i UNIVERSITY OF GHANA, LEGON COLLEGE OF HEALTH SCIENCES SCHOOL OF NURSING AND MIDWIFERY EXPLORING PERSPECTIVES OF NURSES AND MIDWIVES ON PAIN MANAGEMENT AFTER CAESAREAN SECTION AT THE GREATER ACCRA REGIONAL HOSPITAL BY PHILIMON GYAPONG 10631957 THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL NURSING DEGREE DECEMBER, 2022 DECLARATION I therefore declare that the research conducted for this thesis was done by myself independently. This thesis/dissertation has not been submitted in any way to a university or University of Ghana http://ugspace.ug.edu.gh ii other tertiary educational institution for a degree or diploma. The text and references list properly credit the authors and publishers whose works were used in this study. University of Ghana http://ugspace.ug.edu.gh iii DEDICATION To the Gyapong family, my wife, Comfort, and my children, D.D, Ewurabena, and Paa Kwesi. University of Ghana http://ugspace.ug.edu.gh iv ACKNOWLEDGEMENT Thanks be to God for his faithfulness and unfailing love for us all. My sincerest gratitude goes to my supervisor Prof Lydia Aziato, Vice Chancellor of the University of Health and Allied Sciences, Ho, for her immense contribution, passion, encouragement and continual guidance amidst all her busy schedule to enable me finish and submit this work on time. My special appreciation goes to Dr David Tenkorang-Twum, Lecturer School of Nursing, College of Health Sciences, University of Ghana for being my mentor and supervisor despite his busy schedule. I’m forever grateful for your love, expert advice and constant support throughout my study. I want to thank Dr. Kwadwo Korsah, Head of the Adult Health Department at the School of Nursing, as well as the other faculty members once more for their advice and direction throughout my research. Finally, I am thankful to my colleagues especially Lena, the management and staff of the Greater Accra Regional Hospital especially Miss Dede Adamptey and staff at the postnatal unit for your commitment and support during my data collection period. University of Ghana http://ugspace.ug.edu.gh v TABLE OF CONTENTS DECLARATION ....................................................................................................................... i DEDICATION ......................................................................................................................... iii ACKNOWLEDGEMENT ..................................................................................................... iv TABLE OF CONTENTS ......................................................................................................... v LIST OF FIGURES .............................................................................................................. viii LIST OF TABLES .................................................................................................................. ix LIST OF ABBREVIATIONS .................................................................................................. x ABSTRACT ............................................................................................................................ xi CHAPTER ONE ...................................................................................................................... 1 1.0 Introduction ...................................................................................................................... 1 1.1 Background of the Study ................................................................................................. 1 1.2 Problem statement ............................................................................................................ 4 1.3 Purpose of the study ......................................................................................................... 5 1.4 Objectives of the study .................................................................................................... 5 1.5 Research Questions .......................................................................................................... 6 1.6 Significance of the Study ................................................................................................. 6 1.7 Operational Definition of Terms ...................................................................................... 7 CHAPTER TWO ..................................................................................................................... 8 LITERATURE REVIEW ....................................................................................................... 8 2.1 Theoretical review ........................................................................................................... 8 2.1.1 Gate Control Theory .................................................................................................. 8 2.1.2 Self-Care Deficit Theory ......................................................................................... 10 2.1.3 Pain Transaction Model ........................................................................................... 12 2.2 Justification for the use of Pain Transactional Model .................................................... 16 2.3 Review of Related Studies ............................................................................................. 17 2.3.1 Knowledge of Nurses/Midwives Regarding POP Assessment and Management ... 17 2.3.2 Attitudes of nurses/midwives regarding POP management after CS ...................... 19 2.3.3 Interpersonal Communication in POP management ............................................... 20 2.3.4 Assessment of Postoperative Pain ........................................................................... 21 2.3.5 Management of POP ............................................................................................... 23 2.3.6 Challenges with assessment and management of POP ........................................... 27 2.4 Summary ........................................................................................................................ 29 CHAPTER THREE ............................................................................................................... 30 University of Ghana http://ugspace.ug.edu.gh vi METHODOLOGY ................................................................................................................ 30 3.1 Research Design ............................................................................................................. 30 3.2 Research Setting ............................................................................................................. 31 3.3 Study Population ............................................................................................................ 33 3.4 Inclusion Criteria ........................................................................................................... 33 3.5 Exclusion Criteria .......................................................................................................... 34 3.6 Sample size .................................................................................................................... 34 3.7 Sampling Technique ....................................................................................................... 35 3.8 Tool for Data Collection ................................................................................................ 35 3.9 Data Collection Procedure ............................................................................................. 36 3.10 Methodological rigour.................................................................................................. 37 3.11 Data Management ........................................................................................................ 38 3.12 Data Analysis ............................................................................................................... 39 3.13 Ethical considerations .................................................................................................. 40 CHAPTER FOUR ................................................................................................................. 42 FINDINGS / RESULTS ......................................................................................................... 42 4.1 Demographic characteristics of participants .................................................................. 42 4.2 Emerged Themes and Sub-Themes................................................................................ 43 4.3 Nurse/Midwife Related Factors ..................................................................................... 43 4.3.1 Nursing knowledge ................................................................................................. 44 4.3.2 Nursing attitude ....................................................................................................... 47 4.3.3 Interpersonal communication .................................................................................. 50 4.4 Perceived Nurse/Midwife Skills .................................................................................... 53 4.4.1 Assessment .............................................................................................................. 53 4.4.2 Treatment ................................................................................................................. 57 4.4.2.1 Pharmacological treatment .............................................................................. 57 4.4.2.2 Non-pharmacological treatment ....................................................................... 58 4.5 Challenges associated with assessment and management of POP................................. 59 4.5.1 Individual level challenges ...................................................................................... 59 4.5.2 Structural level challenges ...................................................................................... 61 4.5.2.1 Health system .................................................................................................... 62 4.5.2.2 Health policy ..................................................................................................... 64 4.6 Summary of findings ..................................................................................................... 66 CHAPTER FIVE ................................................................................................................... 68 University of Ghana http://ugspace.ug.edu.gh vii DISCUSSIONS ....................................................................................................................... 68 5.1 Nurses/Midwives Related Factors Influencing the Assessment and Management of POP after C-section ...................................................................................................................... 68 5.2 Nurse/Midwife Skills in the Assessment and Management of POP after C-section at GARH. ................................................................................................................................. 71 5.3 Challenges Faced by Nurses/midwives in the Assessment and Management of POP at GARH. ................................................................................................................................. 74 CHAPTER SIX SUMMARY, IMPLICATIONS, LIMITATIONS, CONCLUSIONS AND ........................................................................................................................................ 77 RECOMMENDATIONS ....................................................................................................... 77 6.1 Summary ........................................................................................................................ 77 6.2 Implications ................................................................................................................... 77 6.2.1 Nursing education ................................................................................................... 77 6.2.2 Nursing practice ...................................................................................................... 78 6.2.3 Nursing research ...................................................................................................... 78 6.2.4 Policy formulation ................................................................................................... 79 6.2.5 Limitations of the study ........................................................................................... 79 6.3 Conclusions .................................................................................................................... 80 6.4 Recommendations .......................................................................................................... 80 6.4.1 Ministry of Health (MOH) ...................................................................................... 80 6.4.2 Ghana Health Service (GHS) .................................................................................. 81 6.4.3 Greater Accra Regional Hospital (GARH) .............................................................. 81 6.4.4 Nurses/Midwives ..................................................................................................... 82 REFERENCES ...................................................................................................................... 83 APPENDIX ............................................................................................................................. 93 Appendix A: Ethical clearance letter ................................................................................... 93 Appendix B: Permissions for research study ....................................................................... 94 Appendix C: Letter of introduction ...................................................................................... 96 Appendix D: Support letter .................................................................................................. 97 Appendix E: Statement of compliance................................................................................. 99 Appendix F: Data collection instrument............................................................................ 100 Appendix G: Informed consent .......................................................................................... 103 University of Ghana http://ugspace.ug.edu.gh viii LIST OF FIGURES Table 1: Emerged themes and sub-themes ............................................................................... 42 University of Ghana http://ugspace.ug.edu.gh ix LIST OF TABLES Figure 1: Pain Transaction Model ............................................................................................ 12 Figure 2: Map of Greater Accra Region, showing the location of Greater Accra Regional Hospital, Ridge and its surrounding environs. ......................................................................... 32 University of Ghana http://ugspace.ug.edu.gh x LIST OF ABBREVIATIONS CS - Caesarean section GARH - Greater Accra Regional Hospital GHS - Ghana Health Service IASP - International Association for the Study of Pain MOH - Ministry of Health NHIA - National Health Insurance Authority N&MC - Nursing and Midwifery Council of Ghana NRS - Numerical Rating Scale NSAIDS - Non-Steroidal Anti-Inflammatory Drugs POP - Post-operative pain PTM - Pain Transaction Model PUD - Peptic Ulcer Disease WHO - World Health Organization University of Ghana http://ugspace.ug.edu.gh xi ABSTRACT Globally, caesarean section has gained increasing attention as the most frequently performed surgical procedure. The assessment and management of pain related to this surgery must therefore be discussed. There is a lack of empirical data on the factors that affect nurses' and midwives' assessments of and management of post-operative pain in a resource- constrained setting like Ghana, despite the fact that they play crucial roles in providing post- operative pain management for puerperal women after caesarean sections. Against this backdrop, this study aimed to explore from nurses and midwives’ perspective, the factors that influence assessment and management of post-operative pain after caesarean section at the Greater Accra Regional Hospital. An exploratory-descriptive qualitative design and an interpretivism approach was employed. A purposefully sampled group of 16 nurses and midwives were interviewed using an interview guide that was designed in accordance with the concepts of the Pain Transaction Model. The study employed content analysis using the Braun and Clarke's (2006) approach to analyse the data Three main themes emerged from the study, which were nurse/midwife related factors, perceived nurse/midwife skills, and challenges associated with the assessment and management of post-operative pain. In addition to the three themes, seven sub-themes emerged. Findings suggest the need for nurses to make conscious efforts to get abreast with current trends in the assessment and management of post-operative pain. Key words: Assessment, Caesarean section; Post-operative pain; Management; Greater Accra Regional Hospital University of Ghana http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE 1.0 Introduction This thesis is about the perspectives of nurses and midwives on the management of post-operative caesarian pain. This chapter presents the background of the study, problem statement, research questions, purpose and objectives of the study. The significance of the study and operational definition of key terms are also detailed in this chapter 1.1 Background of the Study Caesarean section (CS), is a surgical procedure for giving birth that involves making a (transverse or vertical) skin incision above the pubic hairline, then opening the subcutaneous tissue, the aponeurosis of the rectus abdominis muscles, separating the muscles at the midline, opening the parietal peritoneum, the visceral peritoneum, and the uterine wall, from which the fetus is extracted (Toijonen et al., 2022). Caesarean section has been performed for well over four centuries, though the surgery was avoided until the end of the nineteenth century due to its high fatality rate (Antoine & Young, 2020). However, current evidence suggest that the rate of CS has increased significantly over the past 30 years particularly in the high and middle- income countries (Takegata et al., 2020). Caesarean section is considered among the most common surgical procedures and in the United State, for instance, over a million women are delivered by caesarean annually (Sung & Heba, 2021). Caesarean delivery is now performed on one out of every three women in the United States, and up to four out of every five women in various parts of the world undergo CS (Antoine & Young, 2020). By its very nature, the procedure is commonly associated with post-operative pain (POP). Since it contributes to high-quality care and patient satisfaction, post-operative pain management has become a crucial area of attention for the delivery of healthcare. C-section pain may be affective as well as physiological or sensory, with both physiological and psychological factors playing a role (Brianne, Sukalich, & John, 2016). Sensory pain response identifies the location, University of Ghana http://ugspace.ug.edu.gh 2 timing, and physical characteristics of the noxious stimulus, and prompts withdrawal reflexes to prevent or limit tissue damage (Lumley et al., 2011). Furthermore, affective pain dimension describes the unpleasantness associated with exposure to a noxious stimulus and activates defensive behaviors such as escape and recuperation, thereby enabling the individual to cope with the pain (Berger & Baria, 2022; Lumley et al., 2011). Finally, psychological pain is defined as a diffuse subjective experience of pain by an individual (Crombez et al., 2023;Mee et al., 2006). POP is a cause of concern in modern surgical practice, despite the International Association for the Study of Pain's (2018) mission to translate pain management research into better pain care globally (Menlah et al., 2018). There are a number of research works indicating that there are several obstacles with POP management, which are more severe in underdeveloped nations because of insufficient budget allocations for pain management (Kizza et al., 2016; Murray & Retief, 2016; Kizza et al., 2016). Post-operative pain affects more than 80% of surgery patients, with 39% experiencing severe to extreme postoperative pain (Anghelescu & Tesney, 2019). With more CS, there is thought to be a higher likelihood of experiencing pain. Women who have had repeated repeat CS are significantly more at risk of experiencing organ damage after surgery (Antoine & Young, 2020). Evidence from studies done in high-income settings suggests that poorly treated pain after CS is associated with an increased prevalence of chronic pain and post-traumatic stress disorder (de Brito Cançado, Omais, Ashmawi, & Torres, 2012; Kintu et al., 2019). Pain can be expressed in a variety of ways, including vocal (spoken), nonverbal (bodily motions), or a mixture of both (Walsh, Eccleston,& Keogh, 2014). Again, it is the responsibilities of healthcare workers to undertake thorough in patient undergoing CS to ensure adequate pain management. The health system may suffer from inefficient or poor POP management, especially in the modern world University of Ghana http://ugspace.ug.edu.gh 3 when healthcare is a business and patient satisfaction is essential to its profitability (Menlah et al., 2018). Although some discomfort following surgery is common as part of the inflammatory process, the healthcare provider must restrict POP to ensure patients' comfort and happiness (Meissner et al., 2015). Most of the hurdles to ineffective pain treatment have been linked to nurses. This might be the case as nurses and midwives are the sole health workers who spend 24 hours per day with the patient (Aziato & Adejumo, 2014). As a result, nurses, and midwives are critical in the management of postoperative pain (POP) in general and post-caesarean pain in particular because these health care practitioners are required to assess pain and give timely assistance. Medical professionals working in postoperative departments must develop effective pain management techniques (World Health Organization [WHO], 2016). POP management should, according to some earlier studies (Abdalrahim et al., 2011; Yüceer, 2011), include care, commitment, therapeutic communication, appropriate assessment, good knowledge, use of evidence-based multimodal approaches, and proper evaluation of interventions in the presence of additional variables like cultural factors. Effective pain evaluation is considered the cornerstone of effective pain treatment in Ghana and is a must for all postoperative surgeries (Kotekar et al., 2014). Patients' reactions to pain are subjective and individualized, thus they should be assessed individually. However, a study's findings revealed that over 57% of nurses lacked appropriate knowledge of the instruments that could be used for measuring and assessing pain, and 12% of healthcare professionals had never used a tool to do so (Mahama & Ninnoni, 2019). In order to validate the use of three pain rating measures among adult postoperative patients, Aziato et al. (2015) undertook a mixed-method study in Ghana. They noticed that employing a reliable method for pain evaluation provides the practitioner with an impartial standard for pain control. Once more, Aziato and Adejumo (2014) carried out a qualitative study using a clinical ethnography methodology with the intention of examining the perspectives and University of Ghana http://ugspace.ug.edu.gh 4 reactions of Ghanaian surgical doctors on patients' POP. The findings showed that doctors' opinions of POP were subjective, and they treated patients' pain by giving them analgesics and non-pharmacological remedies. With POP management becoming increasingly necessary due to the rising numbers of CS, this study explores the POP management of C- Section mothers particularly in Greater Accra Regional Hospital. Particular focus is given to caregivers, thus nurses and midwives who are directly involved in POP management for puerperal women who had undergone CS. 1.2 Problem statement Post operative pain is usually an acute pain that results from tissue injury during surgical procedures (Masigati & Chilonga, 2014). In world health policies on pain, the management of pain, including POP, has gained traction. Post-operative pain has received a lot of scientific attention in most high-income countries, particularly in America and Europe, resulting in the availability of adequate empirical literature (Aziato & Adejumo, 2013; Kintu et al., 2019; Kotekar et al., 2014; Mahama & Ninnoni, 2019; Manage, 2011; Murray & Retief, 2016). However, POP management continues to be a significant concern, particularly in low- and middle-income countries, for medical professionals such as surgeons, anesthesiologists, and nurses (Eshete et al., 2019). Poorly managed post-operative pain increase hospital stay, cost to the patients, patients dissatisfaction with care, disability to the patients (Tadesse,Yohannes, & ,Bez 201; Eshete et al., 2019; Vickers, 2011). In order to effectively manage POP in mothers who had CS, nurses and midwives must possess a broad range of knowledge and abilities. According to Menlah et al. (2018), nurses are in a good position to manage pain in the post-operative situation and need to make sure that their interventions are customized to each patient's preferences and comfort. However, both midwives and doctors play crucial roles, particularly when it comes to managing POP in mothers who have University of Ghana http://ugspace.ug.edu.gh 5 undergone CS. Adequately managed POP results in early discharge from the hospital (Ofori, 2017) According to Eccleston's (2011) research on POP management, nurses and midwives have subpar pain management techniques. The author claims that this is brought on by professional culture, ward culture, a lack of necessary theoretical understanding, a lack of priority for pain management, and a lack of clarity regarding the evidence for various pain management therapy. Additionally, studies across four district hospitals in Ghana's Ashanti Region indicated that the four hospitals' nurses and midwives lacked basic expertise of POP care (Menlah et al., 2018). Currently, research in POP management has been centered on general surgeries performed at the hospitals with little focus on post-CS pain management. In Ghana, research on POP have been done in major hospitals in the cities such as Accra and Kumasi with result indicating non used of pain assessment scale, fear of addiction, and increase workload as factors affecting POP pain management ((Aziato & Adejumo, 2013; Menlah et al., 2018). The Greater Accra Regional Hospital is a major referral facility in the Greater Accra Region that received patients from other part of the country. The hospital undertakes major surgical procedures. And as such nurses and midwives are expected to effectively managed POP. Anecdotal observation indicates inadequate POP among nurses in the facility. the subject of this study, where nurses and midwives play a key role in managing POP in moms following CS. 1.3 Purpose of the study The purpose of this study is to explore the CS post-operative pain management practices of nurses and midwives at the Greater Accra Regional. 1.4 Objectives of the study 1. To explore nurses/midwives related factors influencing the assessment and management of POP after C-section at the Greater Accra Regional Hospital (GARH). University of Ghana http://ugspace.ug.edu.gh 6 2. To identify the perceived nurses/midwives’ skills in the assessment and management of POP after C-section at the Greater Accra Regional Hospital. 3. To explore the challenges faced by nurses/midwives in assessment and management of POP after C-section at the Greater Accra Regional Hospital. 1.5 Research Questions The following research questions are the focus of the study: 1. What are the nurses/midwives related factors influencing the assessment and management of POP after C-section at the Greater Accra Regional Hospital? 2. How do nurses and midwives conduct POP assessment and management after C- section at the Greater Accra Regional Hospital? 3. What are the challenges faced by nurses/midwives in assessment and management of POP after C-section at the Greater Accra Regional Hospital? 1.6 Significance of the Study This research is significant in a variety of ways as it will aid in the development of strategies to minimize the pain women experience after a caesarean section. There are several reasons why women cannot give birth through spontaneous vaginal delivery and therefore require caesarean section. Therefore, there is the need to attend to the ways of mitigating the pains associated with caesarean section in order to make it a less difficult alternative for women to choose to give birth. The results of this study will add to the body of knowledge on how nurses and midwives should understand, evaluate, and manage POP. The study will also be used as a resource by healthcare professionals, especially nurses and midwives who deal with postoperative pain. Moreover, this study will serve as a starting point for more research into caesarean section POP management in Ghana. It will provide direction for future research that will lead to the University of Ghana http://ugspace.ug.edu.gh 7 development of context-specific guidelines and protocols for caesarean section POP management in Ghana. 1.7 Operational Definition of Terms Challenges: Personal, patient-related and institutional factors that hinder proper assessment and management of POP among women after caesarean section. Knowledge: Understanding of the post-operative discomfort experienced by women who have had caesarean sections by the nurse or midwife. Management: Pharmacological and non-pharmacological methods involved in handling or controlling post-operative pain after C-section. Nurse/Midwife: A registered professional nurse/ midwife working at the recovery ward or lying- in ward of the Greater Accra Regional Hospital. Pain assessment: A method of determining how much pain a patient experience after caesarean section. Post-operative pain: A form of acute pain experienced by women due to surgical trauma with an inflammatory reaction occurring after caesarean section delivery. University of Ghana http://ugspace.ug.edu.gh 8 CHAPTER TWO LITERATURE REVIEW The purpose of the study is to explore the post-operative pain management of nurses and midwives at the Greater Accra Regional hospital. This chapter discusses relevant theories and empirical research on pain man. This was done with literature and reviews on POP management of Online databases like Science Direct, SCOPUS, Google Scholar, and PubMed were used to access the literature. "Nurse," "Midwife," "Knowledge," "Assessment," "Management," "Challenge," Postoperative pain," "Caesarean section," and "Mothers" are some of the key words used in the literature search. A review of three theories, including the Pain Transaction Model, which has been used in the study to give a theoretical framework, is presented in the first section of the chapter. The overview of pain follows this. In this chapter, a review of prior research on POP knowledge, POP assessment and management, and issues related to POP assessment and management are also included. 2.1 Theoretical review 2.1.1 Gate Control Theory The Gate Control Theory presents a unifying explanation for the interplay between the physiological, anatomical, and psychological factors that contribute to the occurrence of pain (Asmundson & Wright 2004). It once more gives a rationale for the fencing principle, which serves as a gate in the dorsal horn of the spinal cord. When it senses a signal, this gate either closes or maintains the upward transmission of painful feeling from various areas of the body to the brain Melzack (2000). At the same time, this hypothesis recognizes that brain impulses may be impacted by emotions and mental processes, which may lessen or obstruct the perception of pain being delivered from the spinal cord (Hadjistavropoulos et al., 2009). University of Ghana http://ugspace.ug.edu.gh 9 On the other hand, a person's interpretation and experience of pain can be greatly influenced by a variety of factors, including culture, emotional state, and the surroundings (Asmundson & Wright, 2004; Hadjistavropoulos et al., 2009). Stronger impulses may be able to open the gate that prevents the uncomfortable sensation from being perceived as pain, which is the fencing system. This can only happen if the system is already compromised (Melzack, 1996). The following is an outline of the actual steps involved in the transmission of pain according to the gate control theory: a painful stimulus that originates in the body's periphery is carried to the dorsal horn of the spinal cord by nerve fibres that move quickly along the A delta and slowly along the C. If the painful stimulus is of sufficient intensity or continues for an extended period of time, the pain will be transferred from the limbic system all the way up to the cerebral cortex. The sensation of pain is identified by the cerebral cortex, which then triggers the activation of the efferent neural pathway in order to produce an appropriate response to the pain (Ekanem, 2020). Emotion has a direct impact on the experience of pain. These include physical contact, focused attention, and emotional support, all of which have the capacity to either lessen or heighten the sensations of pain elicited by impulses sent from the brain (Good et al, 2009). This opens the door for various non-medication techniques that impact a person's psychological state to be effective in blocking pain perception. You may find these techniques here. Additionally, activating thick and quick A delta fibers with massage or other forms of touch can reduce the perception of pain (Bonica & Loeser 2001). Non-nociceptive input, such as massage and touch, which is transmitted by big, myelinated, thick, and fast A delta fibers, has the potential to prevent or lessen the perception of pain in circumstances like these. The degree of pain felt decreases when there is a higher ratio of extensive fiber activity to thin fiber activity at the inhibitory cell. (Garu, 2012). Although it has some practical implications, in the opinion of nurses, this theory is more likely to be used in the management of pain in patients. University of Ghana http://ugspace.ug.edu.gh 10 2.1.2 Self-Care Deficit Theory This is a general idea that nurses can utilize to create and validate nursing knowledge as well as teach and learn nursing, according to Orem (1995). The theory of self-care, the theory of self- care deficits, and the nursing system theory are the three interconnected theories that make up Orem's (1995) thesis. Self-care is the practise of self-initiated and self-performed activities for the purpose of maintaining life, health, and well-being (Orem, 1995). Self-ultimate care's objective is for the patient to administer his or her own healthcare. If this is not possible, the patient and the nursing staff can work together to meet the patient's needs. Since pain is subjective, it is optimal for the patient to assume responsibility for pain management, which is consistent with Orem's (1996) theory of self-care. If this is not feasible, a deficit in self-care is created. The second argument put forth by Orem (1995) centres on the idea of a deficit in self-care. According to Orem (1995), a self-care deficit is a relationship between the therapeutic self-care demand of human properties and a self-care agency in which the agency's developed self-care capabilities are insufficient or inoperable for identifying and addressing some or all of the components of the current or projected therapeutic self-care demand. Orem (1995) uses the word "agency" to describe intelligence or skill. This theory's main tenet is that people can occasionally be prevented from taking care of themselves because of restrictions (Hartweg, 1991). Patients who have extreme acute or chronic pain may experience this. A person becomes a patient and a recipient of nursing care when their ability to take care of themselves is outstripped by their inadequacies in that area (Orem, 1995). Professionals in healthcare should step in at this point. In this circumstance, nurses must be equipped with the knowledge and abilities required to recognize, access, and take action to address patient care University of Ghana http://ugspace.ug.edu.gh 11 shortcomings. Because of this, nurses who work with patients who are in pain need to be familiar with pain and how to manage it (Orem, 1995). The third theory in Orem's (1995) nursing self-care deficit theory is the theory of nursing systems. Both the structure and the substance of nursing practice are determined by this paradigm. This idea explains the connection between patient actions and roles and nursing actions and roles (Hartweg, 1991). According to Orem (1995), nursing systems are a collection of deliberate nursing practices that nurses perform, sometimes in concert with those of their patients, in order to understand and meet the therapeutic self-care needs of those patients as well as to safeguard and control the development or exercise of their patient-centred autonomy. The nursing system theory's concept of nursing agency is a key element. According to Orem (1995), nursing agency refers to the developed abilities of nurses that allow them to represent themselves as nurses and act, know, and assist patients in meeting their self-care needs and controlling the development or exercise of their self-care agency within the context of a legitimate interpersonal relationship (Orem, 1995). Orem (1995) asserts that this theory accurately captures nursing's overarching goal, which is to make up for patients' health-related constraints. She views nursing agency as a force that is developed through specialised education and clinical nursing practise experiences. In this portion of Orem's (1995) theory, the problem of inadequate pain control due to the nurse's lack of knowledge and attitude exists. Orem (1995) emphasises that nursing agency is a developed force. Learning continues after graduation. To remain a competent nurse and to have true "nursing agency," nurses must continue to learn throughout their entire career. Therefore, if a nurse is identified as having a knowledge deficiency, such as an inadequate understanding of pain management, that nurse must take corrective action. According to Orem (1995), knowledge is essential for providing care, responsibility, and respect. Therefore, proper nursing care cannot be provided without knowledge. University of Ghana http://ugspace.ug.edu.gh 12 Orem (1995) also elaborated on additional nursing personal factors, which she defined as factors that are unique to each nurse and crucial to the delivery of care. Age, gender, race, culture, and maturity are examples. In addition to education and experience, personal factors contribute to a nurse's knowledge base and attitude. In the context of caring for a client with pain, these personal factors influence the knowledge and attitudes of an individual nurse regarding pain management. When nurses have a greater understanding of pain and its management, they are more likely to aggressively treat it (Orem, 1995). This, in turn, results in adequate pain management for the patient and, hopefully, an improved sense of well-being. Orem (1995) defines well-being as a state characterised by feelings of contentment, pleasure, and various forms of happiness; by spiritual experiences; by the pursuit of one's self-ideal; and by ongoing personalization. As a result, Orem (1995) emphasises that well-being is attainable even under adverse conditions like illness. Baar (2000) utilised this theory to investigate the knowledge and attitudes of advanced practise nurses regarding pain and pain management. Consequently, this theory may be applicable to study the knowledge and attitude of nurses regarding pain management but not their perspectives in the management of post-operative pain after CS. 2.1.3 Pain Transaction Model The most suitable model for the investigation was determined to be the Pain Transaction Model (PTM). Critically ill patients frequently experience pain, which makes it one of the most difficult clinical issues for nurses and midwives to handle. Therefore, acknowledging it is equally essential (Bloor, 2012). The PTM framework acknowledges that elements related to both the nurse and the patient have an impact on interpersonal communication between the nurse and the patient. These variables include the knowledge and attitudes of the nurse as well as the pain behaviors and coping techniques of the patients (Keen et al., 2017). These variables also have an impact on the evaluation, treatment, and post-treatment management of pain. The linkage University of Ghana http://ugspace.ug.edu.gh 13 between the PTM components is shown in Figure 2.1, which was taken from Keen et al. (2017), to help comprehend the clinical association between pain evaluation, therapy, and management. Figure 1: Pain Transaction Model Source: Keen et al. (2017) Rationalists contend that knowledge is the product of a reasoning process in which our sensory experience has no bearing. Contrarily, empiricists view knowledge as something that is produced by our senses' interaction with the real world and then refined by our brains (Bolisani & Bratianu, 2018). Another empiricist, Locke (1841), defended the empiric method by highlighting the fact that things exist in the real world and that human sensory perception is the primary source of knowledge. Some scholars, such as Dombrowski, Rotenberg, and Bick (2014), explained that there are three categories of knowledge: (a) experiential knowledge, (b) skills, and (c) knowledge claim, each of which has unique qualities despite being interconnected. The term "skills" refers to the knowledge gained from knowing how to do something. Though it is founded on experiential knowledge, it also includes well-planned and action-oriented knowledge derived from repeatedly performing a specific task and learning by doing it. This knowledge is commonly referred to as University of Ghana http://ugspace.ug.edu.gh 14 procedural knowledge because it is primarily concerned with task performance following a predetermined course or protocol (Bolisani & Bratianu, 2018). The behavior and coping mechanisms of the patient are another component of the Pain Transaction Model. Different attitudes and levels of expertise among nurses towards postoperative pain management in various clinical settings have been linked to several particular patient demographic features (Kiekkas et al., 2015). For instance, even though their pain is relatively intense, some patients' drug-induced pain is significantly influenced by their beliefs, which has an impact on overall therapy (Muntlin Athlin, Carlsson, & Gunningberg, 2015). A similar result was demonstrated by Fry et al. (2012) that the ability of a patient to maintain a steady-state balance under all conditions is examined as a trait of stability since it can affect the patient's response to therapy and lower mortality. On the other hand, high-quality nursing care and the right nursing interventions might affect patients' stability (Swickard, Swickard, Reimer, Lindell, & Winkelman, 2014). Nurses are crucial in not only delivering individualized, comprehensive care but also in providing treatment alternatives after a pain evaluation and making sure that treatment methods are continuously revised. Only a nurse with the required level of knowledge and a positive outlook on pain evaluation would be able to achieve this (McIlfatrick, 2015). Another pillar of the PTM framework is nurses' perspectives on pain evaluation and management. According to Chaikin (2010), attitude is a grouping of feelings, thoughts, and actions that are focused on a certain person, thing, or outcome. In many cases, attitudes are the product of experiences or upbringing, and they can have a significant impact on behavior. Although attitudes are enduring, they are also malleable. A subjective judgment of a person's attitude, which can be favorable or bad, is also based on an analysis of how they behave (Ajzen, 1991). University of Ghana http://ugspace.ug.edu.gh 15 Affective, cognitive, and behavioral factors all contribute significantly to attitude. One's sentiments and impressions towards a particular object or event are included in the affective portion of an attitude. Regarding locations, people, or objects, one's thought processes are the focus of the cognitive aspect of attitude. This element also reflects a person's opinions or beliefs regarding a particular subject. The way a person typically acts or is likely to act toward something or someone is referred to as their behavioral attitude, which is the third element of attitude (Kreitner & Kinicki, 2010). According to recent study, our intentions and behavior can both be predicted by how we feel or think about whether or not to engage in a behavior (Richetin, Conner, & Perugini, 2011). A crucial aspect of nursing practice is the interaction between the nurse and the patient (D'antonio, Beeber, Sills, & Naegle, 2014). Because they persuade the patient to take part in activities that ensure a safe recovery and total comfort, the nurse's interpersonal contact skills are crucial (Peplau, 1997). Patient-centeredness, therapeutic listening, and rapid attention to patients' needs and emotions were all emphasized in a recent review of the literature on healing relationships in critical care settings (Kornhaber, Walsh, Duff, & Walker, 2016). Nursing professionals believe their relationships with patients are important and meaningful, but they are nonetheless concerned since time and opportunity have become obstacles they must overcome (Cleary, Hunt, Horsfall, & Deacon, 2012; Humble & Cross, 2010). Palliative care, intervention-based research, pain evaluation and management, evidence-based practice, and patient education are some of the criteria used to measure nurses' performance (Vallerand, Musto, & Polomano, 2011). To increase the standard of pain care, nurses must fulfill their duties to assess and treat patients' pain (Herr, 2011). Regardless of the hospital setting, patients' satisfaction with the caliber of pain care is viewed as a definite sign that pain assessment and management have been appropriate (Larsen et al., 2010; Topolovec-Vranic et al., 2010). University of Ghana http://ugspace.ug.edu.gh 16 The PTM blends the knowledge and attitude of the nurses with the patient's methods of pain management to produce a singular collective transaction. Nurses are strategically positioned to give patients access to their treatment plan and to other resources that can help with pain reduction as much as feasible. To establish a collaborative connection with the patient and an effective care plan, a nurse's expertise and positive outlook on pain evaluation and treatment are essential (Keen, Embree, Lancaster & Bartlett Ellis, 2017). In general, better communication between the nurse and the patient can help with pain management (Youngcharoen & Park, 2017). As a result, the PTM is the best model for this investigation. 2.2 Justification for the use of Pain Transactional Model Three theories were reviewed to guide and expand on the theoretical understanding or the conceptual framework for this study. The Gate Control Theory and the Self Care Deficit Theory although contributed to explaining and providing in-depth understanding about the subject matter of pain, the constructs do not directly relate to the objectives of this study, thus, they only contribute to providing detailed understanding about the concept of pain but not in relation to the objectives of the study being conducted. However, the pain transactional model contains significant similarities between each construct and the objectives of this study. For instance; the constructs for nurse and patient factors related with the first objective of exploring nursing knowledge, attitude and interpersonal communication in POP assessment and management. The second construct of nurse skills also related with the second objective of perceived nurse/midwife skills in assessment and management of POP. In addition, the challenges associated with assessment and management of POP by nurses/midwives also correlated with the third construct of the pain transactional model which stipulates the outcome of pain management. University of Ghana http://ugspace.ug.edu.gh 17 Giving the similarities between the constructs of the pain transactional model and the objectives of this study, it was considered most appropriate to illuminate and broaden the theoretical understanding of pain assessment and management within the context of this study and among the study population. 2.3 Review of Related Studies 2.3.1 Knowledge of Nurses/Midwives Regarding POP Assessment and Management In a descriptive survey in the US, Loomis et al. (2022) assessed the perspective of 92 nurses on postpartum pain management. They discovered that 91.2% of the nurses had received training in general pain treatment. Again, the reported various means of training the nurses. These includes online (74.7%), followed by coursework completed for a degree (48.4%), and emails from leadership that focused on education (37.4%). Similar trends emerged for postpartum-specific pain management training, with online modules accounting for 56% of all training sessions. Sixty- five percent of all respondents said that their training had given them the information they needed for clinical practice. A majority (81.3%) of those who responded to a question about training specifically on opioid management said they have taken some kind of course on using opioids to treat pain. Online modules were the most popular method of training for opioid- specific general (49.5%) and postpartum pain management (38.5%). In addition, Loomis et al. (2022) discovered that nurses indicated a median patient pain score of 7 out of 10 as the level at which they would suggest an opioid for pain treatment. While just 5% of respondents felt the same way about vaginal birth, the majority (95%) said that opioid use is required for pain management in more than half of all patients after a cesarean birth. In Ethiopia, a total of 395 nurses, mostly from 22 to 29 years of age, successfully completed a questionnaire survey on nurses’ knowledge and attitude towards POP management (Dessie, Asichale, Belayneh, Enyew, & Hailekiros, 2019). Nurses’ knowledge on POP management was assessed using the (NKASRP) scale. The average POP management knowledge score of the University of Ghana http://ugspace.ug.edu.gh 18 nurses was 7.74 (SD=2.16). The majority of nurses (93.16%) scored a mean of 5 and 12, whereas only 2.03% of the nurses correctly answered all questions. More than a half (56.5%) of the nurses had adequate knowledge regarding postoperative pain management. The nurses knew that pain is exactly what the patient claims and that the onset, length, variability, location, and intensity of pain are all factors to consider while assessing pain. They knew that untreated POP makes it more difficult to recover, analgesia is a critical component of POP control and that analgesics for POP should be given on a set schedule around the clock at first. They also understood how to treat acute pain using the WHO pain ladder. They incorrectly said that the patient's primary nurse is the best assessor of the severity of the patient's pain and that vital signs are consistently accurate predictors of the severity of a patient's discomfort. Furthermore, they incorrectly stated that injectable opioid analgesic injection is the preferred method for treating abrupt onset, transient, acute pain like POP. In an Ethiopian study, Teshome, Aychew, Mitiku, & Guta (2022) examined the knowledge of nurses regarding POP. Through a systematic random sampling technique, 144 nurses were recruited to participate in the cross-sectional study that found an overall adequate knowledge (54.2%) among them regarding POP management. Similarly, a cross-sectional study was conducted by Wurjine & Nigussie (2018) among 144 nurses who were providing post-operative patient care at hospitals of Arsi zone, Southeast Ethiopia to determine their knowledge regarding POP management. Knowledge regarding POP management was adequate among the population as more than half of them (54.86%) had high scores on knowledge related items. Additionally, Menlah et al. used the Nurses Understanding and Attitudes Survey Regarding Pain (NKASRP) to gauge nurses' knowledge of postoperative pain and its management in University of Ghana http://ugspace.ug.edu.gh 19 Ghana (2018). 168 nurses took part in this descriptive cross-sectional survey that involved 4 district hospitals in Ghana. According to the findings, 48% of the nurses lacked sufficient expertise on POP management. Adams et al. (2020) used a modified version of the knowledge and attitude survey on pain questionnaire to evaluate the expertise of 211 nurses on POP management at the Tamale Teaching Hospital in a related study conducted in Ghana. They discovered that participants' percentages of correctly answered knowledge-related questions ranged from 19.9% to 92.9%. Between 25% and 82%, the total mean knowledge score was 59%. 20.9% of respondents had acceptable understanding of postoperative pain management, compared to 79.1% who had insufficient knowledge. The majority of nurses, or 76.8%, were unable to recognize that a patient might sleep through discomfort. The majority of nurses (58.8%) failed to recognize patients who can be distracted from pain but do not often experience severe pain. The majority of them (87.2%) were also unable to recognize that injecting sterile water into patients as a placebo was not a viable test to establish whether the pain was real. 2.3.2 Attitudes of nurses/midwives regarding POP management after CS Using the Nurses' Knowledge and Attitudes Survey Regarding Pain, Dessie et al. (2019) used a cross-sectional design to examine the attitudes of post-operative pain care among nurses working in Amhara regional referral hospitals in Ethiopia (NKASRP). The majority of nurses (8.9%) had a bad attitude. Similarly, nurses’ attitudes toward the management of POP at Hospitals of Arsi zone, Southeast Ethiopia were assessed by Habte Wurjine & Girma Nigussie (2018) among 144 nurses using a cross-sectional design. More than half of the nurses were found to have unfavorable attitudes toward POP. University of Ghana http://ugspace.ug.edu.gh 20 In another cross-sectional study conducted, Shakya & Shakya (2016) utilized a modified version of Nurses’ Knowledge and Attitude Survey Regarding Pain (NKASRP) in determining the attitudes of nurses toward POP in Nepal. Nurses had low scores regarding their attitudes toward POP management. Similarly, negative attitude was found among nurses in Greece, in a cross-sectional study conducted by Kiekkas et al. (2015) to determine attitudes of nurses regarding POP management. The outcome of the study indicates he knowledge deficits, negative attitudes of the nurses toward postoperative pain, inadequate knowledge on medication. However, increase workload as a barrier affecting nurses management of POP. The study recommends pre-graduate and continuing education, and appropriately specialized for the surgical unit. Also, Rasmi-Issa et al. (2017) conducted a study among the Intensive Care Unit (ICU) nurses’ working at King Saud Medical City (KSMC) in Saudi Arabia revealing poor attitudes among them towards POP and lack of knowledge on POP. Again, 60% of the respondent could not answer knowledge questions on POP. However, some studies revealed positive attitudes of nurses toward management of POP. For instance, Menlah et al. (2018) examined the attitudes of Ghanaian nurses working in four selected district hospitals and found an overall positive attitude among them. Inadequate knowledge on POP among 48% of the respondents, non-use of pharmacological pain intervention method was reported by the researchers 2.3.3 Interpersonal Communication in POP management The importance of effective communication in the assessment and management of POP cannot be understated, as it provides numerous benefits to the patients emotionally, psychological and physically. Thus, through effective communication between the nurse and patient, patients’ University of Ghana http://ugspace.ug.edu.gh 21 problems are identified, education provided to them and they tend to benefit from other interventions that help in the relief of pain. Sugai, Deptula, Parsa, and Don Parsa (2013) conducted an experimental study to investigate how patient education and communication affect post-operative pain outcomes. A random sample of 69 patients who underwent surgery (experimental group) and were communicated with or given education, and 66 who also underwent the surgery but were not given education (control group) were sampled. Two weeks before the surgery, the patients in the experimental group were engaged in series of communications and educations regarding pain but the control group were not given. Post-operatively, it was found that about 90% of those in the experimental group did not receive hydrocodone analgesia after being educated while 10% of the control group required hydrocodone analgesia. Vacek, Wiggins, & Struwe (2021) also demonstrated the importance of communication in the management of POP through their study which sought to describe healthcare providers’ pain education to patients through a qualitative-descriptive study. Among a convenient sample of 206 healthcare providers, it was found that immediate POP management education was a priority although timing of education and communication barriers between healthcare providers and patients were also identified. A systematic review by Reaza-Alarcón & Rodríguez-Martín (2019) summarized the importance of nursing educational interventions in the management of POP among surgical patients. Their literature search found 12 studies, among which 9 studies reported lower pain among the group of surgical patients who received educational interventions. 2.3.4 Assessment of Postoperative Pain Ismail et al. (2012), in their cross-sectional study in Pakistan, investigated pain assessment among 263 women who have had elective caesarean section under general anesthesia (42%) and University of Ghana http://ugspace.ug.edu.gh 22 minor anesthesia (57%). In Pakistan, 263 women underwent elective cesarean sections; their analysis of the overall pain score since the time of surgery using the Visual Analogue Scale (VAS) revealed that mild pain (VAS 0-3) was experienced at rest by 89.7% of patients, moderate pain (VAS 4-6) by 9.5%, and severe pain (VAS 7-10) by 0.8% of patients. 60.1% of patients had mild pain, 33.1% had moderate pain, and 6.8% had severe pain when they moved. The majority of patients (91.6%) said their pain treatment was effective (Ismail et al., 2012). Kintu et al. (2019) evaluated the intensity of pain in 333 Ugandan women who had caesarean sections under spinal anesthesia 24 hours after birth. They discovered that 68% of individuals thought their pain was adequately controlled. At 0 hours and 6 hours following surgery, all subjects' data on pain evaluation scores were complete. However, only 301 patients had data on pain assessment available 24 hours following surgery. Participants on pethidine had statistically significantly lower pain scores than those on tramadol (Z = 3.13, p = 0.01), those who did not receive analgesics (Z = 2.78, p = 0.04), and those who received multiple types of analgesics had lower pain scores than those who received tramadol (Z = 2.9, p = 0.028) after administering prescribed analgesics. For the intervals from right after surgery to six and twenty-four hours later, there was no statistically significant difference in the median pain assessment scores between the rest of the treatment group pairs (Kintu et al., 2019) In addition, during the time period under consideration, South Africa solely employed the Verbal Rating Scale (VRS) to evaluate pain. 13 of the 55 patients whose pain was evaluated on the day of surgery had their pain measured again after receiving analgesia, representing a follow-up rate of the response to pain management of just 24%. 64% of patients had their pain evaluated on day 2 and then had it evaluated again after receiving analgesia. After receiving analgesia on day 3, 43% of patients had their pain assessed again. This was from a descriptive, retrospective, cross- sectional audit of folders of 300 women who had undergone caesarean section in a regional University of Ghana http://ugspace.ug.edu.gh 23 hospital in Cape Town, South Africa (Munsaka, van Dyk, & Parker, 2021). In this study, most of the women (93.3%) had CS through spinal anaethesia. 2.3.5 Management of POP For the management of pain, there are both pharmaceutical and non-pharmacological methods available. Studies on both interventional approaches have been reviewed. With emphasis on non- pharmacological pain interventions, Belay & Yirdaw (2022) hospital-based cross-sectional study was conducted in South Wollo Zone governmental hospitals, Northeast Ethiopia, to assess the POP management strategies adopted by health professionals. Findings revealed that, aside from pharmacological approaches, health workers utilized non-pharmacological measures including application of cold and heat immobilization, massage, acupuncture, and hypnosis. Also, a cross-sectional study by Kia, Allahbakhshian, Ilkhani, Nasiri, & Allahbakhshian (2021) was conducted among 224 conveniently sampled nurses working in ten university-affiliated hospitals in Northern Iran to explore their perspectives on the non-pharmacological pain managements they adopt. Non-pharmacological managements used by nurses include: repositioning, providing serene and comfortable environment, use of assistive devices, acupuncture, acupressure, and reflexology. Similarly, Bayoumi, Khonji, & Gabr (2021) conducted a cross-sectional study to explore perceptions on the non-pharmacological management of pain among 47 nurses who were conveniently sampled in the surgical wards in El-Mansura University Hospital, Egypt. Nurses mostly utilized non-pharmacological pain management interventions such as provision of emotional support, comfortable environment, physical methods (thermal regulation, massage, positioning) and, cognitive methods (distraction, relaxation, positive reinforcement and breathing technique). University of Ghana http://ugspace.ug.edu.gh 24 Using an explorative descriptive qualitative approach, Konlan, Afaya, Mensah, Suuk, & Kombat, (2021) explored the use of non-pharmacological intervention in managing labour pain among nurses and midwives in Adidome Government Hospital in Ghana. The following non- pharmacological pain interventions were utilized in managing labour: encouraging deep breathing, diversion therapy, reassurance, and change of positions. In a narrative review, Sangkum et al. (2021) posited that the primary principle of caesarean birth and pain management is multimodal analgesia. Long-acting neuraxial opioids (such as morphine) and adjunct pharmaceuticals like scheduled acetaminophen and nonsteroidal anti- inflammatory drugs are advised for a traditional analgesic regimen unless they are contraindicated. Opioids, whether taken orally or intravenously, should only be used for severe pain. The most important criteria influencing the nursing decision about the kind and dosage of pain medication in the US were the patient-reported pain score (87%), routine habit (71.7%), and patient preference (70.7%). Fear of patient discontent and worry about opioid abuse had less of an impact on nurses (14.1% and 30.4%, respectively). The nurses stated that when it comes to pain relief options, they always suggest ibuprofen, perineal cold packs, and acetaminophen. They occasionally suggested painkillers, but infrequently massage, Lidoderm patches, and never aromatherapy (Loomis et al., 2022). In Pakistan, 263 women who had elective caesarean section; 111 (42%) under general anesthesia and 152 (57%) under spinal anesthesia were assessed in an observational study for POP management (Ismail et al., 2012). Continuous intravenous opioid infusion was used for POP management in 94% of patients. The obstetrician changed the opioid infusion dose for the following 24 hours at a rate of 10 mg/h for pethidine and tramadol and 1 mg/h for morphine. Following surgery, the obstetric team monitored these patients and managed their insufficient University of Ghana http://ugspace.ug.edu.gh 25 pain medication. 6% of patients chose patient-controlled intravenous analgesia (PCIA). Pethidine was administered to all patients in the PCIA form, with settings chosen by an anesthetist. Acute pain service (AMPS) monitored all PCIA patients for a full day. Additionally, 99% of patients received monthly prescriptions for co-analgesia. Kintu et al. evaluated a prospective study of POP management in 333 Ugandan women who underwent spinal anesthesia for cesarean sections (2019). They discovered that 95% of the subjects had analgesia prescribed by surgeons. A nurse did not prescribe any analgesic drugs. Only 42% of the subjects took their analgesics exactly as directed. The median amount of time among all individuals to receive their first analgesic after leaving the operating room was 241 minutes. According to Kintu et al. (2019), 44% of patients received only one type of analgesic medication in the first 24 hours following surgery, 14% received numerous medications, and 42% received none. Tramadol, then pethidine, was the analgesic most frequently recommended, followed by intramuscular diclofenac. No patient was given morphine intravenously or intramuscularly. In addition, Ogboli-Nwasor et al. (2012) published a study on the management of POP among adult surgical patients in Nigeria with the goal of identifying the typical analgesics utilized in practice and the pattern of prescription in adult postoperative patients. According to the study's findings, 132 patients, or 95.7% of the respondents, had post-operative analgesics recommended by surgeons or surgical residents. Only six patients—representing 4.3%—had their post- operative analgesics suggested by the anesthetist, who acted only in a passive manner. Nine (9) patients (6.5%) received intramuscular injections of non-steroidal anti- inflammatory medicines, and one hundred and twenty-six (126) patients (91.3%) of the responders received intermittent intramuscular injections of opiates. Six patients (4.3%) received oral paracetamol prescriptions, while three patients received no postoperative analgesics. Eight hours following their surgeries, University of Ghana http://ugspace.ug.edu.gh 26 before receiving additional doses of analgesics, 34.5% of the patients who received this pattern of analgesic prescription experienced moderate pain, and 65.2% reported mild discomfort. The study came to the conclusion that despite recent advancements and development of more effective pain management techniques for POP control, a significant number of patients continue to experience POP of moderate to severe intensity with the above pattern of post-operative analgesics prescription. Again, in a tertiary care hospital, Kumarasingam et al. (2014) did a study on the pattern of analgesic usage among post-operative patients. For the study, patients who underwent general surgery, obstetrics and gynecology, and orthopaedic surgery were employed. The study's findings showed that 53% of patients were given monotherapy on the day of surgery, with diclofenac (60%) being the most frequently prescribed medication, followed by tramadol (37%) and pentazocine (3%). For their POP, 45% of the patients received a combination of analgesics. Out of this, 56% received a combination of tramadol and diclofenac, 24% received diclofenac and pentazocine, and the least amount (20%) received tramadol and pentazocine. Only 2% of the respondents had tri-drug therapy (diclofenac, tramadol, and pentazocine) prescribed to them. The most popular method of administering these medications was intramuscularly. The study suggested that non-opiates analgesics like diclofenac and opiates analogues might be added to patients' medications to provide pain relief when non-opiates were ineffective. It was discovered that the choice of the doctor and the type of surgery affected how analgesics were used. Munsaka et al. (2021) in their study in South Africa found that analgesia was prescribed for over 98% of the women who had undergone caesarean section. However, 32.6% of the patients had pain medication administered as prescribed on the first day and 37% on the second day. Oral paracetamol and morphine were prescribed in 99.7% and 82.0% of cases respectively. Minimal use of oral Nonsteroidal Anti-inflammatory Drugs (NSAIDs) was evidenced by low prescription rates throughout (4.0% – 5.0%). None of the patients received either patient- University of Ghana http://ugspace.ug.edu.gh 27 controlled analgesia (PCA) or Transversus Abdominis Plane (TAP) block, while only one patient received a wound infusion catheter (with local anaesthetic) as supplementary strategies. Menlah et al. (2018) observed that the vast majority (97.6%) of the nurses reported that they offered a clean, peaceful, and well-ventilated ward environment postoperatively at four district hospitals in Ghana. Encouragement of early ambulation/exercise with analgesia was another extremely successful intervention the nurses implemented. Here, up to 97.0% of respondents said they have utilized this measure. Approximately 73% and 25.6% of the respondents said they typically strengthened, wrapped, splinted, and dressed wound sites after surgery. These actions are among the standard POP therapies used by nurses worldwide, with the majority being chosen by nurses. 2.3.6 Challenges with assessment and management of POP Due to various new rules and advancements in POP management approaches over the past 20 years, there has been an increased focus on improving POP management. Despite these advancements, POP is frequently inadequate and may put patients at risk for developing chronic pain disorders (Guillemot-Legris et al., 2018). Over the past 20 years, the prevalence of moderate to severe POP has been persistently high, affecting 20–80% of postoperative patients (Gan, 2017; Capdevila et al., 2017). Despite a sizable amount of research and therapeutic recommendations, POP management still confronts a number of challenges (Cooney, 2016). The complexity of pathophysiological mechanisms, the overlap and diversity of pain pathways, and the frequent incidence of negative side effects are some of these barriers to the creation of therapeutic drugs (Borsook, 2017). According to Drzycka-Dbrowska et al. (2016), inadequate pain management affects 80% of the world's population and is a major issue in more than 150 nations. According to Drzycka-Dbrowska et al. (2016), certain vulnerable populations are more susceptible to poor pain management than others, including the elderly, pregnant and breastfeeding women, children, persons who abuse drugs or alcohol, and people who are mentally ill. University of Ghana http://ugspace.ug.edu.gh 28 According to Bishop et al. (2019), post-caesarean discomfort is a significant but often overlooked complication. It causes pain, interferes with breastfeeding, and is linked to postpartum depression and the onset of chronic pain syndromes. Significantly in resource-rich circumstances, pain control is difficult; it is likely to be even more difficult in resource-limited settings, when the focus is on lowering the high maternal mortality rate. In resource- constrained areas, the lack of proper staffing, education, and postoperative monitoring severely limits the alternatives. Limited access to critical analgesic medications and equipment for their administration exacerbates the problem in resource-constrained situations. Consequently, Francis and Fitzpatrick (2013) advocated the need for nurses to gain more knowledge on pain management since they found that nurses had poor knowledge on pain assessment and management practices. Ismail et al. (2012) discovered that 9% of the women in their study who had caesarean sections in Pakistan complained of various problems. 0.8% of the patients had backaches, 1.5% had headaches, 2.3% had nausea and vomiting, and 0.4% had drowsiness. The remainder (4.2%) cited other difficulties. All of these issues, though minor, were successfully treated, and they didn't cause any delays or require readmission after release. In four district hospitals in Ghana, nurses responded minimally to not at all to interventions such as music therapy, frequent administration of the painkiller pethidine, promoting use of transcutaneous electrical nerve stimulators, and the use of acupuncture. This was related to the lack of several essential tools and medications needed to carry out specific POP control strategies (Menlah et al., 2018). Additionally, Adams et al. (2020) discovered that the majority of the nurses in Ghana who participated in their study (61.6%) had never undergone POP management training. University of Ghana http://ugspace.ug.edu.gh 29 Existing literature reveals several hindrances (such as system-related, staff-related, nurse- related, physician-related, and patient-related) that have been identified to hinder health care professionals from achieving optimal pain management (Mędrzycka-Dąbrowska et al., 2016). System-related hindrances include a lack of clearly defined standards and pain management protocols and limited access to pain specialists and analgesics (Shoqirat et al., 2019; Mędrzycka- Dąbrowska et al., 2016). Staff-related hindrances include inadequate knowledge and skills, and a lack of teamwork (Shoqirat et al., 2019; Mędrzycka-Dąbrowska et al., 2016). Lack of knowledge and false concerns about addiction and overdosing are examples of physician-related barriers (Shoqirat et al., 2019; Mędrzycka-Dąbrowska et al., 2016). Nurse- related hindrances include inadequate knowledge, heavy workload, and lack of time (Shoqirat et al., 2019; Mędrzycka-Dąbrowska et al., 2016). Reluctance to take analgesics, fear of side effects, and fear of addiction are examples of patient-related factors (Shoqirat et al., 2019; Mędrzycka- Dąbrowska et al., 2016). 2.4 Summary The purpose of this study is to explore POP management by nurses and midwives. Results from the review of studies on pain point to a clear lack of education in pain evaluation and management. There are certain obvious obstacles preventing POP management interventions and indicating the need for greater training in POP pain management. Although studies on POP pain management abound, there is paucity of studies on management of POP in women after caesarean section and the challenges associated with it. The outcome of the literature indicates that experiences is a universal experience associated with surgical procedure. As a result, nurses knowledge and attitude is very crucial. Again, literature was reviewed from resources constraint countries and advanced countries. This study will fill in this gap. University of Ghana http://ugspace.ug.edu.gh 30 CHAPTER THREE METHODOLOGY This chapter introduces the methods of data collection and analysis that was used in this research. The chapter also explores why the chosen framework is suitable for the study. Specifically, this chapter presents the research design, the study population, sampling technique and sample size selection, the inclusion and exclusion criteria, the procedure for data collection and strategies adopted in the analysis of the data. The chapter also addresses methodological rigour and pertinent ethical issues pertaining to qualitative research. 3.1 Research Design This study employed the exploratory-descriptive qualitative research design to assess the phenomenon under study. The philosophical underpinning of this research is interpretivism. According to an interpretivist viewpoint, social worlds cannot be examined in the same way that physical phenomena can since complexity must be considered (Saunders, Lewis, & Thornhill, 2016). The goal of interpretivist research is to develop new and more complex perspectives on the world we live in. With interpretivism, the starting point for the development of knowledge is the interpretation of reality (Duberley, Johnson, & Cassell, 2012). This research falls under the paradigm of qualitative research as it uses words as data and utilizes a meaning-based form of data analysis (Braun & Clarke, 2013). According to Creswell (2013), qualitative research intends to provide a complex and detailed understanding of a phenomena, which can only be identified by talking directly with people and allowing them to share their lived experiences. Mack et al. (2005) also suggest that qualitative research is a type of scientific research and, in general terms, consists of an investigation that seeks answers to a question, systematically uses a pre-defined set of procedures to answer the question, collects evidence, produces findings that University of Ghana http://ugspace.ug.edu.gh 31 were not determined in advance, and that are applicable beyond the immediate boundaries of the study. The strength of a qualitative research lies in the opportunity to provide complex textual descriptions of how people experience a given research issue (Mack, Woodsong, MacQueen, Guest, & Namey, 2005). Rather than offering observations and explanations regarding the phenomena under inquiry, exploratory qualitative studies entail a thorough examination of the phenomenon. This gives a more comprehensive explanation and comprehension of the phenomenon of interest (Polit & Beck, 2010). The exploratory method to qualitative research has several advantages, including the flexibility of data sources, such as the use of interviews and conversations, as well as a focus on understanding a topic under study rather than drawing firm conclusions. The descriptive research approach aids the researcher in obtaining an objective and accurate description of the phenomenon being investigated (Polit & Beck, 2018). It gives a broad picture of the notion and how particular phenomena occur, making it easier to describe and deliver information. However, it is important to acknowledge and accept that researcher’s values and experience inevitably influence data interpretation. Therefore, good qualitative research is committed to using critical reflection on how the research process may have been affected and the data that it produced (Morrow, 2005). Moreover, given the usually small sample size and absence of statistical analyses, qualitative research is not generalizable and it is important for the researcher not to imply that the findings can be generalized to other population or setting (Morrow, 2005). 3.2 Research Setting The study was conducted at the Obstetrics and Gynaecological Department of the Greater Accra Regional Hospital (Ridge Hospital) in the Greater Accra Region of Ghana. The Greater Accra Regional Hospital is one of the largest hospitals in Ghana and also serves as one of the main referral centres for other health facilities in the South-Eastern part of Greater Accra. University of Ghana http://ugspace.ug.edu.gh 32 The Greater Accra Regional Hospital (GARH) is situated at North Ridge in the Osu-Klottey Sub- Metro of the Accra Metropolitan Area in the Greater Accra Region (GAR) of Ghana. It occupies a total land area of about 15.65 acres. As the Regional Hospital for Greater Accra, its catchment area is the whole of the region with an estimated population of over 5,455,692 (based on 2021 population and housing census by the Ghana Statistical Service) The GARH started as a Hospital for the European expatriates around 1928. It became a District Hospital after Ghana’s independence in 1957 and was later designated as Regional Hospital in 1997. The hospital is now redeveloped and transformed into an ultra-modern 420 bed capacity hospital with the full complement of specialist services that reflects the current social aspirations of the rapidly growing capital city of Ghana. The hospital has departments which include internal medicine, general surgery, paediatrics, theatre, obstetrics and gynaecological care as well as accident and emergency services among others. Its specialized clinics and units include neurosurgery services, spine health service, ophthalmology, services, dental services, maxillofacial service. Supporting services include medical laboratory, blood bank, radiology, ultrasound scan, pharmacy and physiotherapy. The Obstetrics and Gynaecological department is one of the clinical departments and it provides free antenatal care services, childbirth and postpartum services and child health services. It is equipped with state of the art and modern health care delivery services such as ECG, CT scan, MRI, and carry out major surgical procedures. All deliveries are attended by registered nurses, midwives and doctors. University of Ghana http://ugspace.ug.edu.gh 33 Figure 2: Map of Greater Accra Region, showing the location of Greater Accra Regional Hospital, Ridge and its surrounding environs. 3.3 Study Population The target population is referred to as the general aggregate of people or subjects with certain properties that are of particular interest to the investigator and for the research (Nieswiadomy, 2008). The population for the study is professional nurses and midwives at the Greater Accra Regional Hospital. 3.4 Inclusion Criteria 1. Registered nurses and midwives working at the obstetrics and gynecological department of the Greater Accra Regional Hospital. 2. Registered nurses and midwives with at least two-year work experience at the obstetrics and gynecological department of the Greater Accra Regional Hospital. Greater Accra Regional Hospital University of Ghana http://ugspace.ug.edu.gh 34 3. Registered nurses and midwives who have been involved in post-operative assessment and management of women who have undergone caesarean section. 3.5 Exclusion Criteria 1. Registered nurses and midwives at the obstetrics and gynecological department of the Greater Accra Regional Hospital who are sick or on study leave at the time of the study. 2. Registered nurses and midwives at the Obstetric and gynecological department of GARH who declined participation. 3. Nurses and midwives with less than two years’ experience at the obstetric and gynecological department of the Greater Accra Regional Hospital. 3.6 Sample size The decision on sample size was based on several factors. According to Kish (1965), one factor that affects the decision of sample size is the homogeneity of the population. In this research, nurses and midwives in the Greater Accra Regional Hospital are homogeneous in that they offer very similar services and have little distinguishing characteristics. Again, since the data collected was more qualitative in nature, a smaller sample size was reasonable. Qualitative researchers are concerned with cases that can afford clarity and deeper understanding (Neuman, 2006). According to Patton (2002) there are no rules for sample size in qualitative research. Morse (2000) also suggests that the more useful data are collected from each person, the fewer participants are needed in qualitative research. A total of 16 nurses and midwives were selected as the sample to represent the target population for the study. This number was determined at the point of saturation, where no new data could be extracted from participants. The concept of data saturation is considered as important in qualitative research because it addresses whether a study is based on an adequate sample to demonstrate content validity (Francis et al., 2010). University of Ghana http://ugspace.ug.edu.gh 35 3.7 Sampling Technique The sampling technique is a means to determine how a sample is identified and recruited and the number of subjects involved in the sample (Polit & Beck, 2012). This study employed the purposive sampling technique to recruit participants for the study. The purposive sampling technique is a form of non-probability sampling technique defined by Parahoo (2014) as a method of sampling in which participants are actively picked by the researcher based on their (participants') ability to contribute relevant information for the study being undertaken. This sampling technique was applied by collaborating with the nurse or midwifery managers in charge of the Obstetrics and Gynaecological department to help identity the nurses and midwives who met the criteria for inclusion into the study. This was done by identifying and selecting on purpose only registered nurses and midwives at the Obstetrics and Gynaecological department of the Greater Accra Regional Hospital who have at least 2 years work experience and have been involved in post-operative management of women who have undergone caesarean section. Only those who agreed to take part in the study were recruited for the study. This recruitment was done until the required number was achieved. 3.8 Tool for Data Collection A semi-structured interview guide was developed and used to collect data for the study. The semi-structured interview guide helped to conduct in-depth face-to-face interviews with participants. This is a tool in which open and direct questions are used to elicit detailed narratives and stories (DiCicco-Bloom & Crabtree, 2006). It is very flexible and provides the interviewees the opportunity to freely express themselves and provide in-depth information concerning their experiences of the phenomenon under study. Furthermore, it allows the researcher the opportunity to seek clarifications through follow up questions (Kusi, 2012). The semi-structured interview guide was developed in accordance with the objectives of the study and in relation to the constructs of the model being adopted for the study. Therefore, the University of Ghana http://ugspace.ug.edu.gh 36 researcher prepared a list of indicative questions around what participants experienced in terms of the phenomenon under study. In developing the interview guide for the study, the researcher carefully drafted, edited and polished the interview questions and guide based on the objectives of the study and review of the extant literature. The interview guide was structured into two sections. The first section (section A) covered demographic characteristics of respondents such as age, sex, profession (nurse or midwife), unit or ward, religious affiliation, highest educational level. The questions in section B comprised open-ended questions to elicit data from the participants in regard to nurse/midwife related factors, perceived skills in POP assessment and challenges with assessment and management of POP of women who have had caesarean section. The researcher probed further with follow up questions such as “could you describe more about that”? “Could you give me an example”? “What does that mean to you”? to better understand how nurses and midwives manage POP of women who have undergone caesarean section and the challenges they face with assessment and management of their POP. The interview guide was refined after pretesting on a total of 5 nurses and midwives at the 37 Military Hospital. 3.9 Data Collection Procedure Prior to commencement of data collection, ethics clearance was obtained from the Ghana Health Service Ethics Review Committee and permission sought from management of the Greater Accra Regional Hospital to conduct the interviews. Face-to-face in-depth interviews were conducted using the semi-structured interview guide. According to Braun and Clarke (2013), interviews are the most utilized method for collecting qualitative data, as interviews are well suited for experience-type questions such as the one presented in the current study. Seidman (2013) also suggested that when people tell stories, they select details of their experience from their stream of consciousness. Hence, the interview is a technique designed to elicit a vivid picture of the participant’s perspective on the research topic. University of Ghana http://ugspace.ug.edu.gh 37 The participants were identified at the obstetric and gynecological department while providing care. The participants information sheet containing the purpose and nature of the study was given to them. Again, the nature of the study was further explained to them. Those who agreed to participate in the study were made to signs a consent form and an appointment booked. The interviews were conducted at a venue and time of choice of the participants. The interviews were conducted in a private, and noise free environment where participant could easily express themselves. The researcher ensured that the venue where data was being collected was quiet and appropriate for the interview. Each interview lasted for a time period of 45 to 60 minutes and was audiotaped with the consent of the participants. The data collection process lasted for one (1) week. The interview started with general questions about the participant’s work before focusing on their knowledge and management of POP of women after caesarean section and the challenges they face. The open-ended questions gave participants the opportunity to respond in their own words, rather than forcing them to choose from fixed responses (Mack et al., 2005). The interviews were conducted in English. Responses from participants were followed by probes to gain more understanding into the accounts of the participants. Follow-up questions helped elicit clarification from participants, where necessary. Field notes on observations made during each interview were also taken and added to the data during analysis to provide some more clarity. 3.10 Methodological rigour There are four measures or criterion for ensuring trustworthiness of qualitative research by Lincoln and Guba (1985) and they were applied in this study. These include principles of credibility, transferability, dependability and confirmability. • Credibility: The degree to which the findings are consistent with reality is referred to as credibility (Speziale & Carpenter, 2007). This was ensured through longer involvement University of Ghana http://ugspace.ug.edu.gh 38 with the topic matter and member checking, which involved returning the final report to the participants to determine if it accurately reflected their report (Creswell, 2015). • Transferability: The amount to which findings can be transferred to similar situations is referred to as transferability (Creswell, 2014). To ensure transferability, full descriptions were depicted exactly as the participants delivered them. This included enough contextual information on the fieldwork to allow readers to make this connection. The research setting, the calibre of people who participated in the study, and the methodologies used were all described in detail. • Dependability: The degree to which content judgments regarding similarities and differences are constant across time is referred to as dependability (Graneheim & Lundman, 2004). The researcher generated extensive documentation of the study's processes to assure dependability. This includes (1) a description of the research strategy and how it was carried out; (2) a full explanation of the data collection procedure; and (3) a description of the field work. • Confirmability: Confirmability refers to the degree to which impartiality in qualitative research is assured without the researcher's prejudices (Kusi, 2012). Confirmability entails comparing the procedures and maintaining an audit trail. During the data analysis phase, data triangulation was done using a combination of field notes and interviews. 3.11 Data Management Hard copies of information collected including signed consent forms and hard copies of demographic data were kept safely in a file and kept under lock and key. Audio transcripts were also stored on a password protected computer and made accessible only to the researcher and supervisor. Codes were used in the stead of real names of the participants in the report of results University of Ghana http://ugspace.ug.edu.gh 39 from the study. All information forms of data collected for the study will be stored securely for a period of at least 5 years before they will be destroyed. 3.12 Data Analysis The study adopted the thematic analysis approach as postulated by Braun and Clarke (2006) to analyse the data collected. According to Braun and Clarke (2006), thematic analysis is a qualitative method for identifying, analysing and reporting patterns (themes) within data. It is a widely used method for recovering the theme or themes that are embodied and dramatized in the evolving meaning and imagery of work (Van Manen, 1997). In this study, thematic analysis helped in the identification and analysis of the themes that emerged from the data analysis. Data was transcribed verbatim and analysed concurrently after each interview. The thematic analysis involves a thorough and a rigorous data familiarization (transcripts) and then coding and recoding to identify the major themes and sub themes from the data collected (Braun & Clarke, 2006). The researcher followed the six phases of the thematic analysis as enumerated by Braun and Clarke (2006). These phases are familiarization with the data, generating initial codes, searching for themes, reviewing the themes, defining and naming themes and producing the report. In familiarizing with the data, the researcher took time to transcribe the interviews as recorded. The transcriptions helped the researcher to better understand the data collected. The transcription of the data helped to create a better meaning to the interviews to be conducted. The time spent on the transcription was very useful as it informed the patterns of the data set. The researcher then proceeded to use codes to organize the data in a meaningful manner as suggested by Braun and Clarke (2006). This involves using words or phrases to represent sentences or parts of transcribed data from the transcripts. The researcher after coding the data, grouped similar codes together to form sub-themes. Similar sub-themes were also grouped University of Ghana http://ugspace.ug.edu.gh 40 together to form themes that fell under the constructs of the pain transaction model adopted for the study. Essentially, the researcher began by analysing codes and considered how similar codes could be combined into potential themes. At the phase of reviewing the themes, the researcher checked and rechecked the themes identified for consistency. According to Braun and Clarke (2006), the next phase after reviewing the identified theme is to define and name themes. The researcher identified the aspect of the data each theme carries and also identified how each theme fits into the overall purpose of the study. Finally, the researcher produced a report from the findings of the study. The themes identified were integrated and the findings presented in chapter four of the study. Verbatim quotes were used to support the findings. 3.13 Ethical considerations The study was guided by the guidelines of the American Psychological Association (APA, 2002) ethical code for research that involves using humans as research participants. The principles per the APA (2002) standard include being conscious of multiple roles in the research process, following informed-consent rules, and respecting the confidentiality and privacy of the participants. Ethical approval for the study was sought from the Ghana Health Service Ethics Review Committee. Formal permission was also sought from the management of the Greater Accra Regional Hospital. This was done by sendi