Modes of thought, feeling, and action in infant pain assessment by pediatric nurses

Understanding caregiver judgments of infant pain: contrasts of parents, nurses and pediatricians

BACKGROUND

Research suggests that caregivers' beliefs pertaining to infant pain and which infant pain cues are perceived to be important play an integral role in pediatric pain assessment and management.

OBJECTIVES

Following a recent quasi-experimental study reporting on caregiver background and age differences in actual infant pain judgments, the present study clarified these findings by analyzing caregivers' pain beliefs and the cues they use to make pain assessments, and by examining how the wording of belief questions influenced caregivers' responses.

METHODS

After making pain judgments based on video footage of infants between two and 18 months of age receiving immunizations, parents, nurses and pediatricians were required to respond to questionnaires regarding pain beliefs and importance of cues.

RESULTS

Parents generally differed from pediatricians. Parents tended to have less optimal beliefs regarding medicating the youngest infants, were more influenced by question wording, and reported using many more cues when judging older infants than other caregiver groups. In terms of beliefs, influence of question wording and cue use, nurses tended to fall in between both groups; they displayed similarities to both parents and pediatricians.

CONCLUSIONS

Paralleling the original findings on pain judgments, these findings suggest that parents differ from pediatricians in their pain beliefs and the cues they use to make pain judgments. Moreover, some similarities were found between parents and nurses, and between nurses and pediatricians. Finally, caution must be taken when interpreting research pertaining to beliefs about infant pain because question wording appears to influence interpretation.

Neonatal Facial Coding System for Assessing Postoperative Pain in Infants: Item Reduction is Valid and Feasible

OBJECTIVE

The objectives of this study were to: (1). evaluate the validity of the Neonatal Facial Coding System (NFCS) for assessment of postoperative pain and (2). explore whether the number of NFCS facial actions could be reduced for assessing postoperative pain.

DESIGN

Prospective, observational study.

PATIENTS

Thirty-seven children (0-18 months old) undergoing major abdominal or thoracic surgery.

OUTCOME MEASURES

The outcome measures were the NFCS, COMFORT "behavior" scale, and a Visual Analog Scale (VAS), as well as heart rate, blood pressure, and catecholamine and morphine plasma concentrations. At 3-hour intervals during the first 24 hours after surgery, nurses recorded the children's heart rates and blood pressures and assigned COMFORT "behavior" and VAS scores. Simultaneously we videotaped the children's faces for NFCS coding. Plasma concentrations of catecholamine, morphine, and its metabolite M6G were determined just after surgery, and at 6, 12, and 24 hours postoperatively.

RESULTS

All 10 NFCS items were combined into a single index of pain. This index was significantly associated with COMFORT "behavior" and VAS scores, and with heart rate and blood pressure, but not with catecholamine, morphine, or M6G plasma concentrations. Multidimensional scaling revealed that brow bulge, eye squeeze, nasolabial furrow, horizontal mouth stretch, and taut tongue could be combined into a reduced measure of pain. The remaining items were not interrelated. This reduced NFCS measure was also significantly associated with COMFORT "behavior" and VAS scores, and with heart rate and blood pressure, but not with the catecholamine, morphine, or M6G plasma concentrations.

CONCLUSION

This study demonstrates that the NFCS is a reliable, feasible, and valid tool for assessing postoperative pain. The reduction of the NFCS to 5 items increases the specificity for pain assessment without reducing the sensitivity and validity for detecting changes in pain.

Observational visual analog scale in pediatric pain assessment: useful tool or good riddance?

DESIGN

The authors reviewed the available pediatric pain literature and selected those studies that reported quantitative information on the reliability and validity of, and the optimal cutoff points for, the visual analog scale (VAS) when used as an observational pediatric pain tool.

RESULTS

Available psychometric findings concerning the observational VAS (VAS obs ) are limited. The estimated interrater reliability of the VAS (obs) from 9 studies ranged from 0.36 to 0.91. The correlation between self-report and the VAS (obs) was variable and ranged 0.23 to 0.83 in 6 studies. The concurrent validity of the VAS (obs) and other pain instruments ranged from 0.42 to 0.86.

CONCLUSIONS

Further psychometric testing needs to be conducted on intraobserver reliability, responsiveness, and optimal cutoff points. Future research may guide the choice between VAS (obs) and the numerous behavioral pain instruments.

Nursing students' knowledge of and views about children in pain

It is important to evaluate the outcomes of the given education to gain knowledge about the abilities of our students to meet the needs of nursing practice. Pain associated with different illnesses and procedures is one of the most common symptoms that children experience in the hospital. The purpose of this study was to evaluate the views and knowledge base of graduating nursing students in the area of taking care of children in pain. The data were collected with a purpose-designed Likert-type instrument from all nursing students that graduated during one year from the child nurse specializing program in Finland (n = 85), with a response rate of 86%. Results indicate that students have mainly positive views and attitudes towards taking care of children in pain. The views and attitudes differ when older and younger students and students from different schools are compared. Students lack knowledge especially in the area of pain medications as well as in the assessment of pain. In the knowledge section, the results did not differ greatly when different schools, younger and older students or previous working experience and no working experience were compared. In some of the researched schools, many of the students felt a lack of confidence about their knowledge. There is a need for more detailed education in the area of taking care of children with pain.

Validity and reliability of a practice-based infant pain assessment instrument

The purpose of this study was to determine the validity and reliability of an infantpain assessment instrument. This instrument is an algorithm derived from a model of infant pain assessment that emerged from interviews with pediatric nurses and includes methods for evaluating clinical data that suggest the Iikelihood of pain. Unlike other instruments, this instrument is not restricted to use in clinical situations where the likelihood of pain is evident. This instrument determines the three levels of pain that guide subsequent nursing interventions: no pain, mild pain (discomfort), and severe pain. Content validity was determined by obtaining and incorporating feedback from a focus group of practicing pediatric nurses on various developmental stages of the instrument. Criterion-like validity was excellent: Mean Pearson correlations between the pain ratings of 18 videotaped infants by 24 nursing students using the instrument with ratings performed by a panel of 5 expert nurses not using any instrument was 0.96. Test-retest reliability, as measured by Pearson correlations between pain ratings 3 months apart, was also excellent (r = 0.91).

Assessment of pain and agitation in critically ill infants

Critically ill infants are subjected to many painful experiences that, if inadequately treated, can have severe physiological and psychological consequences. Optimal management of pain relies on the adequacy of nurses' assessment; this, however, is complicated by another common condition, agitation. A multidimensional assessment is therefore necessary to adequately identify pain and agitation. The aim of this descriptive study was to identify the cues that nurses caring for critically ill infants use to assess pain and agitation. A questionnaire, developed from the literature, was distributed to all registered nurses (85) working in the neonatal and paediatric intensive care units of an Australian teaching hospital. Questionnaires were completed by 41 nurses (a 57 per cent response rate). Results revealed that, except for diagnosis, there were no significant differences between the cues participants used to assess pain and those to assess agitation. Nurses used numerous cues from various sources: most importantly, their own judgement (99 per cent); the parents' judgement (90 per cent); the infant's environment; documentation (78 per cent), and the infant's cues (70 per cent). These findings demonstrate the relevance of the nurse's role in assessment of pain and agitation in critically ill infants. Nurses used cues specific to the critically ill rather than the less sick infant. Results of this study also show the difficulty of differentiating between pain and agitation. Further research on ways of distinguishing between the construct of pain and agitation needs to be undertaken.

The influence of background clinical data on infant pain assessments

The purpose of this study was to determine the importance of knowledge of clinical background data on nursing assessments of infant pain. In a quasi-experimental design, the infant pain assessments of two groups of pediatric nurses were compared. Both groups assessed the levels of pain of the same videotaped infants. One group also read clinical background data about each infant; the other group did not. The group who read clinical background data evidenced higher mean levels of assessed pain per videotaped infant than did the group who only viewed the videotapes. Findings underscore the importance of clinical data and clinical context in the process of assessing infant pain and the risk of underestimating pain when all factors are not considered.

The process of infant pain assessment

This study describes the process pediatric nurses used to assess pain in 0- to 12-month-old infants. Qualitative analyses of open-ended interviews with 40 pediatric nurses with from 1 to 20 years of experience produced an infant pain assessment model. This model explicates a "principle of consolability" and describes how nurses apply this principle, using comfort measures, in assessing pain of preverbal infants. Because this model makes processes involved in infant pain assessment explicit, it can be useful in teaching nursing students or novice pediatric nurses and in formulating hypotheses for further study.