This was a descriptive cross-sectional multi-centred study carried out in five different tertiary hospitals of Nepal located in four different provinces, out of which four were academic institutes namely Tribhuvan University Teaching Hospital, Manipal Teaching Hospital, Lumbini Medical College Teaching Hospital and BP Koirala Institute of Health Sciences. The fifth was Bhaktapur Cancer Hospital.

Ethical approval for the study was obtained from Government based Nepal Health Research Council (NHRC, Reg’no.5o9/2017J). The study was also funded by NHRC and the contract period of one year was decided. The investigator had to complete the study and submit the report at the end of one year. Formal permission was also taken from the concerned authorities of the selected hospitals.

The study included doctors and nurses working in the hospitals. For calculation of sample size, confidence interval was taken 95% and allowable error was 5%. Fifty percent proportion was assumed as there was no specific proportion of good practice in previous studies. Thus, total sample size calculated was 385.

Operation room, Intensive Care Unit, Medical and Surgical wards and Emergency room of these hospitals were selected. The list of doctors and nurses were obtained from the duty rosters. Then simple random sampling technique, through lottery method, was adopted to select the proportionate number of doctors and nurses from different hospitals.

Written informed consent was obtained from each of the participants before data collection. Pre-designed self administered questionnaire was used for the study. An enumerator was chosen from each hospital. They were provided orientation on the tool and the technique of data collection. The questionnaires were distributed to the respondents in person and the filled questionnaires were returned after 2 days.

Pre-designed self administered questionnaire was used to collect information on pain management practice and perceived barriers. The practice questionnaire consisted of close-ended questions and the barrier questionnaire was in the form of 5-point Likert scale. For each item, frequency of scales 1, 2 and 3 were combined as negative response, and 4 and 5 were combined as positive response. The practice related questions were prepared based on the study of Louri M et al., and Ferrante P et al., [5,7]. Some of the barrier questions were extracted from the study of Jho HJ et al., and Jeon YS [6,9].

Pretesting of the questionnaire was done among nurses and residents of Department of Anaesthesiology of Tribhuvan University Teaching Hospital. The reliability of the tool was assessed by calculating the Cronbach’s alpha (r), the value of which was 0.78. As per findings and feedback from pretesting, some questions were rewritten in simple format to make them more meaningful and comprehensible.

Data were entered in Epidata version 3.1 and analysed by using SPSS version 16.0. Data was analysed by using descriptive (frequency, percent, mean and standard deviation) and inferential statistics (chi-square test) as per the nature of the variables. These were then presented in tables and figures with the use of Microsoft Word and Microsoft Excel 2007. Statistical significance was considered at p<0.05.

Although the calculated sample size was 385, due to incomplete questionnaires and non-response, the total samples taken were 292. Most of the participants were doctors (61.6%), followed by nurses (34.9%) and paramedics (3.4%). The mean age of the participants was 29.6±8.4 years. The participants with postgraduate qualification were 80 (27.4%). Majority (69.5%) had work experience of <5 years [Table/Fig-1]. Only 56 participants (19.2%) had received pain management training in the past.

More than half of the participants (53.8%) always did assessment of pain on their patients. Documentation of pain was poor, with only 22.3% always doing documentation. Pain re-assessment was always done by most of the participants (67.8%). The side-effects of pain medication were assessed by only 45.2% [Table/Fig-2].

Only 39.7 % always used pain scale for assessment of pain. The frequently used Pain scale was Visual Analog Scale (VAS) (42%). Despite pain re-assessment always been done by most of the participants, only 33.2% always used standard tools for pain reassessment [Table/Fig-3].

The main barriers to pain management as perceived by the participants were opioids being strictly regulated (75.7%), insufficient staff in the hospital (73.4%), lack of knowledge among patients about pain management (66.8%) and least priority for pain management by hospital (60.1%) [Table/Fig-4].

While comparing the pain management practice between physicians and nurses, no significant difference was found in the practices, except in documentation of pain assessment, in which significantly more nurses were found to be documenting pain than the physicians (p<0.05) [Table/Fig-5].

The perceived barriers to pain management are significantly different in physicians and nurses. Barriers like reluctance of patient to report pain and strict regulation of opioids are perceived significantly more by nurses. Similarly, among the physicians, perceived barriers like lack of knowledge of patient, lack of communication between patient and staff, lack of proper assessment, inadequate knowledge and experience among staff, lack of time etc., are found to be more significant [Table/Fig-6].

This multi-centre study, done among health professionals, has shown the current scenario of pain management practices in the tertiary level hospitals of Nepal. It also highlights the barriers to pain management. For effective pain management, the pain must be assessed using standard pain measurement tools and later re-assessed to test the adequacy of pain relief treatments. Documentation of pain scores is vital to know the dynamics of pain scores and adequacy of treatments. In this study, about half of the participants (53.8%) always asked about pain. However, only (39.7%) participants always used pain scale for assessment of pain. The frequently used Pain scale was VAS (42%). The documentation of pain was also poor with only 22.3% always documenting pain. Despite many participants (67.8%) claiming that the reassessment of pain was always done; only 33.2% used pain scale for reassessment. The side-effects of pain medication were always assessed by only 45.2%. The inadequate assessment of pain and poor documentation was also found in study done in mainland China by Ying GT et al., [8]. The importance of standardised pain scale was shown in study by Zoega S et al., where use of pain scale was associated with better pain management [10].

The responses to the questionnaire were also compared between two groups of physicians and nurses in regard to the pain management practices. The significant difference was noted in regard to the documentation of pain, where documentation was better among nurses (p<0.05). This might be due to the habit of documentation of vitals and plan in nursing chart by nurses. The study about pain documentation was also done in the year 2000 in the Emergency Department of one of the hospitals of Chicago, USA by Eder SC et al., [11]. Initial pain assessment was done in 94% of patients but pain scale was used only in 24% of patients. Documentation of reassessment of pain after therapy was done in 39% and pain scale was used in only 19%. In their study also, it was found that nurses were 2.2 times more likely to document pain than physicians.

The present authors also compared pain management practices among different hospitals of Nepal. The pain management practices were almost similar among all hospitals.

Overall the pain assessment and reassessment by using Standard pain assessment tools was only practised by few health professionals. The barriers that prevent adequate pain management are divided into 3 groups; barriers related to patient, related to health professionals and related to health care system. In this study, the barriers related to health care system as rated by the participants were opioids being strictly regulated (75.7%), insufficient staff in the hospital (73.4%) and least priority for pain management by hospital (60.1%). Among the barriers related to patient, lack of knowledge of patient about pain management was rated high (66.8%) by the participants. The barriers related to health professionals were not rated high as compared to previous two barriers and lack of experience of pain management (57%) was scored highest among the barrier related to health professionals.

The comparison of perceived barriers among the physicians and nurses showed difference in their perception regarding the barriers in many areas. Both doctors and nurses were consistent that insufficient staffing is one of the most important barriers preventing effective application of pain management. The results are compared with similar studies done in Morocco and South Korea [6,7]. The study done by Jho HJ et al., showed that barrier related to health professionals like time constraints was rated highest 75.8% by physicians and 66.1% by nurses [6]. The insufficient knowledge of pain control was next common perceived barrier, 60.5% by physician and 57.7% by nurses. In a study done in Morocco by Louri M et al., also, barriers related to health professionals was rated higher which are as follows [5]; inadequate pain assessment by staff 80%, inadequate experience of pain management 78%, insufficient knowledge of pain management 80% and lack of time 70%. Among the barriers related to health care system, the highest score was given to strict regulation of opioids 71%. In the present study, the surprising part is the health professional related barrier is not rated higher. The present authors were expecting the results similar to developing country like Morocco. In fact, poor knowledge of the health professionals on pain management has been identified in many studies [12-15]. The health care related barrier was rated higher in our study where most of the staff think that poor health care system is the main barrier for adequate pain management. The barrier related to health care system is also one of the important barriers that prevent effective pain management. Inadequate nursing staff leading to high workload prevented the pain management in study done in Saudi Arabia by Mohammed A et al., [16]. The consequences of high workload causes failure to deliver pain medication in time and as per demand, improper pain assessment and documentation. This eventually leads to dissatisfaction among nurses [16]. Another study was done among the nurses of Indonesia by Mediani HS et al., about perceived barriers to pain management [17]. The main barriers identified were inadequate nurse patient ratio (inadequate staffing), lack of education and training, lack of hospital support, lack of professional autonomy. Lack of professional autonomy was the one of the findings that ought to be mentioned. In developing countries, the nurses are not authorised to give medication on their own. They have to get permission from the physicians. The nurses in their interview mentioned that even they wanted to manage pain the lack of autonomy prevented to do so.

Strict regulation of opioids is the most frequent perceived barrier that is observed in our study. Opioids have addiction potential so manufacture and distribution of such drugs must be scheduled. Too much strict regulation will lead to formulary restriction, prescription barrier and dispensing barrier and result in unnecessary suffering to those who really need. The Eastern Europe had suffered from such strict regulation of opioid [18]. There exist the guidelines published by World Health organisation which adopt the principle of Balanced Policy for safer management of controlled drugs [19]. Countries can take more practical measure for prevention and control while ensuring patient access.

The comparison was also done among the different hospitals of Nepal. There was no major deviation of data from cumulative data. The health system related barrier was rated higher in each hospital.

Due to the existence of the barriers, the overall pain management practice might not be up to the standard. The knowledge on pain management assessed by using standard tool, Nurses Knowledge and Attitudes Survey Regarding Pain (NKASRP), among nurses in one of the tertiary level hospitals was poor as shown by previous study in Nepal by Shakya B and Shakya S, [15]. As there is lack of multicentred data we can only assume that this is also true for rest of hospitals of Nepal. The authors did not find any other studies done in Nepal that attempt to find out barriers to pain management. The improvement in the pain management can be done by educational programs. The improvement in knowledge and change in behaviour of health personnels, like improvement in quality of pain assessment, use of pain scale and habit of documentation have been achieved by implementation of Pain Education Program (PEP) in China [20]. The “Essential Pain Management Workshop”, a one day workshop which is recognised worldwide to provide basic knowledge of pain management among the health professionals has been running successfully in developing countries including Nepal [21]. However, patient related barriers cannot be ignored and awareness has to be created among the patient about the pain management. And lastly, the authorities involved in health system management have to be made aware of the existing condition regarding pain management in Nepal.

The results may not reflect the pain practices of all the health professionals of Nepal. The pain assessment and documentation were measured using questionnaire. In order to measure the pain practices accurately the additional monitoring system like auditing is necessary. For obvious reasons, this was not done. The study assessed the perceived barriers of health professionals and may not represent actual barriers.

The pain management services have to be developed as necessary health services in Nepal. The major barriers for developing effective pain management service in Nepal as shown by this study are strictly regulated medications, inadequate hospital staffing and poor awareness among patients. The first step in solving the problem is to identify the problem and accept it. There exists barriers at all the three levels and they should be addressed. The health professional related barrier can be overcome by providing adequate trainings on pain management to all health professionals. The medical societies in coordination with authorities of the government should develop policy for improvement of pain management and device action plans to implement in practice.

Declaration: The study was also funded by NHRC and the contract period of one year was decided.