Parent involvement in children's pain care: views of parents and nurses

Doctors' and Nurses' Attitudes of Acupuncture and Acupressure use in Perioperative Care: An Australian National Survey

BACKGROUND

Acupuncture and acupressure are not being systematically used in the management of postoperative nausea and vomiting and pain, despite being included in the guidelines.

AIM

To examine the beliefs, attitudes, and knowledge of Australian nurses/midwives and doctors toward the perioperative use of AA for the management of postoperative nausea and vomiting and pain; to explore the barriers and enablers influencing acupuncture and acupressure integration into hospital setting.

METHODS

A mixed-mode approach was undertaken for data collection. An online approach was used to recruit respondents from Australian College of Perioperative Nurses. Three hospitals from three different Australian states were selected via convenience sampling.

RESULTS

A total of 421 usable surveys were included in data analysis. The respondents comprised 14.3% doctors and 72.9% nurses/midwives. Overall, 69.4% were female, 85% were trained in Australia with 35% and 51.4% having knowledge or personal exposure to AA in general respectively. Over 60% of the respondents agreed AA should be routinely integrated into perioperative care, and over 80% would recommend AA to their patients if it was provided at their hospital, and, 75% would be willing to receive further education. The three main reported barriers included: perceived lack of scientific evidence (80.9%), unavailability of credentialed provider (77.2%) and lack of reimbursement (60.4%).

CONCLUSIONS

Positive attitudes are reported by Australian doctors and nurses toward AA. This is despite of low levels of knowledge or personal exposure to AA. Further studies are required to explore the implementation of barriers and address respondent calls for further education.

Meeting the Needs of Parents of Children With Scoliosis: A Qualitative Descriptive Study

Needs of parents with children with scoliosis are complex and depend on their child’s treatments. The purpose of this study was to identify needs of parents with children with scoliosis. This qualitative description involved interviews with parents of children at various stages of treatment. A convenience, then purposeful sample of 16 parents (12 mothers, two fathers, and two stepfathers) was interviewed; interviews were transcribed and analyzed using thematic analysis. Parents’ needs included: Needing reliable medical information; Desiring information on complementary treatments; Wanting help in supporting and advocating for their child; Needing to protect the child and family; and Seeking connection and support. Although many parents’ needs are being met, this study recommends a nursing role aimed at providing parents with reliable medical information, discussing alternative treatments, assisting parents in their role of supporting their child, helping parents in their advocacy efforts, and referring parents to appropriate connections.

Paediatric oncology patients' definitions of a good physician and good nurse

BACKGROUND

It is stated that the communication and disease experiences of paediatric patients, especially paediatric oncology patients, with healthcare professionals are completely different from those of adults.

OBJECTIVE

The aim of this study was to determine the definitions of a good physician and good nurse provided by elementary school-age oncology patients.

RESEARCH DESIGN

In this qualitative research, data were collected through semi-structured individual interviews. The data were evaluated thorough thematic analysis.

PARTICIPANTS AND RESEARCH CONTEXT

Eighteen children hospitalised due to cancer in paediatric oncology and haematology clinics of a university hospital in Turkey.

ETHICAL CONSIDERATIONS

Permission to conduct the study was obtained from the Institution's Ethics Committee. The objectives of this study were explained to the participants and families, and written consent was obtained from them. Also, participants were assured that necessary measures would be taken to protect their anonymity and confidentiality.

FINDINGS

The definitions of children were based on five main themes: interpersonal relationships, virtues, professional responsibility, security and individual characteristics.

CONCLUSION

Children conveyed important messages to health professionals. They emphasised that a good physician and good nurse should communicate well, not only with themselves but also with their family. In addition, children were sensitive about health professionals who played with them and actively participated in the treatment by informing them about the disease. Meeting the expectations of children can be possible by improving the communication skills of physicians and nurses and by adding games and activities to the treatment and care plan.

A Pilot Randomized Controlled Trial of Outcomes Associated with Parent-Nurse Controlled Analgesia vs. Continuous Opioid Infusion in the Neonatal Intensive Care Unit

PURPOSE

Prospectively compare parent/nurse controlled analgesia (PNCA) to continuous opioid infusion (COI) in the post-operative neonatal intensive care unit (NICU) population.

DESIGN/METHODS

A randomized controlled trial compared neonates treated with morphine PNCA to those treated with morphine COI. The primary outcome was average opioid consumption up to 3 post-operative days. Secondary outcomes included 1) pain intensity, 2) adverse events that may be directly related to opioid consumption, and 3) parent and nurse satisfaction.

RESULTS

The sample consisted of 25 post-operative neonates and young infants randomized to either morphine PNCA (n = 16) or COI (n = 9). Groups differed significantly on daily opioid consumption, with the PNCA group receiving significantly less opioid (P = .02). Groups did not differ on average pain score or frequency of adverse events (P values > .05). Parents in both groups were satisfied with their infant's pain management and parents in the PNCA group were slightly more satisfied with their level of involvement (P = .03). Groups did not differ in nursing satisfaction.

CONCLUSIONS

PNCA may be an effective alternative to COI for pain management in the NICU population. This method may also substantially reduce opioid consumption, provide more individualized care, and improve parent satisfaction with their level of participation.

CLINICAL IMPLICATIONS

Patients in the NICU represent one of our most vulnerable patient populations. As nurses strive to provide safe and effective pain management, results of this study suggest PNCA may allow nurses to maintain their patients' comfort while providing less opioid and potentially improving parental perception of involvement.

STUDY TYPE

Treatment study.

LEVEL OF EVIDENCE

I.

Tokenism or true partnership: Parental involvement in a child's acute pain care

AIMS AND OBJECTIVES

To explore parental involvement in the child's acute pain care and establish ways in which parental preferences for involvement in their child's care can be identified, facilitated and enhanced by nurses.

BACKGROUND

Despite growing evidence supporting effective acute pain management in children and the availability of national and international practice guidelines, children still experience acute pain. Involving parents in their child's pain care has been identified as being a central tenet of pain management in children.

DESIGN AND METHODS

A qualitative study using an ethnographical approach with nonparticipant observation and follow-up semi-structured interviews was undertaken. Nurses (n = 14), parents (n = 41), grandparents (n = 2), other relative (n = 1) and children (n = 30) participated. The framework approach underpinned data analysis. Consolidated criteria for reporting qualitative research (COREQ) enabled comprehensive reporting of the study.

RESULTS

Three concepts emerged from the data: "parents as advocates for their child," "nurses promoting involvement and partnership" and "nurses unintentionally preventing involvement and partnership." Variations in the way parents were involved in their child's pain care were identified. Despite family-centred care being the dominant model of involving families in their child's care, evidence of this being implemented was limited. Parents attempted to advocate effective pain care for their child, whether or not they were supported by nurses.

CONCLUSIONS

Parental involvement in their child's acute pain care can improve the child's pain experience, reduce parental anxiety and increase parents' satisfaction in care. Nurses aspired to involve parents in pain care, but did not always enact this in practice.

RELEVANCE FOR PRACTICE

Children deserve optimum pain care, which includes parental involvement. Parental involvement underpinned by the principles of family-centred care was poorly implemented. Parents attempted to be involved and advocate for their child's pain care whether or not they were supported by nurses. An alternative approach for supporting parents to advocate in their child's acute pain care is offered, the "Partnership in Pain Care Model."

Parents and Physiotherapists Recognition of Non-Verbal Communication of Pain in Individuals with Cerebral Palsy

Pain assessment is difficult in individuals with cerebral palsy (CP). This is of particular relevance in children with communication difficulties, when non-verbal pain behaviors could be essential for appropriate pain recognition. Parents are considered good proxies in the recognition of pain in their children; however, health professionals also need a good understanding of their patients' pain experience. This study aims at analyzing the agreement between parents' and physiotherapists' assessments of verbal and non-verbal pain behaviors in individuals with CP. A written survey about pain characteristics and non-verbal pain expression of 96 persons with CP (45 classified as communicative, and 51 as non-communicative individuals) was performed. Parents and physiotherapists displayed a high agreement in their estimations of the presence of chronic pain, healthcare seeking, pain intensity and pain interference, as well as in non-verbal pain behaviors. Physiotherapists and parents can recognize pain behaviors in individuals with CP regardless of communication disabilities.

Parent's experiences of their child's withdrawal syndrome: a driver for reciprocal nurse-parent partnership in withdrawal assessment

Withdrawal assessment in critically ill children is complicated by the reliance on non-specific behaviours and compounded when the child's typical behaviours are unknown. The existing approach to withdrawal assessment assumes that nurses elicit the parents' view of the child's behaviours.

OBJECTIVE AND RESEARCH METHODOLOGY

This qualitative study explored parents' perspectives of their child's withdrawal and preferences for involvement and participation in withdrawal assessment. Parents of eleven children were interviewed after their child had completed sedation weaning during recovery from critical illness. Data were analysed using thematic analysis.

SETTING

A large children's hospital in the Northwest of England.

FINDINGS

Parents experienced varying degrees of partnership in the context of withdrawal assessment and identified information deficits which contributed to their distress of parenting a child with withdrawal syndrome. Most parents were eager to participate in withdrawal assessment and reported instances where their knowledge enabled a personalised interpretation of their child's behaviours. Reflecting on the reciprocal nature of the information deficits resulted in the development of a model for nurse-parent collaboration in withdrawal assessment.

CONCLUSION

Facilitating nurse-parent collaboration in withdrawal assessment may have reciprocal benefits by moderating parental stress and aiding the assessment and management of withdrawal syndrome.

The experiences of acute non-surgical pain of children who present to a healthcare facility for treatment: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The qualitative objective of this systematic review is to identify and synthesize the best available evidence on experiences of acute non-surgical pain, including pain management, of children (between four to 18 years) when they present to a healthcare facility for treatment.The specific objectives are to identify:

BACKGROUND

The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage". The pain experience is multifaceted and complex, extending beyond the physiological interpretation of a noxious stimulus, encompassing other dimensions, including; psychological, cognitive, sociocultural, affective and emotional factors. Pain can be described as chronic (persisting for three months or more) or acute (a time limited response to a noxious stimuli). Over the past 50 years clinical research has made revolutionary contributions to better understanding pediatric pain. The once pervasive erroneous notion that infants do not experience pain the same way as adults has been firmly dispelled. We now know that nervous system structures associated with the physiological interpretation of pain are functional as early as fetal development. Despite this critical knowledge and the growing global commitment to improving pediatric pain management in clinical practice, evidence repeatedly suggests that pain management remains suboptimal and inconsistent, a phenomenon commonly referred to as oligoanalgesia. Research evidence has linked poorly managed pain in the pediatric population to negative behavioral and physiological consequences later in life. Effective pain management is therefore a priority area for health care professionals. Improved understanding of children's experiences of acute non-surgical pain may lead to improved pain management and a reduction in oligoanalgesia.In the 1970s and 1980s, studies began exploring the subjective experiences of pediatric pain and discovered children's abilities to articulate their pain experiences, and to link causes and consequences of their pain. Developmental trends or age related patterns with regards to children's expressions and experiences of pain were identified. Recent studies have also recognized apparent trends in children's understanding and expressions of pain; these follow an age and cognitive development trajectory in line with Piaget's theories of development.For many children psychosocial aspects of pain, including emotions like fear, stress and anxiety, are often more unpleasant than the painful experience itself. Emotional responses such as distress and anxiety are commonly associated with the anticipation of pain, can exacerbate and intensify the pain experience, and can significantly lower a child's pain threshold. One study utilized an observational pain assessment tool to explore children's pain experiences. The findings indicated that children who underwent "non-painful" procedures (such as restraint) had equal, and in some cases higher, pain scores than those who underwent painful procedures (such as intravenous cannulation).Several studies exploring pediatric pain within health care settings (including, but not limited to, general practitioners, hospitals, emergency departments and outpatient clinics) have adopted quantitative methods, some examined parents' perspectives, and others explored nurses' perceptions. While results of such studies have added to the existing body of knowledge that supports the need to focus on improving pediatric pain management, it has been suggested that failing to ask children directly risks not capturing subjective experiences of pain from the children's perspectives in their entirety. Seeking the children's perspectives could provide a more reliable and adequate means of gaining insight into their needs and expectations when they are in pain.A single centered study in Singapore used semi-structured face-to-face interviews (n=15) to explore children's experiences of pain management postoperatively. While the children, aged between six and 12 years, identified the role of analgesia in managing their pain, they also placed significant emphasis on the role of parents and health care professionals in implementing non-pharmacological interventions in pain management. These results are relevant as they provide insights into how children experience and express pain, and their expectations of health care professionals in managing their pain. These findings draw attention to effective pain management approaches when caring for children. Similarly, a UK study adopted a cross sectional descriptive design using the draw and write technique aimed at investigating children's views on what helped when they were in pain. The children (n=71) were aged between four and 16 years. Findings revealed that children viewed themselves as active agents in pain management, while also placing significant emphasis on the importance of parents and nurses in managing their pain. In both studies, children valued nurses for social interactions, such as kindness and humor, rather than the provision of clinical care, including analgesia administration. Adjunct therapies such as distraction, visualization and music have also been shown to be effective in managing the pain experience in children.Not only do these findings demonstrate the complexity of the pain experience for the child, they also support the notion that improved pain management may come from research that is designed to better understand the entire pain experience from the child's perspective. While there are systematic reviews on interventions for managing children's pain, and one explored children's experiences in the postoperative context, none have considered children's experiences of acute non-surgical pain when they present for treatment. This qualitative systematic review aims to identify and synthesize results of studies exploring children's experiences of pain and pain management.

Supporting Parents' Pain Care Involvement With Their Children With Acute Lymphoblastic Leukemia: A Qualitative Interpretive Description

Children with acute lymphoblastic leukemia experience pain from the disease, treatment, and procedures. Parents can be effective in managing their child's pain, but little is systematically known about how they do this. Appreciative inquiry was used to frame the study within a strengths-based lens and interpretive descriptive methods were used to describe pain sources, parents' pain care role, and key structures supporting parents pain care involvement. Eight paediatric oncology clinic nurses and 10 parents participated. Six key themes per group were identified. Parent themes included establishing therapeutic relationships, relearning how to care for my child, overcoming challenges and recognizing pain, learning parent specific strategies, empowering to take active pain care role, and maintaining relationships. Nurse themes included establishing therapeutic relationships, preparing parents to care for their child, facilitating pain assessment, teaching parents best pain care, empowering parents, and maintaining relationships. These findings can be used to guide clinical practice and future research.

Experiences of acute pain in children who present to a healthcare facility for treatment: a systematic review of qualitative evidence

BACKGROUND

Pain is a universal and complex phenomenon that is personal, subjective and specific. Despite growing knowledge in pediatric pain, management of children's pain remains sub-optimal and is linked to negative behavioral and physiological consequences later in life. As there is no synthesis of these studies, it was timely to undertake a systematic review.

OBJECTIVES

To identify, evaluate and synthesize the existing qualitative evidence on children's experiences of acute pain, including pain management, within a healthcare facility.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Children aged four to 18 years (inclusive) attending a healthcare facility who experienced acute pain associated with any injury, medical condition or treatment.

PHENOMENA OF INTEREST

Children's experiences and perceptions of their acute pain, pain management and expectations of others in managing their pain. Studies on children's experiences of pain in the postoperative context were excluded as a systematic review exploring this phenomenon had previously been published. Studies reporting on children's experiences of chronic pain were also excluded.

CONTEXT

Any healthcare facility including general practitioners' surgeries, hospitals, emergency departments and outpatient clinics.

TYPES OF STUDIES

Qualitative studies including phenomenology, grounded theory, ethnography, action research and feminist research designs.

SEARCH STRATEGY

Using a three-step search strategy, databases were searched in December 2015 to identify both published and unpublished articles from 2000 to 2015. Studies published in languages other than English were excluded.

METHODOLOGICAL QUALITY

All studies that met the inclusion criteria were assessed by at least two independent reviewers for methodological quality using a standardized critical appraisal tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI).

DATA EXTRACTION

Data were extracted from the papers included in the review using standardized data extraction tool from JBI-QARI.

DATA SYNTHESIS

Findings were pooled using JBI-QARI. Findings were rated according to their level of credibility and categorized based on similarity in meaning and then were subjected to a meta-synthesis.

RESULTS

Four studies were included in this review. Two meta-syntheses were generated from five categories based on 21 findings: first, children can express their pain experiences in terms of cause, location, meaning and quality. Children's pain experiences include both physical and psychological dimensions. Children's pain experiences are influenced by their previous pain experiences, pain expectations and sociocultural factors. Second, children use a range of cognitive/behavioral and sensory/physical self-soothing strategies not only to help manage their pain, but also rely on the actions and presence of others as helpers when they are in pain.

CONCLUSION

Children's pain is a multi-dimensional complex phenomenon relying upon a multi-modal approach to management. Children as young as four years are capable of articulating their pain in terms of location, intensity and depth. The way children perceive, express and respond to pain is shaped by sociocultural factors, previous pain experiences and their expectations of pain. Children, parents and healthcare professionals play an important role in managing children's pain experiences.

Skin-to-skin care for procedural pain in neonates

BACKGROUND

Skin-to-skin care (SSC), often referred to as 'kangaroo care' (KC) due to its similarity with marsupial behaviour of ventral maternal-infant contact, is one non-pharmacological intervention for pain control in infants.

OBJECTIVES

The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and to determine the effects of the amount of SSC (duration in minutes), method of administration (e.g. who provided the SSC) of SSC in reducing pain from medical or nursing procedures in neonatesThe secondary objectives were to determine the safety of SSC care for relieving procedural pain in infants; and to compare the SSC effect in different postmenstrual age subgroups of infants.

SEARCH METHODS

For this update, we used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1); MEDLINE via PubMed (1966 to 25 February 2016); Embase (1980 to 25 February 2016); and CINAHL (1982 to 25 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials.

SELECTION CRITERIA

Studies with randomisation or quasi-randomisation, double- or single-blinded, involving term infants (≥ 37 completed weeks' postmenstrual age (PMA) to a maximum of 44 weeks' PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by healthcare professionals.

DATA COLLECTION AND ANALYSIS

The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A mean difference (MD) with 95% confidence interval (CI) using a fixed-effect model was reported for continuous outcome measures. We included variations on type of tissue-damaging procedure, provider of care, and duration of SSC.

MAIN RESULTS

Twenty-five studies (n = 2001 infants) were included. Nineteen studies (n = 1065) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), three used intramuscular injection (n = 776), one used 'vaccination' (n = 60), and one used tape removal (n = 50). The studies were generally strong and had low or uncertain risk of bias. Blinding of the intervention was not possible, making them subject to high risk, depending on the method of scoring outcomes.Seventeen studies (n = 810) compared SSC to a no-treatment control. Although 15 studies measured heart rate during painful procedures, data from only five studies (n = 161) could be combined for a mean difference (MD) of -10.78 beats per minute (95% CI -13.63 to -7.93) favouring SSC. Meta-analysis of four studies (n = 120) showed no difference in heart rate following the painful procedure (MD 0.08, 95% CI -4.39 to 4.55). Two studies (n = 38) reported heart rate variability with no significant differences. Two studies (n = 101) in a meta-analysis on oxygen saturation at 30 and 60 seconds following the painful procedure did not show a difference. Duration of crying meta-analysis was performed on four studies (n = 133): two (n = 33) investigated response to heel lance (MD = -34.16, 95% CI -42.86 to -25.45), and two (n = 100) following IM injection (MD = -8.83, 95% CI -14.63 to -3.02), favouring SSC. Five studies, one consisting of two substudies (n = 267), used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (MD -3.21, 95% CI -3.94 to -2.47), at 60 seconds (3 studies; n = 156) (MD -1.64, 95% CI -2.86 to -0.43), and at 90 seconds (n = 156) (MD -1.28, 95% CI -2.53 to -0.04); but at 120 seconds there was no difference (n = 156) (MD 0.07, 95% CI -1.11 to 1.25). No studies on return of heart rate to baseline level, cortisol levels, and facial actions could be combined for meta-analysis findings.Eight studies compared SSC to another intervention with or without a no-treatment control. Two cross-over studies (n = 80) compared mother versus other provider (father, another female) on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC (n = 640) with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate (n = 95). SSC either in combination with breastfeeding or alone was favoured over a no-treatment control, but not different to breastfeeding. One study compared SSC alone and in combination with both sucrose and breastfeeding on heart rate (HR), NIPS scores, and crying time (n = 127). The combinations were more effective than SSC alone for NIPS and crying. Expressed breast milk was compared to SSC in one study (n = 50) and found both equally effective on PIPP scores. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies.

AUTHORS' CONCLUSIONS

SSC appears to be effective as measured by composite pain indicators with both physiological and behavioural indicators and, independently, using heart rate and crying time; and safe for a single painful procedure. Purely behavioural indicators tended to favour SSC but with facial actions there is greater possibility of observers not being blinded. Physiological indicators were mixed although the common measure of heart rate favoured SSC. Two studies compared mother-providers to others, with non-significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. Studies examining optimal duration of SSC, gestational age groups, repeated use, and long-term effects of SSC are needed. Of interest would be to study synergistic effects of SSC with other interventions.

Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council

Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence.

PERSPECTIVE

This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations.

Prevention and Intervention Strategies to Alleviate Preoperative Anxiety in Children

Preoperative anxiety (anxiety regarding impending surgical experience) in children is a common phenomenon that has been associated with a number of negative behaviors during the surgery experience (e.g., agitation, crying, spontaneous urination, and the need for physical restraint during anesthetic induction). Preoperative anxiety has also been associated with the display of a number of maladaptive behaviors postsurgery, including postoperative pain, sleeping disturbances, parent-child conflict, and separation anxiety. For these reasons, researchers have sought out interventions to treat or prevent childhood preoperative anxiety and possibly decrease the development of negative behaviors postsurgery. Such interventions include sedative premedication, parental presence during anesthetic induction, behavioral preparation programs, music therapy, and acupuncture. The present article reviews the existing research on the various modes of intervention for preoperative anxiety in children. Clinical implications and future directions are discussed.

Neglect of Postoperative Pain Management in Children: A Qualitative Study Based on the Experiences of Parents

Identifying parents' experiences of barriers to optimal postoperative pain management in children.

DESIGN AND METHODS

This qualitative-content analysis study was conducted with 16 parents whose school-age children had undergone emergency abdominal surgery in university hospitals of Ahvaz, southern Iran. A purposive sampling method was used to select the participants. The semi-structured interviews with all of the participants were recorded, transcribed, and analysed.

RESULTS

After data analysis, neglect emerged as the main theme. This neglect consisted of three categories including the healthcare system's disregard, insufficient sensitivity of the healthcare providers, and hesitance or delays of parents and children in asking for care.

CONCLUSION

The optimal management of children's postoperative pain requires the provision of relevant infrastructures by the healthcare system, responsible performance of the health professionals beyond the routine, and active and informed participation of both parents and children.

Experiences of Iranian Nurses on the Facilitators of Pain Management in Children: A Qualitative Study

Background. Despite decades of research and the availability of effective analgesic approaches, many children continue to experience moderate-to-severe pain after hospitalization. Greater research efforts are needed to identify the factors that facilitate effective pain management. The aim of this study was to explore the perceptions of Iranian nurses on facilitators of pain management in children. Materials and Methods. This qualitative study collected the data profoundly through unstructured interviews with 19 nurses in Amirkola Children's Hospital in Babol and Children's Medical Center in Tehran, during 2013-2014. Purposeful sampling and analysis of the data were conducted using conventional qualitative content analysis. Results. Four themes were extracted through data analysis: mother and child participation in diagnosis and pain relief, the timely presence of medical staff and parents, proper communication, and training and supportive role of nurses. Conclusion. Mother and child participation in the report and diagnosis of pain and nonpharmacological interventions for pain by the mother, the timely presence of medical team at the patient's bedside, and proper interaction along with the training and supportive role of a nurse enhanced the optimal pain management in hospitalized children.

Partnership With Parents of Technology-Dependent Children: Clarification of the Concept

A strategy based on the Hybrid Model of Concept Development was used to integrate previous concept analyses and research with data from interviews with parents and nurses caring for children dependent on technology to clarify the concept. Partnership was generally described positively in the literature, but some cautions were noted. Six characteristics of partnering were identified from the fieldwork data: respect, flexibility, caring professionalism, communication, acknowledgment of parental control, and support for parents. The concept of participation is clarified and extended to a unique area of nursing practice, the care of children dependent on technology in the home.

Skin-to-skin care for procedural pain in neonates

BACKGROUND

Skin-to-skin care (SSC), otherwise known as Kangaroo Care (KC) due to its similarity with marsupial behaviour of ventral maternal-infant contact, is one non-pharmacological intervention for pain control in infants.

OBJECTIVES

The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates undergoing painful procedures compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and the effects of the amount of SSC (duration in minutes) and the method of administration (who provided the SSC, positioning of caregiver and neonate pair).The secondary objectives were to determine the incidence of untoward effects of SSC and to compare the SSC effect in different postmenstrual age subgroups of infants.

SEARCH METHODS

The standard methods of the Cochrane Neonatal Collaborative Review Group were used. Databases searched in August 2011: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library); Evidence-Based Medicine Reviews; MEDLINE (1950 onwards); PubMed (1975 onwards); EMBASE (1974 onwards); CINAHL (1982 onwards); Web of Science (1980 onwards); LILACS database (1982 onwards); SCIELO database (1982 onwards); PsycInfo (1980 onwards); AMED (1985 onwards); Dissertation-Abstracts International (1980 onwards). Searches were conducted throughout September 2012.

SELECTION CRITERIA

Studies with randomisation or quasi-randomisation, double or single-blinded, involving term infants (> 37 completed weeks postmenstrual age (PMA)) to a maximum of 44 weeks PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by doctors, nurses, or other healthcare professionals.

DATA COLLECTION AND ANALYSIS

The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A weighted mean difference (WMD) with 95% confidence interval (CI) using a fixed-effect model was reported for continuous outcome measures. We included variations on type of tissue-damaging procedure, provider of care, and duration of SSC.

MAIN RESULTS

Nineteen studies (n = 1594 infants) were included. Fifteen studies (n = 744) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), two used intramuscular injection, and one used 'vaccination' (n = 80). The studies that were included were generally strong and free from bias.Eleven studies (n = 1363) compared SSC alone to a no-treatment control. Although 11 studies measured heart rate during painful procedures, data from only four studies (n = 121) could be combined to give a mean difference (MD) of 0.35 beats per minute (95% CI -6.01 to 6.71). Three other studies that were not included in meta-analyses also reported no difference in heart rate after the painful procedure. Two studies reported heart rate variability outcomes and found no significant differences. Five studies used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (n = 268) (MD -3.21, 95% CI -3.94 to -2.48), 60 seconds (n = 164) (MD -1.85, 95% CI -3.03 to -0.68), and 90 seconds (n = 163) (MD -1.34, 95% CI -2.56 to -0.13), but at 120 seconds (n = 157) there was no difference. No studies provided findings on return of heart rate to baseline level, oxygen saturation, cortisol levels, duration of crying, and facial actions that could be combined for analysis.Eight studies compared SSC to another intervention with or without a no-treatment control. Two cross-over studies (n = 80) compared mother versus other provider on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate but not oxygen saturation. SSC either in combination with breastfeeding or alone was favoured over a no-treatment control, but was not different to breastfeeding. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies.

AUTHORS' CONCLUSIONS

SSC appears to be effective, as measured by composite pain indicators and including both physiological and behavioural indicators, and safe for a single painful procedure such as a heel lance. Purely behavioural indicators tended to favour SSC but there remains questionable bias regarding behavioural indicators. Physiological indicators were typically not different between conditions. Only two studies compared mother providers to others, with non-significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. New studies examining optimal duration of SSC, gestational age groups, repeated use, and long-term effects of SSC are needed.

The quality of the face-to-face counselling in paediatric ambulatory tonsillectomy: parental point of view

The objective of this study was to examine parental opinion on the quality of preoperative face-to-face counselling about the child's preoperative fasting. Families, whose child was admitted for ambulatory tonsillectomy were randomly assigned to the study groups (n = 116; 58/58). The intervention group received the information with face-to-face counselling, and the control group in written form. The parents assessed (visual analogue scale) the level of clarity, intelligibility and adequacy of the information, how well they had understood the meaning and the implementation of the child's preoperative fast, as well as their own skills and success to implement the child's fast. The parents in the intervention group felt that the information was significantly clearer, more intelligible and adequate and that they succeeded well. Face-to-face counselling is an effective way to educate the parents.

An interpretive phenomenological study of Chinese mothers' experiences of constant vigilance in caring for a hospitalized sick child

AIM

To examine Chinese mothers' experience of caring for their hospitalized sick child.

BACKGROUND

Engaging the mother in providing care for a hospitalized sick child is considered one of the key elements for high-quality care in advanced paediatric nursing. There is evidence that a mother's belief in her capacity to manage stressful situations could improve the nurse-parent relationship because they might play an important role in protecting mothers against heightened stress during crisis situation.

DESIGN

An interpretive phenomenological approach involving semi-structured interview and thematic analysis was used.

METHOD

Fifteen interviews were conducted in Hong Kong, China from April 2009-January 2010, with 15 mothers caring for their hospitalized sick children with acute injury or illness. Crist and Tanner's circular process of hermeneutic interpretive phenomenology was chosen to guide the data analysis.

FINDINGS

The prevailing concept identified through analysis was the 'constant vigilance' that mothers developed. Interpretation of data resulted in the identification of four key themes: 'being sensitive to others', 'providing helping hands', 'monitoring health conditions', and 'maintaining dialogues'. The findings highlight Chinese mothers' desire for participation in caring for their hospitalized child, their unexpressed needs for communication, and concern about being uncared by the busy health professionals, which affect their care for the child's health outcomes.

CONCLUSION

The findings facilitate the development of family-centred care focuses on partnership of care between the nurse and family to enhance the Chinese family's active and participatory role.

Family-centred care for hospitalised children aged 0-12 years

BACKGROUND

This is an update of the Cochrane systematic review of family-centred care published in 2007 (Shields 2007). Family-centred care (FCC) is a widely used model in paediatrics, is thought to be the best way to provide care to children in hospital and is ubiquitous as a way of delivering care. When a child is admitted, the whole family is affected. In giving care, nurses, doctors and others must consider the impact of the child's admission on all family members. However, the effectiveness of family-centred care as a model of care has not been measured systematically.

OBJECTIVES

To assess the effects of family-centred models of care for hospitalised children aged from birth (unlike the previous version of the review, this update excludes premature neonates) to 12 years, when compared to standard models of care, on child, family and health service outcomes.

SEARCH METHODS

In the original review, we searched up until 2004. For this update, we searched: the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library, Issue 12 2011); MEDLINE (Ovid SP); EMBASE (Ovid SP); PsycINFO (Ovid SP); CINAHL (EBSCO Host); and Sociological Abstracts (CSA). We did not search three that were included in the original review: Social Work Abstracts, the Australian Medical Index and ERIC. We searched EMBASE in this update only and searched from 2004 onwards. There was no limitation by language. We performed literature searches in May and June 2009 and updated them again in December 2011.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) including cluster randomised trials in which family-centred care models are compared with standard models of care for hospitalised children (0 to 12 years, but excluding premature neonates). Studies had to meet criteria for family-centredness. In order to assess the degree of family-centredness, we used a modified rating scale based on a validated instrument, (same instrument used in the initial review), however, we decreased the family-centredness score for inclusion from 80% to 50% in this update. We also changed several other selection criteria in this update: eligible study designs are now limited to randomised controlled trials (RCTs) only; single interventions not reflecting a FCC model of care have been excluded; and the selection criterion whereby studies with inadequate or unclear blinding of outcome assessment were excluded from the review has been removed.

DATA COLLECTION AND ANALYSIS

Two review authors undertook searches, and four authors independently assessed studies against the review criteria, while two were assigned to extract data. We contacted study authors for additional information.

MAIN RESULTS

Six studies found since 2004 were originally viewed as possible inclusions, but when the family-centred score assessment was tested, only one met the minimum score of family-centredness and was included in this review. This was an unpublished RCT involving 288 children post-tonsillectomy in a care-by-parent unit (CBPU) compared with standard inpatient care.The study used a range of behavioural, economic and physical measures. It showed that children in the CBPU were significantly less likely to receive inadequate care compared with standard inpatient admission, and there were no significant differences for their behavioural outcomes or other physical outcomes. Parents were significantly more satisfied with CBPU care than standard care, assessed both before discharge and at 7 days after discharge. Costs were lower for CPBU care compared with standard inpatient care. No other outcomes were reported. The study was rated as being at low to unclear risk of bias.

AUTHORS' CONCLUSIONS

This update of a review has found limited, moderate-quality evidence that suggests some benefit of a family-centred care intervention for children's clinical care, parental satisfaction, and costs, but this is based on a small dataset and needs confirmation in larger RCTs. There is no evidence of harms. Overall, there continues to be little high-quality quantitative research available about the effects of family-centred care. Further rigorous research on the use of family-centred care as a model for care delivery to children and families in hospitals is needed. This research should implement well-developed family-centred care interventions, ideally in randomised trials. It should investigate diverse participant groups and clinical settings, and should assess a wide range of outcomes for children, parents, staff and health services.

Nurses' views about the barriers and facilitators to effective management of pediatric pain

Children continue to experience moderate to severe pain during hospitalization. This paper presents data from two modified focus groups undertaken as part of a larger study exploring pediatric pain management practices in one hospital in the south of England. Thirty nurses took part in the focus groups and were asked questions about their views about the barriers and facilitators to effective pain management in the hospital. Participants identified a number of barriers which related to the staff, children and parents and the organization. Nurses indicated that they and the medical staff lacked knowledge about pain management. They also felt that staff shortages and a heavy workload detracted from the quality of the care they could provide. Several participants indicated that insufficient analgesic drugs were sometimes prescribed. Many of the barriers identified related to parents and children. It appears that nurses may not take as active a role as they could do in managing pediatric pain rather seeing it as the parents and child's responsibility to let them know when they are experiencing pain. Nurses also felt that parents exaggerate their child's pain and ask for analgesic drugs before their child needs them. There is a need to explore the interactions between nurses, children and parents in this context in more detail.

Procedural pain management for neonates using nonpharmacological strategies: part 2: mother-driven interventions

This is the second of a 2-part series to provide an overview of our current level of knowledge related to nonpharmacological strategies to diminish the pain associated with commonly performed procedures in the NICU. In our first article we discussed the prevalence of repeated pain exposure in the NICU and the importance of nonpharmacological strategies specifically containment or facilitated tucking, swaddling, positioning, nonnutritive sucking, and sweet solutions. These strategies are generally nurse-driven and we believe their importance has been underutilized. In this article we will emphasize the importance of maternal presence as a mediator for pain relief. The efficacy of breastfeeding, maternal skin-to-skin care (often referred to as kangaroo care), and multisensorial stimulation such as auditory and olfactory recognition will be the primary focus of our discussion. In addition, although primarily mother-driven, these strategies are ultimately nurse-enabled, thus the importance of this connection cannot be under appreciated with respect to successful implementation in the NICU.

Singaporean nurses' provision of guidance to parents on non-pharmacological postoperative pain-relief methods: An educational intervention study

This study examined the impact of an educational intervention (booklet distribution and lectures) on Singaporean nurses' provision of guidance to parents on the use of non-pharmacological methods of pain relief for their child's postoperative pain. Using a quasi-experimental one-group pre- and post-test study design, 134 and 112 registered nurses completed the questionnaires pre- and post-test, respectively. More than 75% of the nurses "always" guided parents to use breathing techniques, relaxation, positioning, comforting/reassurance, helping with activities of daily living, and creating a comfortable environment in the pretest and touch, presence, and distraction in addition to the aforementioned methods in the post-test. The nurses' provision of guidance to parents on all non-pharmacological methods increased, but statistically significant increases only were found in relation to massage and positive reinforcement. The results suggested that the educational intervention had some impact on nurses' provision of guidance to parents on the use of non-pharmacological methods of pain relief for children's postoperative pain. Continuing education in pain management should be provided to nurses in order to equip them with the knowledge to improve their practice.

Parent-provider communication during hospitalization

Parents and health care providers interact and communicate with each other during a child's hospitalization. The purpose of this study was to compare communication experiences of parents, nurses, and physicians. A unique aspect of this study involved combining three individual data sources into a collective unit of study (triad). Triads involved in the care of three children in the inpatient setting of an urban children's hospital served as the sample for this study (n = 10). Participants were asked semistructured questions during face-to-face interviews. Findings included (a) the importance of providing information by health care providers using a caring and inclusive approach, (b) the benefits of establishing interpersonal connections and nurturing relationships, and (c) the identification of specific behaviors in all members of the triad that contribute to and sustain positively perceived communication. Future research directions examining triadic interactions, communication, and relationships among parents, nurses, and physicians are recommended.

Parental involvement in their school-aged children's post-operative pain management in the hospital setting: a comprehensive systematic review

BACKGROUND

Paediatric pain management remains a challenge in clinical settings. Parents can contribute to the effective and accurate pain assessment and management of their child. No systematic reviews regarding the parental involvement in their child's post-operative pain management have been published.

OBJECTIVE

To determine the best available evidence regarding parental involvement in managing their children's post-operative pain in the hospital setting.

INCLUSION CRITERIA

The review considered studies that included parents of all ethnic groups with children aged between 6 to 12 years old who were hospitalised and undergone surgery of any kind with post-operative surgical or incision site pain where care was provided in acute hospital settings. The phenomena of interest were the experiences of parents in managing their children's post-operative pain.

SEARCH STRATEGY

A three-step search strategy was utilised in each component of this review. Major databases searched included: MEDLINE, CINAHL, Scopus, ScienceDirect, the Cochrane library, PubMed as well as Google Scholar. The search included published studies and papers in English from 1990 to 2009.

METHODOLOGICAL QUALITY

Each included study was assessed by two independent reviewers using the appropriate appraisal checklists developed by the Joanna Briggs Institute (JBI).

DATA COLLECTION

Quantitative and qualitative data were extracted from the included papers using standardised data extraction tools from the JBI, Meta-analysis Statistics Assessment and Review Instrument data extraction tool for descriptive/case series and the JBI-Qualitative Assessment and Review Instrument data extraction tool for interpretive and critical research.

DATA SYNTHESIS

The five quantitative studies included in this review were not suitable for meta-analysis due to clinical and methodological heterogeneity and therefore the findings are presented in a narrative form. The two qualitative studies were from the same study, therefore meta-synthesis was not possible. Hence the results of the studies were presented in a narrative format.

RESULTS

Seven papers were included in this review. The evidence identified topics including: pharmacological and non-pharmacological interventions carried out by parents; the experience of concern, fear, helplessness, anxiety, depression, frustration and lack of support felt by parents during their child's hospitalisation; communication issues and knowledge deficits; need for information by parents to promote effective participation in managing their child's post-operative pain.

CONCLUSION

This review revealed pharmacological and non-pharmacological interventions carried out by parents to alleviate their children's post-operative pain. Obstacles and promoting factors influencing parents' experiences as well as their needs in the process of caring were identified.

IMPLICATIONS FOR PRACTICE

Parents' roles in their child's surgical pain management should be clarified and their efforts acknowledged, which will encourage parents' active participation in their child's caring process. Nurses should provide guidance, education and support to parents.

IMPLICATIONS FOR RESEARCH

More studies are needed to examine parents' experiences in caring for their child, investigate the effectiveness of education and guidance provided to parents by the nurses and explore the influence of parents' cultural values and nurses' perceptions of parental participation in their child's care.

Mothers' View on Late Postoperative Pain Management by the Nursing Team in Children After Cardiac Surgery

Postoperative pain management in children is a complex, multidimensional and subjective phenomenon. It represents a challenge for children, parents and health professionals. This study aimed to understand how mothers assess their children's pain management by the nursing team in the late postoperative phase of cardiac surgery. Empirical data collection was carried out through semistructured interviews with 17 mothers who accompanied their children. Data were subject to qualitative analysis, revealing that, for the mothers, taking good care results from the confidence they vest in the nursing team and from the observation of the medication interventions this team performs. Not taking good care of their children is a consequence of lack of information or inadequate communication between the team and the mothers. The results of this study permit identifying aspects that strengthen and weaken nursing care for these clients, contributing to the improvement of the delivered care.

Pain management: an adolescent scoliosis patient

Recovery units can be busy environments not often conducive to reflective practice. Reflection is, however, an important aspect of high quality care. Using Gibbs model of reflection (see Figure 1), applied to the experience of caring for a 15 year old patient who had undergone surgery to correct a scoliosis deformity, this article illustrates how a deeper understanding of holistic pain management and assessment can be achieved and high standards of care maintained through careful reflective practice.

Understanding the views of parents of children with special needs about the nursing care their child receives when in hospital: a qualitative study

This article reports a qualitative study designed to explore parents' views on how their child with additional needs had been cared for by hospital nursing staff, focusing on how well their own and their child's needs had been identified and met. Twelve interviews with parents of children with additional needs and a thematic analysis of the interview data was conducted. Four themes were developed to provide an insight into parents' views about their experiences: their prior experiences of hospital care, including the process of being told the original diagnosis; communication with staff; nurse-parent relationships; and perceptions of nurses and nursing care. It concludes that parents experience some difficulties in developing a trusting relationship with the nurses caring for their child with additional needs. Parents perceive that nurses are not always able to recognize and respond to their needs when caring for their child. Failure to address these needs can interfere with the development of effective nurse-parent relationships.

Home enteral tube feeding in children following percutaneous endoscopic gastrostomy: perceptions of parents, paediatric dietitians and paediatric nurses

BACKGROUND

The perceptions of parents and professionals are important in deciding to feed children by gastrostomy, yet there are few published studies in this field. This study explored and compared the perceptions of parents to those of paediatric outreach nurses and paediatric dietitians.

METHODS

A cross-sectional mixed-method study with purposive sampling was undertaken using structured interviews and questionnaires to explore perceptions of percutaneous endoscopic gastrostomy (PEG) placement and feeding. Binomial regression was used to investigate differences in perceptions across the groups of participants.

RESULTS

Parents, paediatric outreach nurses and dietitians shared similar perceptions regarding success of feeding, support for gastrostomy reinsertion and the acceptability of the child's quality of life. Much greater differences in perceptions were evident regarding the parents' involvement in the decision-making process for PEG placement and the adequacy of the support received from healthcare professionals.

CONCLUSIONS

A high level of support for feeding was demonstrated together with strong perceptions across all groups that feeding was successful. It is important for healthcare professionals to consider the perceptions of the parents throughout decision making and provision of care following PEG placement because it is highly likely there will be differences in the perceptions between parents and healthcare professionals.

Parents' self-identified stressors and coping strategies during adolescents' spinal surgery experiences

Spinal fusion surgery for idiopathic scoliosis during adolescence is a tremendous stressor for parents. This study investigated parents' pre- and postoperative stressors and their coping strategies. Ninety-two parents identified their predominant stressor and completed the Ways of Coping Questionnaire during their adolescent's preoperative clinic visit and 77 completed this procedure 4 days postoperatively. Results showed that primary stressors were parental role loss (28.26%), possibility of poor surgical outcomes (28.26%), and uncertainty about successful recovery (27.17%) preoperatively, and concerns about pain (32.47%) and parental role loss (32.47%) postoperatively. The greatest increase from pre- to postoperative periods occurred in concerns about pain. Parents used both emotion-focused and problem-focused coping strategies with significant increases postoperatively in confrontive coping, planful problem solving, and positive reappraisal and significant decreases in self-control and seeking social support. Providers should target interventions to alleviate stress and bolster coping for parents.