Influences on nurses' scoring of children's post-operative pain

Identification of Neonatal Infant Pain Assessment Tools as a Possibility of Their Application in Clinical Practice in Croatia: An Integrative Literature Review

OBJECTIVES

This article presents an integrative review of the literature with the aim of identifying instruments already in existence for measuring neonatal infant pain with a view to exploring possibilities of applying them in clinical practice in Croatia.

DESIGN

An integrative review.

DATA SOURCES

The databases searched included MEDLINE, Cinahl Cochrane Library, and Science Direct. The search was limited to available full-text articles in English published between 1990 and 2020. The studies were selected according to the PRISMA strategy and evaluated based on the methodologic framework proposed by Whittemore and Knafl.

REVIEW/ANALYSIS METHODS

The research identified 13 scales for assessing pain in neonatal infants, including 5 one-dimensional and 8 multidimensional scales that assess acute and prolonged pain in preterm and full-term infants.

RESULTS

Overall, the articles in this review confirm that pain is a multidimensional phenomenon and that professionals should consider other specific characteristics of the neonatal infant population while measuring pain.

CONCLUSIONS

Our review showed that various tools exist assessing pain in neonatal infants that could be used in clinical practice in Croatia. However, it is difficult to determine the most appropriate instrument at this stage, as the choice depends on various factors that still need to be considered. The decision on which pain scale to use or which is more appropriate should be based on further psychometric tests, its accuracy, and ease of use.

Effects of Pain-Reporting Education Program on Children's Pain Reports-Results From a Randomized Controlled Post-operative Pediatric Pain Trial

Objective: Accurate assessment of patients' pain is an essential part of adequate analgesic treatment. Although reporting pain is a complex task, limited-to-no instructions are provided to pediatric patients regarding this process. Our goal in this randomized parallel-group clinical trial (Clinicaltrial.gov study protocol number NCT04306679) was to evaluate if a training program designed to improve children's ability to understand and use pain scales in a post-surgical setting would affect their pain scores. Methods: Eligible children (aged 8-17), hospitalized for elective surgery and their parents were randomized into two groups. Pre-surgery the intervention group underwent a multi-media program aimed to teach and train how to report pain. The control group received standard pre-surgical instructions. Post-surgery, the children reported their pain on 4 pain scales. The primary outcome was the concordance between children's pain intensity scores reported on four pain scales, both in terms of within-child standard deviation and absolute difference. Results: Ninety-six children met inclusion criteria and completed the study. The trained subjects' pain reports had significantly (p = 0.002) lower within-subject standard deviation (0.41 ± 0.31) than the control group (0.67 ± 0.46). In line, regarding absolute difference, the concordance of children's pain reports was twice better in the trained group (mean difference of 0.43 ± 0.40) than in the control group (0.88 ± 0.70) (p < 0.001). Discussion: Our results suggests that children's ability to report pain is a skill that can be improved. Future studies should test the potential clinical impacts of educational interventions aimed to improve pain assessment in children and adults.

Development and Pilot Evaluation of an Educational Tool for the FLACC Pain Scale

BACKGROUND

The FLACC (Face, Legs, Activity, Cry, Consolability) pain scale is commonly used for pediatric pain assessment; however, no online educational tool exists to facilitate the use of the scale.

AIMS

This study aimed to develop an online educational tool and evaluate its effect on nurse knowledge, user confidence, and scoring accuracy.

DESIGN AND METHODS

In phase 1, semistructured interviews were conducted to identify preferred educational features and content. Eight informants were interviewed in phase 1. Recommendations informed the development of the educational tool. Data were analyzed via conventional content analysis. Phase 2 involved a pre-post evaluation of the tool through online surveys. Posteducational data were collected immediately after the tool was completed. Wilcoxon signed rank and McNemar-Bowker tests were used to compare pre- and post-training knowledge, confidence, and FLACC scores. Scoring accuracy was examined using percentage agreement and consensus analysis.

RESULTS

Thirty-four nurses participated in phase 2. The educational tool significantly improved knowledge (p < .0001) and increased user confidence, although not to a significant level (p = .06). There was a significant improvement in correct assessment of moderate pain (p = .04). Almost all nurses correctly assessed severe pain before and after education (91%). However, there was a decrease in accurate assessment of mild pain (p = .01).

CONCLUSIONS

Because the intervention improved knowledge, user confidence, and assessment accuracy of moderate pain, it would be useful to implement such a tool as part of clinician education. However, further modifications will be needed to improve assessment of mild pain.

Validation of the Greek Version of Comfort-B, FLACC, and BPS Scales in Critically Ill Children and Their Association with Clinical Severity

BACKGROUND

A variety of valid pediatric pain assessment tools are used in clinical practice globally; however, none have been validated for use in the Pediatric Intensive Care Unit (PICU) in Greece. Furthermore, the association between pain behavioral responses and clinical status is unclear.

AIMS

To assess the reliability and validity of the Greek version of FLACC, Comfort B, and BPS pain scales in critically ill children and to explore their association with clinical severity (Denver MOF, PMODS) and levels of sedation and analgesia.

METHODS

A methodological and descriptive correlational study was performed in a 6-bed PICU. A total of 60 observations in a sample of 30 children (mean age 4.1 years; 63.3% male) were obtained by 2 independent nurses during rest and painful procedures. At the same time, the bedside nurse assessed the child's pain intensity using the VASobs.

RESULTS

High internal consistency and strong interrater reliability were detected (Cronbach's alpha ≥ .85; ICC > .95, p < .001). The agreement between observers was satisfactory (0.71 ≤ Kappa ≤ 0.96, p < .001). Strong correlations were found among the scales (0.65 ≤ rho ≤0 .98, p < .05). Increased pain scores (≥moderate pain) were observed during painful procedures regardless the administration of analgesia. Statistically significant correlations were found between clinical severity and the FLACC and Comfort B scores (-0.577 ≤ rho ≤ -0.384, p < .05).

CONCLUSIONS

These pain tools were found to be suitable for this sample of children in Greece. Wider application of these tools in Greek PICUs and further research regarding their association with the clinical severity and the pain responses is required for the improvement of pain management in critically ill children.

A Meta-Synthesis of Children's Experiences of Postoperative Pain Management

BACKGROUND

Ineffective management of postoperative pain in children has been reported widely. To improve the effectiveness of postoperative pain management for children, it was necessary to conduct a systematic review to better understand the current knowledge of children's experiences of their postoperative pain management.

AIMS

The aim of this review was to update and synthesize current qualitative research of postoperative pain management based on children's experiences.

METHODS

Qualitative studies published between January 1990 and July 2014 were searched from the electronic databases of CINAHL, MEDLINE, MedNar, ProQuest, PsycINFO, Scopus, ScienceDirect, Sociological Abstracts, and Web of Science. A broad range of search keywords and a three-step search strategy were used. Meta-syntheses were used to summarize the findings from the included studies.

RESULTS

Nine qualitative studies were included. Three meta-syntheses from 22 categories based on 72 findings were generated: (a) Children experienced various negative emotions related to postoperative pain, and could assess and express their pain but need their parents as advocates; (b) apart from pain medication, various nonpharmacological strategies to relieve children's postoperative pain were employed by children, parents, and nurses; and (c) suggestions from children for their parents and nurses to better relieve postoperative pain.

LINKING EVIDENCE TO ACTION

This review provided preliminary support for increasing the provision of information and education for children and their parents about postoperative conditions, pain, and pain relief strategies. Nurses should also be encouraged to employ more nonpharmacological pain-relieving strategies and build rapport with children and their parents. Future intervention studies are needed to improve children's postoperative experiences.

[Pain assessment scales in newborns: integrative review]

OBJECTIVE

To analyze studies on methods used to assess pain in newborns.

DATA SOURCES

Integrative review study of articles published from 2001 to 2012, carried out in the following databases: Scopus, PubMed, CINAHL, LILACS and Cochrane. The sample consisted of 13 articles with level of evidence 5.

DATA SYNTHESIS

29 pain assessment scales in newborns, including 13 one-dimensional and 16 multidimensional, that assess acute and prolonged pain in preterm and full-term infants were available in scientific publications.

CONCLUSION

Based on the characteristics of scales, one cannot choose a single one as the most appropriate scale, as this choice will depend on gestational age, type of painful stimulus and the environment in which the infant is inserted. It is suggested the use of multidimensional or one-dimensional scales; however, they must be reliable and validated.

Nurses' Beliefs Regarding Pain in Critically Ill Children: A Mixed-Methods Study

The purpose of this study was to provide a current and comprehensive evaluation of nurses' beliefs regarding pain in critically ill children.

DESIGN AND METHODS

A convergent parallel mixed-methods design was used. Nurse beliefs were captured via questionnaire and interview and then compared.

RESULTS

Forty nurses participated. Most beliefs reported via questionnaire were consistent with effective pain management practices. Common inaccurate beliefs included the need to verify pain reports with physical indicators and the pharmacokinetics of intravenous opioids. Beliefs commonly shared during interviews concerned the need to verify pain reports with observed behavior, the accuracy of pain reports, the need to respond to pain, concerns regarding opioid analgesics, and the need to "start low" with interventions. Convergent beliefs between the questionnaire and interview included the use of physical indicators to verify pain, the need to take the child's word when pain is described, and concerns regarding negative effects of analgesics. Divergent and conflicting findings were most often regarding the legitimacy of a child's pain report.

CONCLUSIONS

Findings from this study regarding the accuracy of nurses' pain beliefs for critically ill children are consistent with past research. The presence of divergent and conflicting responses suggests that nurses' pain beliefs are not static and may vary with patient characteristics.

PRACTICE IMPLICATIONS

While most nurses appreciate the risks of unrelieved pain in children, many are concerned about the potential adverse effects of opioid administration. Interventions are needed to guide nurses in minimizing both of these risks.

Pain assessment scales in newborns: integrative review

OBJECTIVE: To analyze studies on methods used to assess pain in newborns.DATA SOURCES: Integrative review study of articles published from 2001 to 2012, carried out in the following databases: Scopus, PubMed, CINAHL, LILACS and Cochrane. The sample consisted of 13 articles with level of evidence 5.DATA SYNTHESIS: 29 pain assessment scales in newborns, including 13 one-dimensional and 16 multidimensional, that assess acute and prolonged pain in preterm and full-term infants were available in scientific publications.CONCLUSION: Based on the characteristics of scales, one cannot choose a single one as the most appropriate scale, as this choice will depend on gestational age, type of painful stimulus and the environment in which the infant is inserted. It is suggested the use of multidimensional or one-dimensional scales; however, they must be reliable and validated.

Nurses' aims when managing pediatric postoperative pain: is what they say the same as what they do?

PURPOSE

The purpose of this study was to explore nurses' aims when managing postoperative pain and whether reported aims reflect actual practices.

DESIGN AND METHODS

Participant observation was used to collect data regarding nurses' (n = 17) pain management practices. Nurses (n = 19) were asked: When managing postoperative pain, what is your overall aim?

RESULTS

Around half the participants (n = 10) aimed for patients to be comfortable while others aimed for a pain score of 2-3 (n = 7), or below 5 (n = 2). Observed practices matched aims for just more than half the participants (n = 9).

PRACTICE IMPLICATIONS

There is evidence of individual variation in practices. This may impact on the care provided.

Pain management for pediatric tonsillectomy: an integrative review through the perioperative and home experience

PURPOSE

This integrative review aims to increase our understanding of current pain management care practices for children undergoing tonsillectomy.

CONCLUSIONS

Synthesis of the literature resulted in four main opportunities for care providers to manage pain: preoperative education and preparation, intraoperative surgical interventions, and postoperative pharmacologic and nonpharmacologic interventions in the post anesthesia care unit and home settings.

PRACTICE IMPLICATIONS

Nurses have many opportunities to understand pain management practices and intervene to minimize pain experienced in pediatric outpatients undergoing tonsillectomy.

Pediatric nurses' postoperative pain management practices: an observational study

PURPOSE

This study was an in-depth examination of pediatric postoperative pain care.

DESIGN AND METHODS

Participant observational data were collected on the care of 10 children. Particular attention was paid to actions when pain scores were ≥5 and to the relationship between pain scores and medications administered.

RESULTS

A pattern of care emerged of giving pain medications regularly even if they were prescribed pro re nata. Actions when pain scores were ≥5 varied. Recorded pain scores rarely guided treatment choices.

PRACTICE IMPLICATIONS

The use of pain scores to guide treatment choices needs further debate. Future research should explore the implications of divorcing treatment from pain scores on children's pain experience.

Uncovering pain in critically ill non-verbal children: nurses' clinical experiences in the paediatric intensive care unit

Critically ill paediatric patients are frequently exposed to pain that is required to be assessed and treated effectively. The most reliable resource for assessing pain is the child itself, but children in the paediatric intensive care unit (PICU) are commonly unable to communicate their needs, requiring professional caregivers to uncover and interpret pain. However, nurses and paediatricians do not have sufficient knowledge of how critical illness affects childrens' signs of pain. The aim of this study was to illuminate clinical experiences of pain in the PICU; describing nurses' perceptions of expressions of pain in non-verbal, critically ill 2-6 year old children. The participants were 17 experienced PICU nurses. Data were analysed according to the phenomenographic method and three qualitatively different main categories, gained from clinical experience, emerged: changes in the measurable parameters; perceived muscular tension; and, altered behaviour. Furthermore, contrasting the categories revealed two diverse perspectives to focus pain: measure-oriented and patient-oriented. Subtle expressions of pain were recognised when focus was patient-oriented. These findings support the necessity of actively looking for pain deriving from various perspectives and considering diverse caring needs when doing so. Acknowledging pain makes pain visible.

[Pediatric pain management: what do German nurses know?]

BACKGROUND

In order to provide efficient pain treatment clinicians need to know the latest developments in pain management and to implement this knowledge into clinical practice. The knowledge of pediatric nursing staff with regards to pediatric pain management has not yet been investigated. In this study we therefore investigated nurses' knowledge of pediatric pain management strategies.

METHODS

Nursing staff knowledge was analyzed using the German version of the PNKAS-Sr2002. This questionnaire was distributed to 310 pediatric nurses and the response rate was 51.3% (n=159). Analyses of variance (ANOVA) were conducted to examine whether educational level and work experience had an influence on knowledge. Independent from work experience the educational level of nurses is important for their knowledge in pediatric pain management.

RESULTS

On average nurses obtained a mean individual test score of 69.3%. Nurses with advanced qualification and nurses with 6-10 years work experience obtained the highest scores.

CONCLUSION

Pediatric nurses must be trained more efficiently in pediatric pain management so that an adequate pain management is available for children and adolescents.

Implementation of a standardized pain management in a pediatric surgery unit

Postoperative pain is still a major complication causing discomfort and significant suffering, especially for children. Therefore, every effort should be made to prevent pain and treat it effectively once it arises. Under-treatment of pediatric pain is often due to a lack of both knowledge about age-specific aspects of physiology and pharmacology and routine pain assessment. Factors for long term success require regularly assessing pain, as routinely as the other vital signs together with documentation of side effects. The fear of side effects mostly prevents the adequate usage of analgesics. Essential is selecting and establishing a simple concept for clinical routine involving a combination of non-pharmacological treatment strategies, non-opioid drugs, opioids and regional anesthesia.