Paediatric pain management: knowledge, attitudes, barriers and facilitators among nurses - integrative review

AIMS

To identify and synthesize evidence regarding the knowledge and attitudes of nurses, and barriers and facilitators to effective pain assessment and management in infants and children.

BACKGROUND

Pain among children is a common experience. Relief from pain is a fundamental human right, yet hospitalized children continue to experience unrelieved pain. Provision of effective pain management is an integral part of the nurse's role.

METHODS

Guided by Whittemore & Knafl's five-stage framework, primary peer-reviewed studies published in English between 2000 and 2018 were searched using CINAHL, PubMed, ProQuest, PsycINFO and Scopus. The initial search yielded 292 papers. Twenty-seven papers were included in this review: quantitative (n = 18), qualitative (n = 5) and mixed-methods (n = 4).

RESULTS

Findings showed that nurses internationally have poor knowledge and attitudes of basic pain assessment and management principles. Barriers to effective pain management include the absence of pain education and assessment tools, parents' reluctance to report pain and insufficient prescription of analgesia by physicians. Facilitators for the effective management of pain include parental participation in care, trusting and respectful relationships between nurses and children, and adequate nurse-patient ratios.

CONCLUSION

The review findings suggest a need to improve education for nurses, doctors and the patients' family in relation to paediatric pain management, communication and interprofessional collaborations. There is a need to maximize facilitators and overcome barriers, such as those identified in this review, to ensure the quality of paediatric pain management.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Nursing and health policy should mandate the prioritization of paediatric pain management and the clinical roles and responsibilities of the interdisciplinary team members. Undergraduate, postgraduate and in-service education for nurses and other health professionals should also address paediatric pain management. In-service education on paediatric pain management should be compulsory for all health professionals caring for children.

On being cared for by a nurse

The hospitalised patient's experiences of nursing care, the nature and the value of the patient's and nurse's relationships are relatively unexplored territory in terms of Australian research. This is despite the importance and centrality of caring to the practice of nursing and the very significant contributions that overseas researchers have made to understanding the phenomenon of care in nursing practice. Given the social, economic and cultural differences between Australia and other countries, a study which examines Australian perspectives of the nursing caring experience is long overdue. That caring makes a difference to the patient's sense of well being should come as no surprise to those of us who care. In this paper the writer aims to demonstrate how that difference comes about.

Reflections on conducting qualitative research with elderly people

It should come as no surprise that conducting research with elderly people can be challenging and problematic. A review of the literature in this area provides some indication of what many other researchers have encountered, particularly in relation to doing quantitative studies. The majority of these challenges deal with issues involving consent. Although there have been a few articles dealing with doing qualitative research with this population, they were not informative in terms of preparing the author for day-to-day situations. This article is an attempt to redress some of this by sharing the author's experience of collecting data for a phenomenological study involving elderly people who reside in nursing homes. The aim is not to provide solutions but rather to highlight some of the challenges that confront qualitative researchers in this context.

Plasma homocysteine as a risk factor for vascular disease. The European Concerted Action Project

CONTEXT

Elevated plasma homocysteine is a known risk factor for atherosclerotic vascular disease, but the strength of the relationship and the interaction of plasma homocysteine with other risk factors are unclear.

OBJECTIVE

To establish the magnitude of the vascular disease risk associated with an increased plasma homocysteine level and to examine interaction effects between elevated plasma homocysteine level and conventional risk factors.

DESIGN

Case-control study.

SETTING

Nineteen centers in 9 European countries.

PATIENTS

A total of 750 cases of atherosclerotic vascular disease (cardiac, cerebral, and peripheral) and 800 controls of both sexes younger than 60 years.

MEASUREMENTS

Plasma total homocysteine was measured while subjects were fasting and after a standardized methionine-loading test, which involves the administration of 100 mg of methionine per kilogram and stresses the metabolic pathway responsible for the irreversible degradation of homocysteine. Plasma cobalamin, pyridoxal 5'-phosphate, red blood cell folate, serum cholesterol, smoking, and blood pressure were also measured.

RESULTS

The relative risk for vascular disease in the top fifth compared with the bottom four fifths of the control fasting total homocysteine distribution was 2.2 (95% confidence interval, 1.6-2.9). Methionine loading identified an additional 27% of at-risk cases. A dose-response effect was noted between total homocysteine level and risk. The risk was similar to and independent of that of other risk factors, but interaction effects were noted between homocysteine and these risk factors; for both sexes combined, an increased fasting homocysteine level showed a more than multiplicative effect on risk in smokers and in hypertensive subjects. Red blood cell folate, cobalamin, and pyridoxal phosphate, all of which modulate homocysteine metabolism, were inversely related to total homocysteine levels. Compared with nonusers of vitamin supplements, the small number of subjects taking such vitamins appeared to have a substantially lower risk of vascular disease, a proportion of which was attributable to lower plasma homocysteine levels.

CONCLUSIONS

An increased plasma total homocysteine level confers an independent risk of vascular disease similar to that of smoking or hyperlipidemia. It powerfully increases the risk associated with smoking and hypertension. It is time to undertake randomized controlled trials of the effect of vitamins that reduce plasma homocysteine levels on vascular disease risk.

Benchmarking in health care: a review of the literature

This paper provides a review of the 10 significant publications related to benchmarking in health care. The discussion which follows is presented according to four headings: what the study did, how the study was conducted, what was learnt from the experience, and what the implications were for health care generally. The findings of this review are reassuring in that all studies provided valuable information, in terms of clinical practice and the health care service or the benchmarking process. They highlight the importance of the maintenance of quality health care, the reduction of health care costs and the need for improved efficiency and effectiveness in providing health care.

Of ethics committees, protocols, and behaving ethically in the field: a case study of research with elderly residents in a nursing home

In this paper we discuss differing discourses of research ethics committees and the clinical research field. Reflections on our experience of conducting research in a nursing home are used to highlight the tensions and inconsistencies that arise from these discourses and the need to behave ethically in the field. While accepting the need for adherence to guiding principles of duty based ethics, we have found that practical moral decisions in the field required that, as individual researchers, we needed to exercise discretionary judgement, informed by the ethic of care and the concern for the well-being of research participants.

National perspective of acute coronary care in the Republic of Ireland

OBJECTIVE

To assess the use of acute coronary care facilities in the Republic of Ireland with regard to case mix, patient characteristics, mortality and factors associated with mortality, time intervals to admission, utilisation of thrombolysis, and risk factor profiles.

DESIGN

A 1 week prospective census of all hospitals admitting acute coronary cases. These comprised 23 coronary care units (CCU) and 17 combined coronary care/intensive care units (CCU/ICU). Data were collected by standardised methods on each new patient "upon whom a cardiac monitor was placed".

RESULTS

Acute coronary heart disease was confirmed in 185 (44.9%) of 412 patients. Of these 109 (26.4%) had a confirmed myocardial infarction and 76 (18.4%) unstable angina. Women were significantly older than men in all groups. Of those with proven acute coronary heart disease, 42.6% were current smokers, 23.1% were aware of having a raised cholesterol concentration, and 42.3% gave a history of prior hypertension. Only 44% were transported by ambulance. Median delay time from the onset of symptoms to admission was 6 h in Dublin and 4 h elsewhere. 34.9% of patients with a confirmed myocardial infarction received thrombolysis. Mortality of patients with myocardial infarction CCU/ICU at 7 days was 10.9 %.

CONCLUSIONS

There is potential for considerable improvement in the management of coronary heart disease in the Republic of Ireland through a reduction in delay times to admission to hospital, increased use of thrombolytic treatment, and intensification of advice on primary and secondary risk factors.

Psychological, nutritional and physical status of olympic road cyclists

Six members of the Irish Olympic Road Cycling Squad underwent a comprehensive medical, nutritional, psychological and biochemical assessment in January 1983. They were given specific medical and dietary recommendations and were reassessed in January 1984 after a period spanning the competitive racing season. The cyclists' diets at both sessions were comparable and generally conformed with recommended daily intakes. Supplementary ingestion was unnecessary to attain recommended daily intakes of vitamins. Serum levels of HDL-cholesterol increased and triglyceride decreased during the period of the study. The squad had characteristics indicating traits of self-sufficiency, toughness and practical mindedness. At the second assessment there was evidence of heightened ambition and competitiveness and an improvement in mood states with reduced ratings for confusion and tension.

Arsenic exposure, smoking, and respiratory cancer in copper smelter workers

A report by Lee and Fraumeni in 1969 linked exposure to arsenic and other contaminants to a threefold excess of respiratory cancer among 8,047 employees at the Anaconda copper smelter. We established vital status through December 1977 for a sample of 1,800 men from the original cohort. Average arsenic concentrations were estimated for each smelter department based on industrial hygiene measurements made from 1943 to 1965. Departments with similar concentrations were combined into four categories of exposure: 1) low (less than 100 micrograms/m3), 2) medium (100-499 micrograms/m3), 3) high (500-4,999 micrograms/m3) and 4) very high (greater than or equal to 5,000 micrograms/m3). Three indices of individual arsenic exposure were developed: time-weighted average, 30-day ceiling, and cumulative. Exposures to sulfur dioxide and asbestos were also examined. Smoking habits were obtained by questionnaire. Mortality was compared to that of men in the State of Montana using the modified lifetable method. A clear dose-response relationship between arsenic exposure and respiratory cancer was demonstrated. Men in the highest exposure category had a sevenfold excess. Those in the low and medium categories had a risk close to that expected. Ceiling arsenic exposure appeared to be more important than did time-weighted average exposure. Sulfur dioxide and asbestos did not appear to be important in the excess of respiratory cancer, although sulfur dioxide and arsenic exposures could not be separated completely. Smoking did not appear to be as important as arsenic exposure. Our findings suggest that had men worked only in departments with low or medium arsenic exposures (i.e., less than 500 micrograms/m3) there would have been little excess respiratory cancer. Since the estimates of arsenic exposure were based on department averages rather than on concentrations for individual jobs, these results must be interpreted with caution.

An index of risk for obstructive airways disease

Predictors of obstructive airways disease (OAD) have been identified, and models for estimating risk of developing OAD have been derived for the adult population of Tecumseh. Men and women 16 to 64 yr of age when first studied were reexamined after an average interval of 15 yr. Incidence rates of OAD increased with age and were higher in men than in women more than 45 yr of age. Incidence rates were significantly higher in men and women with low degrees of lung function initially, and in cigarette smokers, especially those who continued to smoke. Other risk factors included a physician's diagnosis of chronic bronchitis, or asthma, a history of cough, wheeze, shortness of breath, frequent upper or lower respiratory tract infections, bronchitis or pneumonia, leanness, and familial chronic bronchitis. Multiple logistic regression analyses identified combinations of risk factors that placed 70% of the male and 73% of the female incidence cases in the top 10% of the risk distribution. The excess risk of obstructive airways disease associated with cigarette smoking and reduced lung function and the benefits of stopping smoking are clearly apparent. For example, the risk of developing obstructive airways disease in the next 15 years is about 1 in 200 for a 45-yr-old male nonsmoker whose Vmax50 equals to 100% of predicted, if he doesn't take up smoking. The risk for a man of the same age who smokes 40 cigarettes a day and whose Vmax50 equals 80% of predicted is 1 in 5 or 6 if he doesn't cut down on his smoking and about 1 in 15 if he stops smoking.

Influence of arsenic exposure and smoking on lung cancer among smelter workers: a pilot study

A pilot study of 300 smelter workers from the cohort reported by Lee and Fraumeni [1969] has been studied: 150 men from their heavy exposure group and 150 men from the rest of the cohort randomly selected. Usable smoking habits were obtained from 86% of the sample. Estimates of the total lifetime work exposure were made from available measurements. A very high risk of lung cancer (SMR 1429) was observed among the most heavily exposed workers. Excess risks, though still present, were much less in those with lower exposures. There was a lower proportion of nonsmokers among the heavily exposed arsenic workers than among the other workers. This suggests that there may be some interaction between smoking and arsenic exposure. Moreover, comparison of smoking habits reported by smelter workers suggested that, as a group, they smoked more heavily than average for the United States population. A small study of proxy smoking histories suggested that these were valid and unbiased. The work continues on an enlarged sample.

Metabolism of resorcinylic compounds by bacteria. Purification and properties of orcinol hydroxylase from Pseudomonas putida 01

Orcinol hydroxylase (EC 1.14.13.6), which catalyzes the first reaction of orcinol catabolism in Pseudomonas putida 01, has been purified to homogeneity, and crystallized. Orcinol hydroxylase catalyzes the hydroxylation of orcinol with equimolar consumption of O2 and NADH (or NADPH) to 2, 3, 5-trihydroxytoluene, which is nonenzymically oxidized to a quinone. The visible absorption spectrum of the enzyme shows maxima at 373 and 454 nm and a shoulder at 480 nm. FAD can be dissociated from the protein. Reconstitution of enzymic activity was achieved with FAD, and to a limited extent by FMN. The enzyme has a molecular weight of 63,000 to 68,000 and contains 1 mol of FAD per mol of protein. K-m values for the three substrates orcinol, NADH, and O2 are 0.03, 0.13, and 0.07mM, RESPECTIVELY. The molecular activity of the crystalline enzyme is 1560 min minus 1. In the absence of orcinol, NADH is only slowly oxidized with formation of H2O2. Several analogs of orcinol also serve as substrates for hydroxylation, namely resorcinol, 4-methylresorcinol, and 4-bromoresorcinol. Other analogs, m-cresol, m-ethylphenol, 4-ethylresorcinol, and phloroglucinol, mimic orcinol as effectors, in that they (a) accelerate electron flow from NADH to the flavin and (b) decrease the apparent K-m for NADH but not to the same extent as the substrates that are hydroxylated. The latter compounds are not hydroxylated. Instead H2O2 accumulates as the only product of O2 reduction. The enzyme therefore behaves either as a hydroxylase or an oxidase. The ratio of hydroxylase to oxidase activities of the enzyme is decreased by an increase in the temperature of incubation; at 60 degrees the reaction with orcinol is almost 50% uncoupled from hydroxylation. The apparent K-m values for the effectors are in good agreement with the D-D values obtained for orcinol, resorcinol, and m-cresol. K-D values were obtained by measurement of the effector-induced perturbations of the visible absorption spectrum of the flavoprotein by difference absorption spectroscopy. The circular dichroism spectrum of orcinol hydroxylase is also altered in the presence of orcinol. The participation of the flavin in the over-all reaction is demonstrated by its rapid reduction under anaerobic conditions by NADH in the presence or orcinol, resorcinol, or m-cresol. Subsequent introduction of oxygen restores the oxidized form and yields H2O2 when m-cresol is the effector, but not when orcinol is the effector. Transfer of reducing equivalents from the reduced flavoprotein to free FAD may also occur. Reduction of orcinol hydroxylase by NADH in the absence of an effector is 10-4-fold slower than in the presence of an effector. The minimal structural requirements for effectors appear to be a 1,3-dihydroxy or 1-alkyl-3-hydorxybenzene, but only the former are substrates for hydroxylation.

Spontaneous pneumothorax in infancy

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