Please read it carefully and take as much time as you need
 You are a volunteer. You can choose not to take part and if you join, you may quit at any
time. There will be no penalty if you decide to quit the study
Provide here a brief background to the study
Assessment of pain is a critical step to providing good pain management. Patients’ self-reports of
pain are the most valid measure of pain and should be obtained if at all possible. Unfortunately,
especially in critical care, many factors may alter verbal communication with patients, such as
administration of sedative agents, mechanical ventilation, and patients’ changes in level of

45
consciousness. However, an individual’s inability to communicate verbally does not negate the
possibility that he or she is experiencing pain needs appropriate pain-relieving treatment
Although unconscious patients cannot speak, they do communicate with facial expressions, or
hand motions, or by seeking attention with other movements. Healthcare professionals should
use these indicators for pain assessment.
Purpose of the research project: Include a statement that the study involves research, estimated number of
participants, an explanation of the purpose(s) of the research procedure and the expected duration of the subject's
participation.
The objective of the study is to assess knowledge about pain assessment in unconscious patients;
and whether education intervention improves knowledge of pain assessment.
The study will involve 44 participants; 22 from Mbarara and 22 from Masaka Regional Referral
Hospitals.
You will be asked to answer a self-administered structured questionnaires as a pretest for about
25-30 min each. You shall receive a training about pain assessment for one day and you will be
required to choose which model of assessment to use in your hospital. After one month, you will
be required to do a post test.

46
Why you are being asked to participate: Explain why you have selected the individual to participate in the
study.
You are invited to take part in a research study to assess nurses’ knowledge about pain
assessment in unconscious patients and to evaluate whether educational intervention improves
knowledge. This is because you take part in caring for critically ill patients including
unconscious patients and knowledge of pain assessment is of great importance to patients’ better
management and recovery. I expect that your contributions in participating in this study shall
improve your knowledge of pain assessment in unconscious patients.
Procedures: Provide a description of the procedures to be followed and identification of any procedures that are
experimental, clinical etc. If there is need for storage of biological (body) specimens, explain why, and include a
statement requesting for consent to store the specimens and state the duration of storage.
Your participation is voluntary. Participation in this study may take about 30 minutes while
answering pre intervention Questionnaire and it will be a self-administered, then education
intervention that is likely to take 1day and you will be contacted at a later time to answer post
intervention questionnaire.
Risks / discomforts: Describe any reasonably foreseeable risks or discomforts-physical, psychological, social, legal
or other associated with the procedure, and include information about their likelihood and seriousness. Discuss the
procedures for protecting against or minimizing any potential risks to the subject. Discuss the risks in relation to the
anticipated benefits to the subjects and to society.
There are no side effects or risks associated with this study
Benefits: Describe any benefits to the subject or other benefits that may reasonably be expected from the
research. If the subject is not likely to benefit personally from the experimental protocol note this in the statement
of benefits.
If you agree to participate, you will benefit from the Pain assessment training.
Incentives / rewards for participating: It is assumed that there are no costs to subjects enrolled in research
protocols. Any payments to be made to the subject (e.g., travel expenses, token of appreciation for time spent)
must also be stated, including when the payment will be made.
No incentives /payments shall be given to participants.

47
Protecting data confidentiality: Provide a statement describing the extent, if any, to which confidentiality or
records identifying the subjects will be maintained. If data is in form of tape recordings, photographs, movies or
videotapes, researcher should describe period of time they will be retained before destruction. Showing or playing
of such data must be disclosed, including instructional purposes.
Your identity will not be revealed as names shall not be used. It will be a self-administered
questionnaire and any information given shall not be shared with anybody without your consent.
All the study data and other materials that will be used will be coded for anonymity and all study
data will be collected by the researcher and kept in lockable cupboard when not in use until the
study has been completed and published and the paper work can be destroyed by burning.
Protecting subject privacy during data collection: Describe how this will be ensured.
Your identity will not be revealed as names shall not be used. All the study data that will be
collected will be coded with unique number so that they are not linked to you and your name
shall not be required anywhere.
Right to refuse / withdraw: Include a statement that participation is voluntary, refusal to participate will involve
no penalty or loss of benefits to which the subject is otherwise entitled.
Your participation is voluntary and you are free to opt out/withdraw from the study and this will
not in any way affect your working conditions/privileges
What happens if you leave the study? Include a statement that the subject may discontinue participation
at any time without penalty or loss of benefits.
When you leave the study, neither you nor hospital will incur any expense or compensation for
your participation and no consequences whatsoever.
Who do I ask/call if I have questions or a problem? Include contact for researcher or Faculty advisor and
Chairman MUST-IRC

48
You are free to ask any questions about the study or participation and you may call the principal
investigator at following contact;
Principal investigator: Valence Mfitumukiza
Telephone: 0772974952/0702974952 for further clarifications and inquiries.
Email: valemfite@gmail.com
 Contact for IRC office
Dr. Francis Bajunirwe
Chairman MUST-IRC
P.O Box 1410
Mbarara
Tel: 0485433795
What does your signature (or thumbprint/mark) on this consent form mean?
Your signature on this form means
 You have been informed about this study’s purpose, procedures, possible benefits and
risks
 You have been given the chance to ask questions before you sign
 You have voluntarily agreed to be in this study
----------------------------------- --------------------------------------- -------------------
Print name of adult participant Signature of adult participant/legally Date
Authorized representative
______________________ _______________________ ___________
Print name of person obtaining Signature Date
Consent
----------------------------------- -------------------------------------- -------------------
Thumbprint/mark signature of witness

49
APPENDIX I I: QUESTIONNAIRE
This questionnaire is intended to understand knowledge of pain assessment in unconscious
patients
Section A: Demographic characteristics
1. Age in years…………
2. Sex: male female
3. What is your level of education
a. Enrolled Nurse
b. Registered Nurse (Diploma)
c. Graduate Nurse (BNS)
d. Others Specify ………………………………………..
4. On which ward are you currently working?
a. Medical ward
b. Emergency ward
c. ICU
d. Surgical ward
e. Other ………………………….
5. For how long have you worked in this ward
a. 6 months to 11months
b. 12 to 23 months
c. 2-4 years

50
d. > 5years
6. How long have you been in service as a nurse…………………….. years
Section B: Nurses’knowledge about Pain assessment in unconscious patients
7. Pain is an unpleasant sensory and emotional experience associated with actual or
potential tissue damage or described in terms of such damage
a. True
b. Not true
c. Not sure
d. None of the above
8. Patients who are unconscious experience pain?
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly disagree
9. A nurse should assess pain in unconscious patients
a. Yes
b. No

51
For question 10 to 20, read the statement and choose your response by placing a tick in the
selected column.
Question Strongly
Agree
Agree Disagree Strongly
disagree
10. Raised blood pressure is an indicator of pain in
11. Raised pulse is indicator of pain in unconscious
patients
12. Raised temperature is an indication of pain in
13. Agitation is an indication of pain in unconscious
patients
14. Pupillary dilatation is an indicator of pain in
15. Facial grimacing is an indicator of pain in
16. Muscle rigidity is an indication of pain in
17. Sighing, crying and moaning is an indicator of pain
18. Intolerance to mechanical ventilation (for patients
on mechanical ventilators) is an indication of pain
19. Pain should be anticipated and analgesia given
before invasive procedure to unconscious patients
20. Abnormal limb movement is an indication of pain in
21. Patients who are unconscious don’t feel pain
therefore it should not be a priority concern for the
nurse

50
22. Do you feel your current knowledge about pain assessment is adequate?
Yes No
Section C: Nurses’ practice about Pain assessment in unconscious patients
23. Have you ever assessed pain in an unconscious patient?
a. Yes
b. No
24. If no, what are some of the reasons why you have never assessed for pain in unconscious
patients?
………………………………………………………………………………………………
………………………………………………………………………………………………
…………………………………………………………………………………………….
25. If yes to no. 23; Identify all the tools for pain assessment you have ever used
a. Behavioural Pain Scale (BPS)
b. Critical Care Pain Observation tool (CPOT)
c. Wong Baker Faces Rating Scale
d. The Ramsay Sedation Scale
e. Others tool (Specify) …………………………………….
f. Have not used tools
26. If you haven’t used a tool, describe how you would assess pain in an unconscious
patient?

51
_____________________________________________________________________________-
______________________________________________________________________________
_____________________________________________________________________________
27. In your opinion, how important is a pain assessment TOOL ?
Not at all important Minimally important
Moderately important Extremely important
28. Have you ever received training about pain assessment in unconscious/unable to talk
patients?
Yes No
THANK YOU

52
APPENDIX III: MUST REC APPROVAL LETTER

53
APPENDIX IV: APPROVAL LETTER FROM UGANDA NATIONAL COUNCIL FOR
SCIENCE AND TECHNOLOGY

54
APPENDIX V: AMENDMENT LETTER FROM MUST-REC

55
APPENDIX V: MRRH APPROVAL LETTER

56
APPENDIX VI: TEACHING FORMAT FOR THE PAIN ASSESSMENT
The training is intended to impart knowledge about pain assessment in unconscious patients.
Pretest knowledge assessment will be done using questionnaire before training and posttest will
be done three months after the training.
Training will be conducted in a hall using discussion method with a feedback given using
projector and manila papers.
Power point presentation will be done and handouts will be given
 Define pain
 Explain how pain assessment in unconscious patients is done
 List parameters used in pain assessment in unconscious patients
 Describe the tools used to assess pain in unconscious patients
 Adopt a pain assessment tool to be used in your settings
Pain Assessment
Goals
1. Define pain
2. Understand various types of pain.
3. Describe various methods of pain assessment
4. Identify and adopt pain assessment tool
5. Explain management options for pain
PAIN
Pain is an unpleasant sensory and emotional experience associated with actual or potential
damage or described in terms of such damage (ASP, 2012).
• Pain is an important stressor for critical care patients.
• Sources include;
• Acute illness, surgery, trauma, invasive equipment, nursing and medical
interventions, and immobility (Glinas et al. 2004).

57
Consequences of untreated Pain
Acute pain:
• increase metabolic rate and blood clotting,
• impair immune function
• induce negative emotions
• Without intervention, pain receptors become sensitive and may have long lasting
changes in the neurons
Chronic pain may lead to:
• fatigue,
• anxiety,
• depression,
• confusion,
• impaired sleep, and
• Increased morbidity and mortality
• Increased length of hospital stay
Classification of Pain
Duration
• Acute- lasts only through the expected recovery period whether it has a sudden or
slow onset and regardless of intensity.
• Chronic-Is prolonged, usually recurring or persisting over 6 months or longer, and
interferes with functioning.
Intensity
• Classified using a standard 0(no pain) to 10 (worst possible pain) scale.
• Mild pain- rating of 1-3
• Moderate pain- rating of 4-6
• Severe pain- reaching 7-10 and is associated with worst outcome.

58
Aetiology
• Physiological pain- experienced when an intact, properly functioning nervous
system sends signals that tissue are damaged, requiring attention and proper care.
• Somatic pain- originates in the skin, muscles, bones or connective tissue with
sharp sensation of a paper cut or aching of sprained ankle. Visceral pain- poorly
located and may have cramping, throbbing, pressing, or aching quality. Often
associated with feeling sick.
• Neuropathic pain- experienced by people with damaged or malfunctioning nerves.
• Peripheral neuropathic pain- follows damage and/or sensitization of
peripheral nerves.
• Central neuropathic pain- results from malfunctioning nerves in Central
nervous system.
• Sympathetically maintained pain- occurs occasionally when abnormal
connections between pain fibers and the sympathetic nervous system
perpetuate problems with both the pain and sympathetically controlled
function.
Quality: Visceral Pain
• Descriptors: cramping, squeezing, pressure
• Distribution/Examples:
• Referred
• heart attack, kidney stone
• Colicky
• Bowel obstruction, gallstone
• Diffuse
• Peritonitis
• Quality: Somatic pain
• Descriptors: aching, deep, dull, gnawing
• Distribution/Examples:

59
Well localized—patients can often point with one finger to the location of their pain
• Bone, strained ankle, toothache
Pain Assessment
• Best done by Self report; Description of pain experience by a person experiencing it.
• It can be rated or categorised using;
• Simple description of pain
• Visual analogue scale
• Numeric pain intensity scale
• Wong-Baker FACES scale
Use a standard scale to track the course of pain (This is only used to assess pain in patients
who able to communicate)

60
Pain Assessment strategies for unconscious patients
Unconscious patients can speak
They can communicate pain through physiological and behavioural responses
Vital signs may not be reliable because disease condition mat also alter the signs.
Tools have been developed and validated to help health care providers to assess pain. These
include;
• Behavioural Pain scale (BPS)
• Critical care pain observation tool (CPOT)
• Non Verbal Pain Scale(NVPS)
• Pain assessment intervention and notation algorithm (PAIN)
Table 1: Potential clinical manifestations associated with pain
Physiological system Changes potentially associated with pain
Respiratory Tachypnea
Patient-ventilator dysnchrony
Cardiovascular Tachycardia
Bradycardia
Hypertension
Neurology Agitation
Low mood
Pupillary dilation
Facial grimacing
Other Sweating
Crying
Adopted from Alderson and Mckechnie,( 2013)

61
Table 2: The Behavioural Pain Scale (BPS).
Sub scale Description Score
Facial Expression Relaxed 1
Partially tightened 2
Fully tightened 3
Grimacing 4
Upper limbs No movement 1
Partially bent 2
Fully bent with finger flexion 3
Permanent retracted 4
Compliance with ventilator Tolerating movement 1
Coughing but tolerating ventilation for
most of the time
2
Fighting ventilator 3
Unable to control ventilation 4
Adopted from Alderson and Mckechnie,( 2013)

62
Table 3: The Critical care Pain Observation Tool (CPOT)
Sub scale Description Score
Facial Expression Relaxed, Neutral 0
Tense 1
Grimacing 2
Body Movements Absence of movements 0
Protection 1
Restlessness 2
Muscle Tension Relaxed 0
Tense or rigid 1
Very tense or rigid 2
Compliance with Ventilation Tolerating ventilator or movement 0
Coughing but tolerating 1
Fighting ventilator 2
Vocalization (with extubated
patients)
Talking in normal tone or no sound 0
Sighing or moaning 1
Crying or sobbing 2
Adopted from Alderson and Mckechnie, 2013

63
Table 4 :Adult Non Verbal Pain Scale (NVPS)

64
• Which tool wound you prefer?

Pain assessment in Unconscious patients

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