Pain Assessment Practice and Associated Factors Among Nurses Working in Public Hospitals of West Hararge Zone,Eastern Ethiopia,2023

Abstract

Background

Pain assessment is a fundamental aspect of nursing care. Problems in applying pain assessment principles are more severe in low-income countries. This study aimed to assess pain assessment practice and associated factors among nurses working at the adult care unit at a public Hospital in West Hararghe Zone, Eastern Ethiopia, 2023.

Methods

An institution-based cross-sectional study was conducted from July 15 to August 15, 2023, among 394 randomly selected nurses working in adult care units at public hospitals in West Hararghe Zone. A structured self-administered questionnaire and chart review were used for data collection. Pain assessment practice was evaluated using 8 “yes/no” questions, and total scores were computed. Nurses scoring ≥70% were categorized as having adequate practice, while those scoring below 70% were considered to have poor practice. Data was entered into EpiData version 3.1software and exported to the Statistical Package for Social Science (SPSS) version 26 for analysis. Bivariate and multivariable logistic regression were used to identify factors associated with pain assessment practice, with significance interpreted at p-value <0.05.

Results

The overall self-reported pain assessment practice among study participants was found to be 63.5% (95% CI: 59.0% - 68.0%). Work experience of >5 years [AOR: 3.13 (95% CI: 1.21-8.14)], knowledge of pain assessment [AOR: 4.25 (95% CI: 2.51-7.18)], attitude towards pain assessment [AOR: 3.43 (95% CI: 2.05-5.72)], and having in-service training on pain assessment [AOR: 3.58 (95% CI: 1.05-12.23) were significantly associated with pain assessment practices.

Conclusion

The study revealed that a moderate level of pain assessment practice was reported among participants, indicating room for improvement in clinical settings. Work experience, knowledge, positive attitudes toward pain assessment, and in-service training are significantly associated with pain assessment practice. These findings highlight the importance of enhancing healthcare workers’ knowledge, attitudes, and training programs to improve pain assessment practices.

Keywords

nurse pain assessment practice Ethiopia

Introduction

Pain is always a uniquely individual response that is to varying degrees influenced by biological, psychological, and social factors, whereas all people feel pain at some time in their life as a subjective reaction to biological and psychological pressures (Rajaa S.N et al., 2020). Globally, hospital-wide pain prevalence obtained ranged from 37.7 to 84%, and severe pain prevalence ranged from 9-36% (Gregory & McGowan, 2016). According to the evidence, one of the main reasons patients seek medical care is pain (Cox, 2018; Onianwa et al., 2017).

Emerging literature highlights that assessment is not merely a preliminary step but a fundamental component of comprehensive pain management (Eull et al., 2023). Pain that is not assessed or treated by nurses can have a debilitating effect and can significantly impact a patient’s quality of life by significantly impacting their physical, emotional, and mental health, causing uncontrollable pain, delaying healing, increasing the risk of several complications, and prolonging stay in the Hospitals (Belay Bizuneh et al., 2020; Kotfis et al., 2018).

Nurses are in a unique position to support patients who are experiencing pain and play a vital role in providing pain assessment and management (Cox, 2018; Samarkandi, 2018). While utilizing assessment methods and tools, nurses should take the pain assessment concepts into mind (I. Kizza & Muliira, 2015). Subjective data, objective data, and evaluation tools are all necessary for a comprehensive pain assessment (Melile Mengesha et al., 2022). Behavioral observations, such as facial expressions and movements, are also considered, while changes in vital signs may provide supportive cues, but are not reliable indicators of pain assessment (Gélinas, 2016).

According to the most recent study and quality improvement initiatives, nurses should incorporate pain assessment tools into their routine practice (Puntillo, 2016). Standardized pain assessment tools/scales are available for different patient groups, which enhance communication by promoting consistency and making a subjective experience measurable (Das et al., 2020; I. B. Kizza et al., 2016). The right tool should be selected; if patients are unable to communicate, tools may involve a review of a critical ill pain observation tool (CPOT) and the behavioral pain scale (BPS), which are valid and reliable tools (Pasero & Herr, 2015; Thompson et al., 2017). Pain scales for patients able to communicate include a Visual Analogue scale (VAS), a 0-10 Numerical Rating Scale (NRS), and a Verbal Rating Scale (VRS), which are valid and reliable tools (Edra F, 2016). There are additional interview methods available to gather a complete pain history, including location, onset, nature, radiation, associated factors, aggravating or relieving factors, and intensity (Breivik et al., 2008). Salivary biomarkers, such as cortisol and alpha amylase, are gaining recognition as promising noninvasive tools for pain assessment, offering valuable insight into pain perception and physiological stress response (Sobas et al., 2020; Stendelyte et al., 2023).

Review of Literature

In Rwanda, 20% of nurses had a good practice pain assessment (Umuhoza, 2017), in Addis Ababa, 55.9% did, and only 17.74 % of them used tools routinely (Ayenew et al., 2021). Overall, pain-assessment remains poor across settings due to a lack of guidelines and tools, high workload, limited experience and training, unfamiliarity with assessment instruments, and weak organizational support (Ayenew et al., 2021; Gélinas, 2016).

Most studies in Ethiopia focus on pain management practices among nurses and associated factors. However, a recent systematic review and meta-analysis reported that only about 48% of nurses demonstrated adequate pain management practice, underscoring the inconsistency and gaps in clinical practice nationwide (Munie et al., 2025). By contrast, the present study investigates pain assessment practice among nurses working in medical and surgical wards in Eastern Ethiopia, a region where empirical evidence is scarce. Importantly, this study incorporates organizational and patient-related factors alongside knowledge, attitude, and practice domains, and uniquely integrates chart review to capture documented evidence of pain assessment. Chart review is an objective way to assess nurses’ documentation and adherence to pain assessment protocols, capturing practice patterns such as assessment frequency, use of standardized tools, and intervention records. Nevertheless, there is still a significant gap between past study findings and current realities in clinical practice. This study aimed to assess pain assessment practice and associated factors among nurses working at the adult care unit at a public Hospital in West Hararghe Zone, Eastern Ethiopia.

Methods and Material

Study Design

An institution-based cross-sectional study design was used.

Study Setting and Period

This study was conducted in the public hospitals of the West Hararge Zone, Eastern Ethiopia. West Hararge Zone is one of the 20^th zones in the Oromia region, which is located in Eastern Ethiopia. Administratively, West Hararge Zone is subdivided into 15 districts and 5 rural towns. Chiro town serves as the capital of the West Hararge Zone administration. According to the 2007 Ethiopian Census projection for 2020/2021, the Zone has an estimated total population of 2,667,000 (CSA & International, 2012).

There are seven public hospitals, 80 health centers, 44 private clinics, and 446 health posts in the zone. The total number of nurses working at adult care units of each hospital was 550. Two general Hospitals provide a multidimensional aspect of care to patients who need highly qualified/specialized healthcare services, and the remaining five hospitals provide inpatient, outpatient, emergency, and delivery services. (Source: West Hararge Zonal Health Bureau Office). The study was carried out from July 15 to August 15, 2023.

Population

Source Population

All nurses working in the adult care unit in public hospitals in West Hararge Zone.

Study Population

All nurses working in the adult care unit of public hospitals in West Hararge Zone during the data collection period.

Eligibility Criteria

The study included all nurses working in adult care units. Nurses who were present during the data collection period and had been working in these units for at least six months were included.

Sample Size Determination

A single population proportion formula was used to calculate the sample size by using the following assumptions: the proportion of good nurses’ pain assessment practice was found to be 38.2% in Wolaita Zone, Southern Ethiopia (Melile Mengesha et al., 2022), with a margin of error of 5%, 95% confidence interval, and a 10% non-response rate. The final sample size of 400 is yielded.

Sampling Procedure and Sampling Technique

All seven hospitals in the West Hararge Zonal Administration were included in this study. The total number of nurses working at adult care units of each hospital was considered to proportionally allocate the sample size for each hospital. Following the proportional allocation of sample size to each hospital, study participants were selected using a simple random sampling technique (Figure 1).

Figure 1.

Schematic presentation of sampling procedure to assess pain assessment practice and associated factors among nurses working at adult care unit in public hospital in West Hararge Zone, Eastern Ethiopia, 2023

Data Collection Tools and Procedures

Data were collected using a pretested, structured, self-administered questionnaire and checklist. The data collection tool for the self-administered questionnaire was developed by reviewing different literature (Ayenew et al., 2021; Liyew, Dejen Tilahun, & Habtie Bayu, 2020; Melile Mengesha et al., 2022; Negese et al., 2020). The questionnaire contains six parts: sociodemographic information, knowledge-related questions, practice-related questions, attitude-related questions, organization-related factors, and patient-related factors.

The questionnaire was adapted from previously validated instruments used in similar studies. Content validity was established through expert review by senior nursing faculty and public health professionals, who assessed the relevance and clarity of each item. Reliability was tested during the pre-test phase on a sample of nurses outside the study area. Internal consistency was confirmed using Cronbach’s alpha, which demonstrated acceptable reliability across all domains: knowledge (α = 0.82), attitude (α = 0.79), and practice (α = 0.84).

Chart Review Checklist

A structured and pre-tested English version standard checklist was adopted from different reviewed literature and the Health Sector Transformation in pain guidelines (Angeletti et al., 2018; Ortiz et al., 2014; Rajaa S.N et al., 2020) to collect data regarding nurses’ pain assessment practice through chart review. The checklist contained 11 items with “Yes” and “No” responses.

Study Variables

Dependent Variable

The dependent variable in this study was nurses’ pain assessment practice.

Independent Variables

Age, sex, marital status, educational level, work experience, presence of protocols and guidelines, availability of standardized tools, perceived organizational support, working unit, training on pain management, knowledge, attitude, nurse workload, and patient-related factors such as patients unable to self-report and patients’ instability.

Operational Definition of Terms

Knowledge of Nurses

It was measured using 10 “yes/no” questions, and the total scores were computed. Nurses who correctly answered above or equal to 70% of knowledge questions are considered to have adequate knowledge on pain assessment in the adult care unit, and those who correctly answered below 70% of knowledge questions are deemed to have inadequate knowledge (Ayenew et al., 2021).

Attitude of Nurse

It was measured using 7 “yes/no” questions, and the total scores were computed. Nurses who scored 70% and above on attitude-related questions were considered to have a favorable attitude, but, on the contrary, those who answered below 70% were considered to have an unfavorable attitude (Liyew et al., 2020).

Good Practice

The measurement was conducted using 8 “yes/no” questions, and the total scores were calculated. Nurses who correctly answered above or equal to 70% of practice questions were considered to have adequate practice on pain assessment in adult care unit patients, but on the contrary, those who correctly answered below 70% were considered to have poor practice (Melile Mengesha et al., 2022).

Nurse Workload

If one nurse provides for more than six patients in inpatient service other than ICU and emergency per shift, it is considered nurse work overload (Fekede et al., 2023).

Patient Instability

Those patients with a clinical presentation of either an altered level of consciousness, systolic BP < 90 mmHg, shortness of breath, pulse rate > 120 bpm, pulmonary edema, and poor skin sign (Haregeweyn Kibret et al., 2022).

Data Quality Assurance and Management

The study involved a structured questionnaire prepared in English. Before the actual one-week data collection, the items were tested on 20 (5 % of 400) nurses working out of the study area (Chelanko Hospital), and the result was used to check the clarity and completeness of the questionnaire, and any ambiguities or differences in understanding were revised. Each questionnaire was coded with a unique identification number. Data collectors and supervisors received adequate training on the study’s objectives, data collection methods, ethical considerations, and the impact of data on participants. Regular meetings were held between data collectors, supervisors, and the principal investigator to address any issues arising from respondents. Data was kept in a secure shelf to protect against unauthorized access, loss, and tampering while ensuring confidentiality by not recording personal identities.

Data Processing and Analysis

After data collection, the data were coded, checked, cleaned, and entered into EpiData version 3.1 Software and then exported to SPSS version 26 for analysis and interpretation. Descriptive statistical analysis, such as simple frequencies, measures of central tendency, and measures of variation, was computed to summarize and describe the characteristics of study participants, and the information was presented using frequencies, summary measures, graphs, tables, and figures. Bivariate analysis was used to assess the association between independent and outcome variables using binary logistic regression. Independent variables with a p-value of < 0.25 at 95% CI in bi-variable analysis were retained for multivariable logistic regression analysis. AOR with 95% CI was estimated to show the relationship between the independent variables and the dependent variable after controlling for the effects of confounders with 95% CI. Variables with a P-value ≤ 0.05 were declared as having a statistically significant association with the outcome variable.

Ethical Considerations and Informed Consent Statements

This study was approved by the Institutional Health Research Ethics Review Committee. Letters of cooperation were obtained from each participating hospital to facilitate the conduct of the research. Written informed consent was secured from all study participants after providing an adequate explanation of the study’s purpose, procedures, potential risks, and anticipated benefits. Participants were assured of their right to withdraw at any stage without consequence, and confidentiality was strictly maintained by anonymizing responses and restricting data access to the research team. The study adhered to the principles of the Declaration of Helsinki and national research ethics guidelines.

Results

Socio-Demographic Characteristics of Nurses

Out of the 400 sampled nurses, 394 returned the questionnaires, which made the response rate 98.5%. From a total of 394 nurses who participated in this study, 145(36.8%) were females. The mean age was 28.51 (SD ± 2.969) years, and the majority of the respondents, 267 (67.8%), were in the 22-30 age group. The majority of nurses, 290(73.9%), held a bachelor’s degree or above. More than half of them, 256(65.0%), had over five years of total work experience (Table 1).

Table 1.

Socio-Demographic Characteristics of Nurses Working at Adult Care Units in Public Hospitals, West Hararge Zone, Eastern Ethiopia, 2023 (n=394)

Variables	Category	Frequency	Percent
Sex	Male	249	63.2
Sex	Female	145	36.8
Age (in years)	22–30	267	67.8
Age (in years)	>30	127	32.2
Marital status	Never Married	111	28.2
Marital status	Ever Married	283	71.8
Educational level	Diploma	104	26.1
Educational level	Degree and above	290	73.9
Work experience	<2years	29	7.3
	2–5years	109	26.7
	>5years	256	65.0
Working unit	Emergency	81	20.6
	Outpatient	95	24.1
	Inpatient	218	55.3
In-service training on pain assessment	Yes	35	8.9
In-service training on pain assessment	No	359	91.1

Organizational Related Factors

Three hundred sixty-three (92.1%) and two hundred ninety-one (73.9%) of respondents was easily got pain assessment protocol and guideline, respectively, in their working unit. Only 86(21.8%) of respondents received organizational support (Table 2).

Table 2.

Organizational-Related Factors Regarding Pain Assessment Practice Among Nurses Working at Adult Care Units in Public Hospitals, West Hararge Zone, Eastern Ethiopia, 2023 (n = 394)

Variables	Category	Frequency	Percent
Presence of protocols and guidelines	Yes	363	92.1
Presence of protocols and guidelines	No	31	7.9
Presence of standardized tools	Yes	291	73.9
Presence of standardized tools	No	103	26.1
Perceived organizational support	Yes	86	21.8
Perceived organizational support	No	308	78.2
Workload	Yes	363	92.1
Workload	No	31	7.9

Knowledge of Nurses About Pain Assessment

Out of 394 participants, more than half, 245 (62%) (95% CI: 57.9%-67.5%), of the participants had adequate knowledge about pain assessment practice, and 149(38%) of them had inadequate knowledge (Table 3).

Table 3.

Knowledge of Nurses Regarding Pain Assessment Among Nurses Working at Adult Care Units in Public Hospitals, West Hararge Zone, Eastern Ethiopia, 2023 (n = 394)

Variables	Response	Frequency	Percent
Pain assessment is part of professional responsibilities	Yes	392	99.5
Pain assessment is part of professional responsibilities	No	2	0.5
Do you know pain assessment scales/protocols?	Yes	385	97.7
Do you know pain assessment scales/protocols?	No	9	2.3
Do you know that pain assessment should be done according to guidelines?	Yes	377	95.7
	No	17	4.3
Vital signs are always reliable indicators of the intensity of a patient’s pain.	Yes	357	90.6
	No	37	9.4
The most accurate judge of the intensity of the patient’s pain is the patient.	Yes	368	93.4
	No	26	6.6
Patient verbal reports of pain are verified with a vital sign check	Yes	351	89.1
	No	43	10.9
Do you know as an observation is one-part method of pain assessment?	Yes	350	88.8
	No	44	11.2
A patient’s behavior and facial expressions can reflect their pain?	Yes	347	88.1
	No	47	11.9
A pain should be assessed before and after administering pain drugs?	Yes	353	89.6
	No	41	10.4
A pain should be assessed before, during and after any procedure?	Yes	372	94.4
	No	22	5.6
Overall knowledge	Adequate	245	62
Overall knowledge	Inadequate	149	38

Attitude of Nurses Toward Pain Assessment

Out of 394 participants, more than half, 256 (65%) (95% CI: 56.9%-66.5%) of the respondents had favorable attitudes towards pain Assessment practice, and the remaining 138(35%) of them had unfavorable attitudes (Table 4).

Table 4.

Attitude of Nurses Toward Pain Assessment Among Nurses Working at Adult Care Units in Public Hospitals, West Hararge Zone, Eastern Ethiopia, 2023 (n = 394)

Variables	Response	Frequency	Percent
Do you feel that you are competent in assessing pain in patients effectively?	Yes	387	98.2
	No	7	1.8
Nurses the best judges of the patient’s pain intensity because they spend 24 hours with the patient?	Yes	376	95.5
	No	18	4.5
Does using pain assessment tools usually doesn’t not make nursing more complicated?	Yes	341	86.5
	No	53	13.5
Pain assessment tools are not time-consuming for other ward activities	Yes	341	86.5
	No	53	13.5
Do you always agree with patients’ statements about their pain?	Yes	348	88.3
	No	46	11.7
Nurses should also focus on the pain assessment NOT only actual/practical patient care	Yes	343	87.1
	No	51	12.9
Nurses’ pain assessment helps nurses gain sufficient knowledge about patients?	Yes	368	93.3
	No	26	6.7
Overall attitude	Favorable	256	65
Overall attitude	Unfavorable	138	35

Patient-Related Factors Impacting Pain Assessment Practice

The majority of nurses 90.6%, reported that patient self-reporting influences their ability to quantify pain, whereas 9.4% indicated that it does not. Additionally, 91.4% of nurses believe patient instability affects their pain assessment, while only 8.6% claim it doesn’t.

Nurses’ Pain Assessment Practice

The study found that 98.5% of nurses reported that they assessed pain for their patients. Only 26.2% of the study participants discussed pain scores during a nurse-to-nurse report. According to this, two third 63.5%, (95% CI: 59.0-68.0) of the participants were found to have good practice regarding pain assessment, whereas the remaining 36.5% had poor practice (Table 5).

Table 5.

Pain Assessment Practice Among Nurses Working at Adult Care Units in Public Hospitals, West Hararge Zone, Eastern Ethiopia, 2023 (n = 394)

Variables	Response	Frequency	Percent
Assess the pain for their patients	Yes	388	98.5
Assess the pain for their patients	No	6	1.5
Use self-report of pain as a valid measure of pain if a patient is able to communicate	Yes	370	93.9
	No	24	6.1
Use vital signs as extra indicators of the intensity of a patient’s pain/as a cue for pain assessment	Yes	345	87.6
	No	49	12.4
Use pain assessment scale	Yes	170	43.1
Use pain assessment scale	No	224	56.9
Use observation (patient’s behaviors and body movement) of pain as a valid measure of pain if a patient can communicate	Yes	326	82.7
	No	68	17.3
Assess pain before and after any procedure	Yes	316	80.2
Assess pain before and after any procedure	No	78	19.8
Discus pain scores during a nurse-to-nurse report	Yes	103	26.2
Discus pain scores during a nurse-to-nurse report	No	291	73.8
Document pain assessment scores	Yes	246	62.4
Document pain assessment scores	No	148	37.6

Results From the Chart Review

Among 394 charts reviewed, 323 (81.8%) had attached pain assessment tools completed, which means pain assessment was conducted. 235 (58.8%) of the charts with pain assessment sheets had an appropriate pain assessment tool or scale utilized for patients who were able to talk and those who were unable to communicate. Of the charts with pain assessment tools, 94 (21%) had completed thorough pain assessments. 130 (32.5%) had assessments that were performed before and after any procedure for the patient. Similarly, from 327 charts that had attached nursing pain assessment tools, only 99 (24.8%) had discussed pain assessment during nurse-nurse report. From the chart attached and recorded, 68 (17%) of the charts had appropriately legible, dated, and signed. Whereas the remaining 332 (83%) of charts’ nursing pain assessment records were not appropriately legible, dated, and signed (Table 6).

Table 6.

Checklist on Pain Assessment Practice and Associated Factors Among Nurses Working at Adult Care Units in Public Hospitals, West Hararge Zone, Eastern Ethiopia, 2023 (n=394)

Variables	Response	Frequency	Percent
Is a nursing pain assessment tool/scale attached to the patient chart?	Yes	323	81.8
	No	71	18.2
Comprehensive pain assessment is done for a patient	Yes	83	21
Comprehensive pain assessment is done for a patient	No	311	79
A pain assessment was used as the fifth vital sign	Yes	55	14
A pain assessment was used as the fifth vital sign	No	339	86
An appropriate pain assessment tool/scale was used for patients who able to communicate and be unable to communicate	Yes	232	58.8
	No	162	41.3
A self-report of pain is used as a valid pain assessment if a patient can Communicate	Yes	236	60
	No	158	40
Observation of patient behavior and Activity/Body Movement was used as a valid pain assessment if a patient is unable to communicate	Yes	224	56.8
	No	170	43.3
Use observation (patient’s behaviors and body movement) of pain as a valid	Yes	184	46.8
	No	210	53.2
Assess pain before and after any procedure	Yes	128	32.5
Assess pain before and after any procedure	No	266	67.5
Pain assessment tools are well arranged and contain important scale	Yes	104	26.5
	No	290	73.5
Discuss pain assessment during nurse-nurse report	Yes	98	24.8
Discuss pain assessment during nurse-nurse report	No	296	75.3
Pain assessment is well-documented and attached to the patient’s chart	Yes	88	22.3
	No	306	77.8
Is all entire pain assessment record legible, dated, and signed	Yes	67	17
	No	327	83

Factors Affecting Pain Assessment Practice Among Nurses Working in Adult Care Units

In the bivariable analysis, age, work experience greater than five years, availability of standardized tools, organizational support, nursing workload, having in-service training on pain assessment, patient instability, absence of protocols or guidelines, patient inability to self-report, patient pain and distress, nurses’ knowledge, and nurses’ attitude were identified. Finally, multivariable regression analysis showed that work experience >5 years, nurses’ knowledge, nurses’ attitude, and in-service training on pain assessment were significantly associated with nurses’ pain assessment practice in the adult care unit.

The study revealed that nurses with working experience of >5 years were three times more likely [AOR: 3.13 (95% CI: 1.21-8.14)] to have good pain assessment practice in adult care units when compared with nurses with working experience of <2years, nurses with good knowledge of pain assessment in adult care unit were about four times [AOR: 4.25 (95% CI: 2.51-7.18)] good in pain assessment practice than those with poor knowledge, nurses with favorable attitude of pain assessment in adult care unit were about three times [AOR: 3.43 (95% CI: 2.05-5.72)] good in pain assessment practice than those with unfavorable attitude, nurse who have training on pain assessment were about four times [AOR: 3.58 (95% CI: 1.05-12.23)] good in pain assessment practice than those who didn’t taken (Table 7).

Table 7.

Bivariate and Multivariate Analysis on Factors Associated With Nurses’ Pain Assessment Practice Among Nurses Working at Adult Care Units in Public Hospitals, West Hararge Zone, Eastern Ethiopia, 2023 (n=394)

Variable	Category	Practice		COR (95%CI)	AOR (95%CI)	P-value
Variable	Category	Good N (%)	Poor N (%)	COR (95%CI)	AOR (95%CI)	P-value
Age	22-30	183 (68.54)	84 (31.46)	1	1
Age	>30	67 (52.76)	60 (47.24)	0.51 (0.33-0.79)	0.83 (0.45-1.54)	0.562
Marital status	Never married	83 (72.17)	32 (27.83)	1	1
Marital status	Ever married	167 (59.86)	112 (40.14)	0.57 (0.36-0.92)	0.60 (0.33-1.07)	0.082
Work Experience	<2years	12 (41.38)	17 (58.62)	1	1
	2-5years	60 (55.05)	49 (44.95)	1.73 (0.76-3.98)	1.49 (0.55-4.05)	0.438
	>5years	178 (69.53)	78 (30.47)	3.23 (1.47-7.09)	3.13 (1.21-8.14)	0.019**
Presence of standard tools	Yes	177 (60.00)	118 (40.00)	0.53 (0.32-0.88)	0.64 (0.34-1.19)	0.159
Presence of standard tools	No	73 (73.74)	26 (26.26)	1	1
Received organizational support	Yes	44 (51.16)	42 (48.84)	0.52 (0.32-0.84)	0.84 (0.46-1.52)	0.559
Received organizational support	No	206 (66.88)	102 (33.12)	1	1
Knowledge	Adequate	187 (77.27)	55 (22.73)	4.80 (3.09-7.47)	4.25 (2.51-7.18)	0.000**
Knowledge	Inadequate	63 (41.45)	89 (58.55)	1	1
Attitude	Favorable	187 (76.95)	56 (23.05)	4.66 (3.00-7.24)	3.43 (2.05-5.72)	0.000**
Attitude	Unfavorable	63 (41.72)	88 (58.28)	1	1
Unable to self-report of patient	Yes	218 (61.06)	139 (38.94)	0.25 (0.09-0.64)	0.27 (0.05-1.38)	0.114
Unable to self-report of patient	No	32 (86.49)	5 (13.51)	1	1
Patient instability	Yes	222 (61.67)	138 (38.33)	0.34 (0.14-0.85)	1.96 (0.39-9.94)	0.418
Patient instability	No	28 (82.35)	6 (17.65)	1	1
Patient pain and distress	Yes	211 (60.98)	135 (39.02)	0.36 (0.17-0.77)	0.46 (0.12-1.75)	0.251
Patient pain and distress	No	39 (81.25)	9 (18.75)	1	1
In-service training on pain assessment	Yes	29 (82.86)	6 (17.14)	3.02 (1.22-7.46)	3.58 (1.05-12.23)	0.042**
In-service training on pain assessment	No	221 (61.56)	138 (38.44)	1	1
Nurse workload	Yes	224 (61.71)	139 (38.29)	0.31 (0.12-0.83)	1.97 (0.50-7.72)	0.332
Nurse workload	No	26 (83.87)	5 (16.13)	1	1

Statistically significant at P<0.05= **, 1: reference, AOR: Adjusted odds ratio, COR: Crude odds ratio, Binary logistic regression for initial associations, Multivariable logistic regression for adjusted analysis and the p-value thresholds for variable retention (<0.25) and significance (≤0.05).

Discussion

This cross-sectional study was conducted to evaluate nursing pain assessment practices and identify factors influencing these practices among nurses working in the adult care unit of a public hospital in the West Hararge Zone, Ethiopia. Based on the study findings, nearly all nurses (98.5%) reported engaging in pain assessment practices. Upon reviewing the charts, it was found that a pain assessment tool was attached in just 81.8% of cases. Even though the findings from the self-administered questionnaire and the reviewed chart support each other, the magnitude of pain assessment practice from the result of the self-administered questionnaire was higher than the magnitude of pain assessment practice from the result of the reviewed chart. A possible reason for this is that the effect of social desirability bias is that nurses may over-report their usual behavior in the self-administered questionnaire. The study identified experience, good knowledge, positive attitudes, and training on pain assessment as significant factors positively influencing nurses’ pain assessment practices.

This study found that 63.5% of nurses demonstrated good pain assessment practices, which is a promising yet incomplete adherence to best practices in patient care. When compared to a similar study conducted in Wolaita Zone, Southern Ethiopia, the proportion of nurses with good pain assessment practices was 38.2%, significantly lower than the findings of the current study (Melile Mengesha et al., 2022). This suggests that pain assessment practices may vary across different regions, possibly due to differences in training, institutional support, or workload. Another study focusing on Comprehensive Specialized Hospitals in Ethiopia found that only a quarter of nurses had good pain management practices, indicating a broader challenge in ensuring effective pain assessment and management across healthcare settings (Fekede et al., 2023). Additionally, research on pain assessment in intensive care units highlighted that only 60% of nurses assessed pain in patients who could report it, and 50% did so for patients unable to communicate (Alnajar et al., 2021). These comparisons suggest that while Ethiopia has made progress in improving pain assessment among nurses, there is still a need for standardized training, institutional support, and policy interventions to ensure consistent and effective pain management practices nationwide.

According to this study, nurses with more than five years of work experience had significantly higher odds of demonstrating good pain assessment practice. This finding is in line with recent evidence and new trends in pain assessment practice (Gélinas, 2016). This may be because professional experience increases the likelihood that nurses working in elderly patient care units would conduct thorough and efficient pain assessments.

Good pain assessment practice was observed among nurses who possessed strong knowledge of pain assessment. This is supported by the study conducted in Ethiopia, Rwanda, and Saudi (AL-Sayaghi et al., 2022; Ayenew et al., 2021; Tuyishimire, 2017), which showed an association between knowledge and practice of the nursing staff regarding pain assessment. This may be since good knowledge improves the confidence and readiness of the nurses to do their routine activities and increases their ability to choose appropriate pain relief measures (Dagnew & Tewabe, 2021; Innab et al., 2022; Kibret et al., 2022; Wondimagegn et al., 2021). While theoretical knowledge of pain management is essential, it does not always translate into a positive attitude or improved practice. Previous research suggests that professionals may possess sufficient knowledge but still not properly practice pain management strategies (Ahmadi et al., 2023; Kahsay & Pitkäjärvi, 2019). This disconnect highlights the need to assess critically how knowledge influences practice and attitude.

This study’s findings showed that nurses with a favorable attitude towards pain assessment demonstrated good pain assessment practices. Previous studies support this (Bell & Duffy, 2009) which identified that the attitude of a caregiver is a significant barrier to effective pain assessment and has a statistically significant and positive relationship with the practice of nurses regarding pain assessment. This may be due to the reason that, as nurses have a favorable attitude, they will be motivated to provide care, to update themselves, and there will be a strong tendency to practice properly (Ahlstedt et al., 2020; Wang et al., 2024).

Nurses who received in-service training showed significantly better pain assessment practice. This was consistent with what has been found in other African countries (I. B. Kizza, 2012; Tuyishimire, 2017). However, having training on pain management was not associated with pain assessment practice, according to the study (Melile Mengesha et al., 2022). A similar conclusion was reached by previous studies, wherein a lack of training on pain management leads to poor pain assessment practice (Dutt, 2020; Onianwa et al., 2017), which found that caregiver training is a significant barrier to effective pain assessment and that it has a statistically significant positive relationship with nurses’ pain assessment practices. This may be due to the reason that, as nurses have training, they will be good at providing care, and there will be a big tendency to practice properly (Ahlstedt et al., 2020; Wang et al., 2024). Combining didactic sessions, practical demonstrations, and case discussions boosts knowledge, confidence, and routine use of standardized tools, so continuous professional development is essential to sustain improvements.

This study found that the majority of nurses reported the presence of standardized pain assessment tools (73.9%) and nearly all were aware of pain scales (97.7%), but less than half (43.1%) actually used these tools in practice. Structured assessments are hindered by heavy workloads, limited training, and weak organizational support, leaving nurses to rely mainly on judgment or patient self-report (Hamadeh et al., 2025; Olufunke, 2018; Rababa et al., 2021). Despite most nurses (86.5%) viewing pain tools as efficient, barriers such as poor bedside access, lack of chart integration, and limited supervisory support hinder their use. Improving practice requires workflow integration, leadership backing, and continuous training to ensure consistent application

Strengths and Limitations

On the strengths side, including self-reported data alongside patient chart reviews enhances the comprehensiveness of the findings. However, the cross-sectional design limits the ability to infer causality, and the exclusion of specialized units, coupled with the lack of direct observational data, restricts a full understanding of pain assessment practices. Additionally, this study may be subject to response bias, as some nurses might have provided socially desirable answers. Although anonymous data collection and confidentiality were ensured, the inherent limitations of self-reporting should be taken into account when interpreting the findings. These factors should be considered and highlight future research and methodological improvement.

Implications of the Study

This study underscores the need for hospitals to prioritize comprehensive in-service training programs that enhance nurses’ competencies and strengthen their approach to pain management through targeted behavioral training. Establish policies that mandate routine pain assessment and integrating monitoring systems will promote consistency and adherence to best practices. Additionally, leveraging technology such as digital pain scales and AI-driven tools can improve assessment accuracy, evaluation processes, and minimize subjectivity in clinical decision-making.

Conclusion

The study showed that while most nurses reported assessing pain, only two-thirds demonstrated adequate practice. Key factors significantly associated with better pain assessment practices included work experience exceeding five years, adequate knowledge of pain assessment, positive attitudes toward pain assessment, and receiving in-service training. These findings highlight the importance of enhancing healthcare workers’ knowledge, attitudes, and training programs to improve pain assessment practices. Addressing these factors through targeted educational interventions and regular training could lead to more consistent and effective pain management in clinical settings.

Supplemental Material

Supplemental material - Pain Assessment Practice and Associated Factors Among Nurses Working in Public Hospitals of West Hararge Zone, Eastern Ethiopia, 2023

Supplemental material for Pain Assessment Practice and Associated Factors Among Nurses Working in Public Hospitals of West Hararge Zone, Eastern Ethiopia, 2023 by Abdella Mohammed, Rudwan Yasin Abrahim, Kadir Abdu, Nesredin Ahmed, Daniel Alemu, Sisay Habte in Sage Open Nursing

Footnotes

Acknowledgments

We would like to acknowledge the data collectors, supervisors, study beneficiaries, health institution administrators, and data clerks

ORCID iDs

Rudwan Yasin Abrahim

Kadir Abdu

Nesredin Ahmed

Ethical Considerations

This study was approved by the Institutional Health Research Ethics Review Committee (Approval no: IHRERC/116/2023). A letter of cooperation was written to each hospital to allow the execution of the research.

Consent to Participate

A written, signed informed consent was obtained from all study participants following adequate explanation on the study’s purpose, risk and benefits. The respondents were assured that the information obtained from them would be kept confidential.

Authors’ Contributions

AM, RY, NA, KA, DA, and SH conceived the review, all authors participated in the literature research and data analysis. All Authors participated in drafting, critically revising, and approving the final version of the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data used for the current study will be available upon submitting a reasonable request from either the corresponding author or the principal investigator.*

Supplemental Material

Supplemental material for this article is available online.

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