Nurses' use of nonpharmacologic techniques with hospitalized children

Nursing management of children's pain: Current evidence and future directions for research

This critical literature review discusses the research evidence underpinning each of the pain standards in the National Service Framework for Children: Standard for hospital services. Relevant evidence-based reviews and clinical practice guidelines are highlighted, and aspects of children's pain management where the research evidence is particularly strong or weak are identified. Priorities are suggested for nurse-led research aimed at generating new knowledge to improve pain management for children.

The effects of audiovisual distraction on children's pain during laceration repair

This study aimed to determine the effects of audiovisual distraction on pain in children during laceration repair in emergency room settings. This study was designed as a randomized controlled trial. Eighty-four children aged 3-10 years were randomized to either the experimental group or the control group. Pain response was assessed by the Faces Pain Rating Scale, a visual analogue scale and the Procedure Behaviour Checklist. We measured salivary cortisol levels as a physiological pain response. The results showed that the sensory and affective pain responses were significantly lower in magnitude in the experimental group than in the control group. There was no statistically significant difference in physiological pain responses between the two groups. Audiovisual distraction might be a helpful method to reduce children's pain during laceration repair in emergency room settings.

Turkish pediatric surgical nurses' knowledge and attitudes regarding pain assessment and nonpharmacological and environmental methods in newborns' pain relief

Effective pain management requires accurate knowledge, attitudes, and assessment skills. The purpose of the present study was to describe Turkish pediatric surgical nurses' knowledge and use of pain assessment and nonpharmacologic and environmental methods in relieving newborn's pain in hospital. The sample consisted of 111 pediatric surgical nurses employed in pediatric surgical unit in 15 university hospitals located in Turkey. A questionnaire was used to measure the nurses' knowledge and use of pain assessment, nonpharmacologic, and environmental methods. Data were analyzed with the use of descriptive statistics. Of the nurses that participated in the study, 83.8% were between the ages of 20 and 35 years, 54.1% had a bachelor degree, and 75.7% had a nursing experience ≤10 years. 50.5% stated that physiologic and behavioral indicators used in the assessment of pain in infants. The most commonly used nonpharmacologic methods were giving nonnutritive sucking, skin-to-skin contact, and holding. The most commonly used environmental methods were avoiding talking loudly close to the baby, minimal holding, care when opening and closing of the incubator, avoiding making noise when using wardrobe, drawers, trash, or nearby devices, such as radio and television, avoiding sharp fragrances, such as alcohol, perfume, near the baby, and reducing light sources. Although Turkish pediatric surgical nurses used some of the nonpharmacological and environmental methods in infant's pain relief, there remains a need for more education about pain management and for more frequent use of these methods in clinical care.

Oncology nurses' use of nondrug pain interventions in practice

Cancer pain management guidelines recommend nondrug interventions as adjuvants to analgesic medications. Although physicians typically are responsible for pharmacologic pain treatments, oncology staff nurses, who spend considerable time with patients, are largely responsible for identifying and implementing nondrug pain treatments. Oncology nurses' use of nondrug interventions, however, has not been well studied. The purpose of this study was to describe oncology nurses' use of four nondrug interventions (music, guided imagery, relaxation, distraction) and to identify factors that influence their use in practice. A national sample of 724 oncology staff nurses completed a mailed survey regarding use of the nondrug interventions in practice, beliefs about the interventions, and demographic characteristics. The percentages of nurses who reported administering the strategies in practice at least sometimes were 54% for music, 40% for guided imagery, 82% for relaxation, and 80% for distraction. Use of each nondrug intervention was predicted by a composite score on beliefs about effectiveness of the intervention (e.g., perceived benefit; P<0.025) and a composite score on beliefs about support for carrying out the intervention (e.g., time; P<0.025). In addition, use of guided imagery was predicted by a composite score on beliefs about characteristics of patients who may benefit from the intervention (e.g., cognitive ability; P<0.05). Some nurse demographic, professional preparation, and practice environment characteristics also predicted use of individual nondrug interventions. Efforts to improve application of nondrug interventions should focus on innovative educational strategies, problem solving to secure support, and development and testing of new delivery methods that require less time from busy staff nurses.

The effectiveness of complementary therapies on the pain experience of hospitalized children

Pain is a complex phenomenon for children, and the concepts of hospitalization and pain are often linked in the minds of children. Despite best-practice guidelines and standards related to pain management, many hospitalized children continue to have unrelieved pain. This suggests that analgesics alone do not sufficiently relieve their discomfort. Complementary therapies may have an important role in holistic pediatric pain management. This review of literature evaluates available evidence related to the use and effectiveness of complementary therapies on the pain experience of children in hospital settings. Thirteen recent research articles relative to this topic were located and included in this review. A variety of complementary therapies, including relaxation, distraction, hypnosis, art therapies, and imagery, are included. Results of the research are mixed, and further investigation is required.

Children's nurses' post-operative pain management practices: an observational study

BACKGROUND

Children continue to experience unrelieved moderate to severe pain post-operatively despite the evidence to guide practice being readily available. Previous studies have relied on self-report measures; there is a need to establish exactly how nurses manage children's pain in practice.

OBJECTIVES

To ascertain how nurses actually manage post-operative pain in children and whether pain management practices adhere to current best practice guidelines.

DESIGN

An observational study was carried out. Structured and unstructured data were collected.

SETTING

A children's surgical ward in the English Midlands caring for children from birth to 16 years.

PARTICIPANTS

Registered nurses (n=13) took part in the study.

METHODS

Each participant was observed continuously for a period of 5 hours per shift for two to four shifts each. The role of the observer as participant was adopted whereby the researcher could shadow the nurse and act primarily as an observer. Data were collected for 36 shifts (185 hours).

RESULTS

While nurses administered analgesic drugs when a child complained of pain, in most other areas practices did not conform to current recommendations and are in need of improvement. Nurses did not, for example, routinely assess a child's pain, nor use non-drug methods of pain relief on a regular basis.

CONCLUSIONS

The sub-optimal pain management practices may be attributable to several factors. The professional culture of nursing and/or ward culture may result in poor pain management practices being perpetuated. Nurses may not have the requisite theoretical knowledge to manage pain effectively. A lack of priority may also be attributed to pain management. These areas need exploring further.

Paediatric nurses’ attitudes to massage and aromatherapy massage

Complementary therapies have continued to increase in popularity in healthcare and it is widely accepted that they can be incorporated into the nursing role. However, this acceptance does not necessarily mean that the introduction of therapies into the nursing arena has been without confusion and without professional and legal implications. Consequently, this small-scale, qualitative study aimed to explore the perceptions and lived experiences of paediatric nurses of two therapies, namely massage and aromatherapy massage. There is a dearth of literature exploring nurses' perceptions to the incorporation of these therapies, especially in the arena of paediatric nursing where massage and aromatherapy massage are common practice. Semi-structured interviews were undertaken with qualified nurses and revealed the themes of 'benefit', 'family centred care', 'nursing care' and 'being held back'. It was found that at some stage during their professional career each nurse had performed massage and/or aromatherapy massage. All nurses were able to recall certain benefits of the therapies for the children that they had observed and many discussed the importance of involving the family as a way of including them in to the care of their child. However, for the nurses in this study, it was evident that the incorporation of complementary therapies into the nursing role was determined by the context in which they practised. Due to the dominance of the medical model, nurses faced pressures and conflicts in the realities of their nursing work, which meant they were often unable to carry out these therapies.

How, and when, can I restrain a patient?

The need to restrain service users will vary according to the area of practice within which practitioners are employed. Many of the principles that relate to the issue of restraining service users are, however, applicable to all, or most, health and social care settings. While the emphasis should be on pre-emptive action, wherever possible, in order to prevent the need to restrain, there are some occasions on which the risks to the service user, or others, of inaction may outweigh those of taking action. Some of the key issues are discussed in this paper.

Factors influencing nurses’ use of nonpharmacological pain alleviation methods in paediatric patients

The purpose of this study was to describe the factors promoting and hindering nurses' use of nonpharmacological methods in children's surgical pain relief, and demographic variables related to this. The data were collected by a Likert-type questionnaire, which was completed by nurses (n = 162) who were working in one of the paediatric surgical wards located in university hospitals in Finland. The response rate was 99%. Factor analysis was used to analyse the data. According to the results, five promoting factors (nurse's competence, versatile use of pain alleviation methods, workload/time, child's age/ability to cooperate, and parental participation), as well as five hindering factors (nurse's insecurity, beliefs regarding parental roles/child's ability to express pain, heavy workload/lack of time, limited use of pain alleviation methods, and work organizational model/patient turnover rate) were found to influence the nurses' use of nonpharmacological methods. Almost all of the nurses (98%) hoped to make progress in their career and to learn different pain alleviation methods, but less than half of them (47%) agreed that they had obtained sufficient education regarding these methods. Demographic variables such as the nurse's age, education, and work experience were significantly related to certain factors influencing the use of nonpharmacological methods. In conclusion, paediatric patients' surgical pain relief in the hospital was affected more by the nurses' personal characteristics, than by work-related factors or characteristics of the child or the child's parents. The nurses had positive attitudes towards learning different pain alleviation methods, which constitute the basis for the development of pain management in paediatric patients.

Computer-taught coping techniques for venepuncture: preliminary findings from usability testing with children, parents and staff

Teaching cognitive and behavioural coping techniques can reduce children's pain and distress during medical procedures. However, these simple techniques are often not taught to children due to lack of staff time, training and teaching aids. We developed a computer-based self-administered programme (CTCT) to teach coping skills to school-aged children in the waiting room prior to venepuncture. All children had topical local anaesthetic and parents were present. Children reported only mild pain and distress from venepuncture and seven children used techniques learned from the CTCT programme. Previous pain coping influenced behavioural distress during venepuncture. Ten children reported that they would use CTCT again. Nine parents stated they would recommend their child use CTCT in future. All staff responded favourably to the use of CTCT for children prior to venepuncture. Our preliminary findings demonstrate that the coping techniques can be taught using a computer game format and that children, parents and staff found the method acceptable.

A descriptive study of the interactive guided imagery experience

The purpose of this Study was to describe the experience of participating in Interactive Guided Imagery (IGI) from the perspective of clients. A qualitative descriptive design guided the research. Ten clients who had engaged in IGI, each with an R.N., IGI-certified practitioner, composed the sample. To explore participants' perceptions of their IGI experience, data were gathered through semistructured, in-depth interviews. Data analysis was carried out through data coding, categorizing, and subcategorizing; thematic synthesis; and structuring of relationships. Six primary themes emerged to compose the description of the experience of participating in IGI: the client's lived experience, use of a nonordinary state of consciousness, the guide, the guide-client relationship, influencing factors, and the results of IGI use. Based on the primary themes and their interrelationships, a model of the IGI experience was developed. The description and the model of the IGI experience provide the basis for further nursing knowledge development of the IGI modality.

Parents' roles in using non-pharmacological methods in their child's postoperative pain alleviation

Increasingly nowadays, parents participate more fully in the care of their hospitalized children. The purpose of this study was to describe parents' utilization of selected non-pharmacological methods in relieving their hospitalized child's (aged 8-12 years) postoperative pain, and factors related to this function. Data were collected by a questionnaire survey completed by parents (n=192) with a child hospitalized on a paediatric surgical ward in the five university hospitals of Finland. The response rate was 90%. Results indicated that non-pharmacological methods, such as emotional support and helping with daily activities, were well utilized whereas cognitive-behavioural and physical methods were less frequently used strategies. Certain background factors specific to the parents and their hospitalized children were significantly related to the non-pharmacological methods used by the parents. The hospitalized child's gender, the time of the surgical procedure, and the parents' assessments of their child's pain intensity, were especially significantly related to many of these strategies. The findings of this study could be used in clinical practice to improve guidance provided to parents regarding interventions for children's pain relief.

Nurses' perceptions of parental guidance in pediatric surgical pain relief

The aim of this study was to describe nurses' perceptions of how they guide parents in the relief of their child's (aged 8-12 years) surgical pain in the hospital, and factors related to this function. The convenience sample consisted of 162 nurses working on the pediatric surgical wards of five university hospitals in Finland. The data was collected with a Likert-type instrument designed for this purpose. The results of this study indicated that nurses felt parents were mostly well informed about their child's surgical procedure, including both cognitive and sensory information, and about the non-pharmacological methods employable for relieving their child's pain. However, some deficiency was identified in the preparatory information, as well as in the cognitive-behavioral and physical methods. Factors related to the nurses' background, such as age, education, work experience and the nurse's own experiences with prior hospitalizations of their children, appeared to have some effects on their perceptions regarding parental guidance.

Use of Music Therapy and Other ITNIs in Acute Care

The purpose of this descriptive study was to examine the clinical use of music therapy as an independent therapeutic nursing intervention (ITNI) in acute inpatient settings. This study identified the frequency, rationale, and perceived effectiveness of its use as an ITNI. In addition, barriers and facilitators to nurses' use of music therapy were identified. Frequency of use of other ITNIs also were investigated. An author-designed questionnaire, based on the literature and reviewed by a panel of experts, was used to survey a convenience sample (N = 321) of RNs at an acute inpatient facility with more than 50 beds, located in the midwestern United States. One hundred thirty-five RNs (42%) participated in the study. Findings indicated that 85.2% (n = 115) of respondents knew of music therapy, with 69.6% (n = 94) of them reporting using it in practice. Of the other listed ITNIs, deep breathing was used most frequently, followed by therapeutic touch and massage. Music therapy was used most commonly to reduce anxiety and was ranked as the ITNI used most often to enhance sleep and decrease distraction, agitation, aggression, and depression. Psychiatry/chemical dependency and intensive care units had the highest incidence of use of music therapy. The ranking of barriers and facilitators identified the strongest barrier as not having time to help patients with music therapy, whereas the strongest facilitator was nurses' comfort with the idea of using music therapy. This research begins to fill an information gap about the frequency, purpose, and perceived effectiveness of use of ITNIs. The use of ITNIs can increase patient comfort and facilitate conservation of energy, which aids healing processes, as described in Levine's Conservation Model. Use of ITNIs also can empower nurses and facilitate their control over nursing practice. This study indicates that nurses need further education on the use of music therapy and other ITNIs.

Nonpharmacological methods in relieving children's postoperative pain: a survey on hospital nurses in Finland

AIM OF THE STUDY

The aim of this study was to describe nurses' use of selected nonpharmacological methods in relieving 8-12-year-old children's postoperative pain in hospital.

METHODS

The convenience sample consisted of 162 nurses working on the paediatric surgical wards in the five Finnish university hospitals. An extensive questionnaire, including a five-point Likert-scale, on the nurses' use of selected nonpharmacological methods and demographic data was used as a method of data collection. The response rate was 99%. Descriptive statistics as well as nonparametric Kruskall-Wallis ANOVA and the chi-squared test were used as statistical methods.

RESULTS

The study indicates that emotional support, helping with daily activities and creating a comfortable environment were reported to be used routinely, whereas the cognitive-behavioural and physical methods included some less frequently used and less well known strategies. The results also show that attributes, such as the nurses' age, education, and work experience, the number of children the nurses had, the nurses' experiences of hospitalization of their children as well as the hospital and the place of work, were significantly related to the use of some nonpharmacological methods.

CONCLUSIONS

The nurses used versatile nonpharmacological methods in children's postoperative pain relief, although some defects could be observed. More research is needed on the methods used by nurses to relieve children's pain in different patient groups and the factors which hinder or promote nurses' use of pain alleviation methods in the clinical practice.

Measuring imaging ability in children

INTRODUCTION

Guided imagery has been suggested as an intervention to help children cope with noxious symptoms associated with medical care. A measure of imaging ability, that is, the ability to generate vivid mental images and to experience those images as if they were real, could be helpful in identifying children most likely to succeed in relieving symptoms with guided imagery. The purpose of this study was to test psychometric properties of a new instrument, the Kids Imaging Ability Questionnaire (KIAQ).

METHOD

Three expert clinicians and researchers were asked to review the KIAQ to assess content validity. A convenience sample of 58 children were invited to complete the questionnaire twice to obtain data for tests of reliability and criterion-related validity.

RESULTS

Content validity, internal consistency (alpha =.75-.76), and test-retest reliability (r =.73) were acceptable. Criterion-related validity using the Singer Fantasy Proneness Interview as a standard was poor (rho =.31-.46).

DISCUSSION

Some psychometric properties were acceptable; however, continued research will be necessary to test validity of the questionnaire and demonstrate a relationship between KIAQ score and success with imagery. With continued research, pediatric nurses may use the KIAQ in practice to identify children most likely to benefit from guided imagery.

Nurses' knowledge about pharmacological and nonpharmacological pain management in children

The purpose of this study was to investigate the knowledge base and practices of Finnish nurses in the area of children in pain. The convenience sample consisted of 265 nurses working on children's wards in university hospitals. Data were collected using an instrument designed for the study. The results showed that there remain gaps in the knowledge base of nurses with regard to both pharmacological and nonpharmacological pain management in children. The education and the area of expertise were significant influences on knowledge scores. Nurses used a fairly wide range of nonpharmacological pain alleviation methods but most of these were such that the nurse was in an active role and the child was passive. There is a clear need for further education. Nurses should take a more active role in seeking new information and also should be encouraged to use nonpharmacological methods that let the children be active participants in their own care.

Nurses' assessments and management of pain in children having orthopedic surgery

The specific aims of this research project were to (a) describe selected verbal, nonverbal, and physiological arousal indicators of the child's pain; (b) describe which pain indicators were most influential to nurses in decision-making about interventions for managing the child's pain; (c) describe pain interventions used by nurses; (d) compare postoperative analgesic orders to recommended dosages for the children; and (e) explore relationships between the child's self-report of pain and medication dosages administered. Subjects included 19 children aged 5-17 years who experienced 20 orthopedic surgical procedures (one child had two surgeries one week apart). Data were collected by staff nurses for the first five days after surgery. Pain levels were reported using the Oucher Scale. Postoperative pain was reported at moderate levels and showed only a gradual decrease throughout the hospital stay. Nonverbal pain indicators included crying and tense face. The child's complaint of pain and reported Oucher scores were most influential in influencing nurses to intervene in the child's pain. Nonpharmacological comfort measures included positioning and reassurance. All children received medications for pain; 49% of the orders were within the recommended therapeutic dosage range. A small but significant correlation was found between the child's reported pain level and the morphine equivalents of pain medication received. Recommendations included development of nursing flow charts that provide space to record pain levels and nursing interventions, in-service education for nurses on nonpharmacological interventions, and further research with a larger sample and a single pain rating scale.

Prospective trial using Virtual Vision as distraction technique in patients undergoing gastric laboratory procedures

To determine whether distraction techniques using Virtual Vision, an audiovisual system integrated into a modified pair of glasses, improves tolerance to routine gastric laboratory procedures, a prospective study of 50 patients was done. Patients were allowed to view/hear a travelogue tape during testing. Patients and registered nurses, who performed the procedure, were asked their interpretation of Virtual Vision as a device that improved patient tolerance, impaired the patient's ability to follow directions, or impaired the nurse's ability to perform the procedure. Patients graded the procedure from 1 (unbearable) to 5 (reasonably comfortable) and were asked whether they would use the device for a repeat procedure. For those who had undergone previous procedures, patients were queried regarding their preference for routine testing or Virtual Vision. Improved tolerance to procedures was noted in 82% of the patients as perceived by nurses and patients. Eighteen percent of the nurses and 8% of the patients thought that the auditory insert and glasses impaired the patient's ability to cooperate with the test, whereas 88% and 86%, respectively, thought that Virtual Vision was a valuable distraction technique. Using an ordinal scale for testing tolerance, patients graded their test at a mean of 3.8 (SD 1.25) and 82% expressed a desire to use the system in conjunction with future testing. Twenty-six of 33 patients (79%) who had undergone previous gastric laboratory testing preferred distraction techniques using Virtual Vision to conventional testing. Distraction techniques using a system such as Virtual Vision have the potential to improve patient tolerance to routine gastric laboratory studies.