Unresolved pain in children: a relational ethics perspective

An Australian survey of health professionals' perceptions of use and usefulness of electronic medical records in hospitalised children's pain care

Pain in hospitalised children is common, yet inadequately treated. Electronic medical records (EMRs) can improve care quality and outcomes during hospitalisation. Little is known about how clinicians use EMRs in caring for children with pain. This national cross-sectional survey examined the perceptions of clinician-EMR users about current and potential use of EMRs in children's pain care. One hundred and ninety-four clinicians responded (n = 81, 74% nurses; n = 21, 19% doctors; n = 7, 6% other); most used Epic (n = 53/109, 49%) or Cerner (n = 42/109, 38%). Most (n = 84/113, 74%) agreed EMRs supported their initiation of pharmacological pain interventions. Fewer agreed EMRs supported initiation of physical (n = 49/113, 43%) or psychological interventions (n = 41/111, 37%). Forty-four percent reported their EMR had prompt reminders for pain care. Prompts were perceived as useful (n = 40/51, 78%). Most agreed EMRs supported pain care provision (n = 94/110, 85%) and documentation (n = 99/111, 89%). Only 39% (n = 40/102) agreed EMRs improved pain treatment, and 31% (n = 32/103) agreed EMRs improved how they involve children and families in pain care. Findings provide recommendations for EMR designs that support clinicians' understanding of the multidimensionality of children's pain and drive comprehensive assessments and treatments. This contribution will inform future translational research on harnessing technology to support child and family partnerships in care.

Pain assessment & management decision-making in pediatric critical care

PURPOSE

The aim of this study was to explore how nurses in the Pediatric Intensive Care Unit (PICU) reach their pain management decisions in children who are mechanically ventilated and chemically paralyzed.

DESIGN AND METHODS

A qualitative descriptive design was used following a quantitative phase of a multi-method study. Eighteen PICU nurses participated in semi-structured interviews aiming at understanding how they assess pain and make management decisions. Content analysis was used to guide coding and generate themes.

RESULTS

Three major themes were identified: 1) Assessment or cues that nurses use to trigger a pain assessment; 2) Mental models or patterns that nurses create to interpret cues to guide decision-making; 3) External factors that inhibit or facilitate decision-making. Overall, nurses rely on physiological cues to assess pain. From there, a large amount of variation exists on how nurses interpret those cues to make their pain management decision. External factors such as unit culture, perceived barriers and facilitators, and the nurse's experiences impacted how decisions are made.

CONCLUSIONS

Variation exists in the mental models' nurses create to make their pain management decision in this population. Nurses reported confusion on pain and sedation scale selection and various documentation practices for pain assessment. "Assume pain present" was identified as a concept and documentation practice that may guide decisions; further research is needed.

PRACTICE IMPLICATIONS

Development of clinician decision support tools that not only aid their understanding of reliable pain cues but also help create clear documentation practices may help nurses make pain management decisions.

Pain Assessment and Management for a Chemically Paralyzed Child Receiving Mechanical Ventilation

BACKGROUND

Pain assessment in the pediatric intensive care unit (PICU) is complex, specifically for children receiving mechanical ventilation who require neuromuscular blockade (NMB). No valid pain assessment method exists for this population. Guidelines are limited to using physiologic variables; it remains unknown how nurses are assessing and managing pain for this population in practice.

OBJECTIVES

To describe how PICU nurses are assessing and managing pain for children who require NMB.

METHODS

A cross-sectional quantitative design was used with an electronic survey. Nurses were asked to respond to 4 written vignettes depicting a child who required NMB and had a painful procedure, physiologic cues, both, or neither.

RESULTS

A total of 107 PICU nurses answered the survey. Nurses primarily used behavioral assessment scales (61.0%) to assess the child's pain. All nurses reported that physiologic variables are either moderately or extremely important, and 27.3% of nurses used the phrase "assume pain present" formally at their organization. When physiologic cues were present, the odds of a nurse intervening with a pain intervention were 23.3 times (95% CI, 11.39-53.92; P < .001) higher than when such cues were absent.

CONCLUSIONS

These results demonstrate variation in how nurses assess pain for a child who requires NMB. The focus remains on behavioral assessment scales, which are not valid for this population. When intervening with a pain intervention, nurses relied on physiologic variables. Decision support tools to aid nurses in conducting an effective pain assessment and subsequent management need to be created.

Impact of music therapy and hand massage in the pediatric intensive care unit on pain, fear and stress: Randomized controlled trial

PURPOSE

This study was performed with the aim of assessing the effect of music therapy and hand massage on pain, fear and stress among 12-18 year-old adolescents treated in the pediatric intensive care unit (PICU).

DESIGN

This study was a randomized controlled trial, with single-blind design.

METHODS

The adolescents were divided into groups with 33 receiving hand massage, 33 receiving music therapy and 33 in the control group. Collection of data used the Wong-Baker FACES (WB-FACES) Pain Rating Scale, Children's Fear Scale (CFS) and blood cortisol levels.

FINDINGS

In the study, adolescents in the music therapy group had lower mean points for WB-FACES before, during and after the procedure by a significant level compared to the control group (p < 0.05). Additionally, the CFS mean points before and during the procedure were lowest in the music therapy group, while the music therapy and massage groups were determined to have lower points by a significant level after the procedure compared to the control group (p < 0.05). However, when the mean cortisol levels of adolescents before the procedure and on the 1st and 2nd day after the procedure were compared, there was no significant difference between the groups (p > 0.05).

CONCLUSIONS

It was determined that hand massage and music therapy were more effective than standard care at reducing pain and fear levels during blood drawing among 12-18-year-old adolescents in the PICU.

PRACTICE IMPLICATIONS

Nurses may use music therapy and hand massage to manage fear and pain related to blood drawing in the PICU.

Assessment of postoperative pain in children with computer assisted facial expression analysis

PURPOSE

The present study was conducted to evaluate the use of computer-aided facial expression analysis to assess postoperative pain in children.

DESIGN AND METHODS

This was a methodological observational study. The study population consisted of patients in the age group of 7-18 years who underwent surgery in the pediatric surgery clinic of a university hospital. The study sample consisted of 83 children who agreed to participate and met the sample selection criteria. Data were collected by the researcher using the Wong Baker Faces pain rating scale and Visual Analog Scale. Data were collected from the child, mother, nurse, and one external observer. Facial action units associated with pain were used for machine estimation. OpenFace was used to analyze the child's facial action units and Python was used for machine learning algorithms. The intraclass correlation coefficient was used for statistical analysis of the data.

RESULTS

The pain score predicted by the machine and the pain score assessments of the child, mother, nurse, and observer were compared. The pain assessment closest to the self-reported pain score by the child was in the order of machine prediction, mother, and nurse.

CONCLUSIONS

The machine learning method used in pain assessment in children performed well in estimating pain severity.It can code facial expressions of children's pain and reliably measure pain-related facial action units from video recordings.

APPLICATION TO PRACTICE

The machine learning method for facial expression analysis assessed in this study can potentially be used as a scalable, standard, and valid pain assessment method for nurses in clinical practice.

Health Care Providers' Experiences of the Non-Pharmacological Pain and Anxiety Management and Its Barriers in the Pediatric Intensive Care Units

OBJECTIVES

Children in the intensive care unit experience a high level of pain and anxiety. This study aimed to reveal the health care providers experience of non-pharmacological pain and anxiety management and its barriers in the pediatric intensive care unit.

METHODS

This qualitative-descriptive study was conducted with thirteen nurses and five physicians in the pediatric intensive care unit in Iran. Individual, in-depth and semi-structured interviews were conducted, which were analyzed by conventional content analysis.

RESULTS

Five main categories were identified from data analysis: 1) The importance of parents' presence, 2) Disturbance in the presence of parents and communication during the COVID-19 pandemic, 3) Choosing non-pharmacological approaches according to the child's interests and conditions, 4) Building trust in the child through non-pharmacological interventions 5) Barriers to non-pharmacological pain and anxiety management in the pediatric intensive care unit.

CONCLUSION

Health care providers implement some non-pharmacological methods to manage pain and anxiety in the pediatric intensive care unit. Facilitating the open presence of parents, using innovative methods to communicate with children, and training and psychological support for nurses and parents, especially during the COVID-19 pandemic are recommended.

Clinical Holding in Pediatric Venipuncture: Caring by Empowering the Caregiver

The use of restraint in the child-adolescent population is highly controversial due to the consequences it can have for patients and their families, although it is sometimes necessary to employ restraint to perform techniques safely and effectively. Clinical Holding is committed to the involvement of parents during venipuncture in the context of family-centred care. This study assesses levels of distress and pain in children undergoing this procedure, as well as satisfaction in parents and nurses. Parents assist in the restraint of children and provide accompaniment during venipuncture. Levels of distress and pain were not particularly elevated. Satisfaction levels among parents and nurses were high. A positive correlation was found between anticipatory and real distress (r = 0.737, p = 0.000), and between real distress and real pain (r = 0.368, p = 0.035). A negative correlation was observed between real pain and parent satisfaction (r = -0.497, p = 0.003). Parental participation during venipuncture contributed to better management of distress and pain. In the future, it would be advisable to incorporate the other pharmacological and non-pharmacological measures recommended by Clinical Holding to ensure care of the highest quality and safety.

Impact of paediatric tonsillectomy perioperative management on pain, nausea and recovery: A prospective cohort study

AIM

Tonsillectomy procedures are a core element of paediatrics; however, perioperative management differs. This study aimed to describe tonsillectomy management, including the burden of pain, nausea and delayed recovery.

METHODS

A prospective cohort study was undertaken through an audit of tonsillectomy perioperative practice and recovery and survey interviews with family members 7-14 days post-surgery. The study was undertaken at an Australian tertiary referral paediatric hospital between June and September 2016.

RESULTS

The audit included 255 children undergoing tonsillectomy, with 127 family members interviewed. Most participants underwent adenotonsillectomy (n = 216; 85%), with a primary diagnosis of obstructive sleep apnoea (n = 205; 80%) and a mean age of 7 years (standard deviation; 3.9). A variety of intra-operative pain relief and antiemetics was administered. Pain was present in 29% (n = 26) of participants at ward return, increasing to 32-45% at 4-20 h and decreasing to 21% (n = 15) at discharge. A third of the children (32%; n = 41) had moderate to severe pain at post-discharge interview, and 30% (n = 38) experienced nausea at home. Most parents (82%; n = 104) were still giving regular paracetamol at 7 days post-operatively, and 31% (n = 39) had finished their oxycodone. Of the participants, 14% (n = 26) presented to the emergency department within 7 days of discharge; 8% (n = 20) of the total cohort were re-admitted.

CONCLUSIONS

There was variety in perioperative and post-discharge care. Pain scores were infrequently documented post-tonsillectomy, and parents are generally dissatisfied with the management of post-operative pain and nausea. Further research is needed to provide a more consistent approach to perioperative management to promote recovery.

Pain Assessment Practices in the Pediatric Intensive Care Unit

PURPOSE

Pain assessment is the first step in managing pain; however, this can be challenging, particularly in settings such as the Pediatric Intensive Care Unit (PICU). This paper reports the current pain assessment practices from a study that was conducted describing the prevalence of pain, pain assessment, painful procedures, interventions, and characteristics of critically-ill children. Specifically, this paper addresses the child's communicative ability, pain scales, and characteristics of pain.

DESIGN AND METHODS

The primary study was a cross-sectional, multi-site, descriptive design. Data from a 24-hour time period were collected from medical records and bedside nurses.

RESULTS

Data were collected from the records of 220 children across 15 PICUs. The average number of pain assessments per child was 11.5 (SD 5.8, range 1-28). Seven behavioral scales and five self-report scales were used. There were times when no scale was used, "assume pain present" was recorded, or a sedation scale was documented. Twelve pain scales, including the target population, scoring, psychometric properties, and clinical utility are described.

CONCLUSIONS

Results of this study indicate that a wide range of pain assessment tools are used, including behavioral scales for children unable to self-report.

IMPLICATIONS

Foremost, the appropriate assessment method needs to be chosen for each child to manage pain. Knowledge of the criteria for the use of each pain assessment scale will help the clinician select the appropriate scale to use for each child. The practice of "assume pain present," as well as standardization of pain scales, and clinical support tools needs further investigation.

Exploring distraction and the impact of a child life specialist: Perceptions from nurses in a pediatric setting

PURPOSE

The purpose of this study is to explore perceptions held by nurses on the use of distraction and the role of a child life specialist in caring for children undergoing painful procedures.

DESIGN AND METHODS

A qualitative focus-group design was conducted with 18 nurses from a 24-bed pediatric unit in New South Wales, Australia; this represented 51% of the staff from the unit. Three focus groups were conducted and transcribed verbatim followed by thematic analysis.

RESULTS

Findings revealed five main themes that reflected the perceptions of the nurses' use of distraction and the impact of the child life specialist. The theme "Distraction as part of everyday nursing practice" was viewed by nurses as an integral component of nursing practice. The theme "Influence of child life specialist" revealed that the child life specialist created a feeling of ease during procedures. Differences were acknowledged between the two roles, "Contrast of roles" the child life specialist was seen as positive for children and families, whereas nurses viewed themselves as mean and unkind due to the nature of their work. The theme "The value of collaboration for positive healthcare experiences" acknowledged distraction as a contributing factor in ensuring the child and their family had a positive healthcare experience. The types of "nurses perception of the child's experience with distraction" shared in each of the focus groups identified nurses felt their techniques for distraction were much more simplified than the child life specialist; nurses felt disadvantaged at times in not having access to the same tools.

PRACTICE IMPLICATIONS

The findings indicate the positive impact that a child life specialist has on a nurse's role while caring for children undergoing painful procedures. Nurses felt they were able to focus on the procedure, therefore ensuring the physician received the right amount of assistance. This reassured the nurses in knowing the child and their families emotional needs were being taken care of. The child life specialist was viewed as being able to provide a positive healthcare experience for the child and families, nurses felt this added to the value of care provided in the pediatric unit. Recommendations include further exploration of the child life specialist role in the pediatric inpatient setting.

Nurses' Knowledge and Attitude toward Pediatric Pain Management: A Cross-Sectional Study

BACKGROUND

Pain in infants and children is often poorly assessed and managed. Although there are many studies on this subject, none have been conducted in the Arab world, including the Kingdom of Saudi Arabia, where nurses are largely expatriates.

AIMS

To examine the knowledge and attitudes of nurses working with infants and children in the Kingdom of Saudi Arabia regarding pain management.

DESIGN

Descriptive cross-sectional survey.

SETTINGS

Five government hospitals in Riyadh region of the Kingdom of Saudi Arabia.

PARTICIPANTS/SUBJECTS

Registered nurses caring for infants and children.

METHODS

A convenience sample of 410 nurses working at five Saudi Arabian government hospitals was surveyed using the Pediatric Nurses' Knowledge and Attitudes Survey Regarding Pain (PNKAS-Shriners Revision). Data were analyzed using descriptive (frequency, percentage, mean, and standard deviation) and inferential statistics, including Pearson correlation, independent t test, and one-way analysis tests.

RESULTS

Poor overall knowledge and attitudes regarding pediatric pain management was evident in this study. The mean correct score achieved by nurses was 18.1 ± 4.0 out of 40 or 45.2% ± 10.0% of a possible score of 100%. A weak but statistically significant correlation was found between years of pediatric nursing experience and total score (r = -0.129, p = .009).

CONCLUSIONS

We concluded that intensive education on pediatric pain and its management is urgently needed for nurses working in the Kingdom of Saudi Arabia.

Could a Certain Sitting Position Reduce the Pain Experienced by a Child? The Benefits of Parental Holding and an Upright Position

Intravenous injection is the most feared medical procedure and gives rise to an experience of mild to severe pain in children. Unrestrained pain has a negative effect on the child. Pain management in the form of a convenient sitting position is needed by children who undergo intravenous injection procedures. This study aims to determine the effect of parental holding and an upright position on children's pain during intravenous injection procedures. The study used the Randomized Clinical Trial method involving 34 respondents, aged 1-4 years, who were included in the intervention and control group. The result of a Mann-Whitney U test analysis showed a significant difference in the pain score between the intervention and control groups (p value = .000; α = .05). The parental holding and upright position can be applied as a nonpharmacological pain management strategy for children who undergo intravenous injection procedures.

Ghanaian nurses' knowledge of invasive procedural pain and its effect on children, parents and nurses

AIM

To explore Ghanaian nurses' knowledge of invasive procedural pain in children who are in hospital and to identify the effect of unrelieved pain on children, parents and nurses.

METHOD

An exploratory, descriptive and qualitative design was adopted. A purposive sampling technique was used and individual face-to-face, semi-structured interviews were conducted with 16 registered nurses from four children's units at a hospital in the Eastern Region of Ghana. Thematic and content analyses were performed.

FINDINGS

Four themes emerged: types of invasive procedure; pain expression; pain assessment; and effects of unrelieved pain. Participants had adequate knowledge of painful invasive procedures, however, they were not aware of the range of available validated pain assessment tools, using observations and body language instead to assess pain.

CONCLUSION

Ghanaian nurses require education on the use of validated rating scales to assess procedural pain in children. The inclusion of pain assessment and management in pre-registration curricula could improve knowledge.

An Integrative Review of the Literature on Pain Management Barriers: Implications for the Canadian Clinical Context

Despite decades of pain research, substandard pain management continues to be distressingly prevalent across health-care settings. This integrative literature review analyzes and synthesizes barriers to effective pain management and identifies areas for future investigation in a Canadian context. Three sets of key barriers were identified through thematic analysis of 24 original research studies published in the period 2003-13: patient, professional, and organizational. These barriers rarely occurred in isolation, with many studies reporting examples in all three categories. This suggests that interventions need to reflect the multifactorial nature of pain management. Reframing pain education as a public health initiative could lead to sustainable improvement, as could the strengthening of partnerships between patients and health-care providers. There are tremendous opportunities for the advanced practice nurse to take a lead in pain management. The delivery of high-quality care that encompasses effective pain management strategies must be a priority for nursing. Research approaches, such as pragmatic mixed methods, that offer contextual understanding of how pain is managed are suggested.

Knowledge and attitudes regarding pediatric pain in Mongolian nurses

The World Health Organization and the International Association for Study of Pain cite the significance of pediatric pain as a significant global health issue. Developing countries may have increased needs compared with developed countries because of limited resources and lack of training. In Mongolia a paucity of data exist regarding nursing knowledge of pediatric pain management. The purpose of this project was to assess the current knowledge of pediatric pain and to assess the effectiveness of educational intervention on improving knowledge and attitudes of pediatric nurses working at a major children's hospital in Mongolia. Knowledge and attitudes of Mongolian nurses were evaluated before and after a 2-hour educational intervention. The translated Modified Mongolian Pediatric Nurses' Knowledge and Attitudes Survey Regarding Pain-Shriner's Revision survey was used as a pre- and postintervention assessment instrument with local nurses at a pediatric hospital in Ulaanbaatar, Mongolia. One hundred sixty-seven nurses attended the conference, with 155 nurses completing the pre- and postsurveys. The mean score on the presurvey was 12.7 out of 35 (26.4% correct), whereas the mean score on the postsurvey score was 16.7 out of 35 (47.8% correct). A paired t test showed a significant statistical difference between scores (p < .0001). Pediatric nurses in Mongolia demonstrate insufficient knowledge of pediatric pain management. The educational intervention was effective in improving pediatric pain knowledge and attitudes in Mongolian nurses. It is recommended to establish similar educational endeavors with nurses around the world to improve pain knowledge and attitudes.

Influences shaping nurses' use of distraction for children's procedural pain

PURPOSE

This study explored pediatric nurses' choices to use distraction for managing painful procedures.

DESIGN AND METHODS

Using interpretive description approaches, interviews with pediatric nurses provided descriptions of choices to manage procedural pain.

RESULTS

Nurses' distress influenced distraction use to mitigate the suffering of children and themselves. Newer nurses described task mastery as influencing distraction choices. Nurses' accounts of performing painful procedures on children mirrored children's descriptions of pain from the literature.

PRACTICE IMPLICATIONS

Nurses' distress and competency performing painful procedures on children influenced practice. Future qualitative studies could extend understanding of pain management choices by pediatric nurses and the impact on undermanaged pain.

Mind the gaps in ethical regulations of nursing research

The introduction of and the commitment to evidence-based nursing in all care settings have led to a rapid increase of intervention and outcome-based research programs. Yet, the topics of nursing research are not only affected by interventions and outcomes but also affected by the concept of caring derived from humanistic philosophy. Considering this twofold orientation of nursing science, nuanced ethical regulations for nursing research programs are called for. In addition to the different research approaches, further arguments for ethical regulations are as follows: first, the different degrees of contextualization and the variety of participation models regarding the target groups; second, the capacities and opportunities of participants; and third, the caring relationship between nurses and research subjects. To capture these special features of nursing science, four approaches to fill the gaps in existing ethical regulations for nursing research are proposed: (a) process orientation, (b) community orientation, (c) context orientation, and (d) relation orientation.

Caring for children in pediatric intensive care units: an observation study focusing on nurses' concerns

Children in the pediatric intensive care unit are indisputably in a vulnerable position, dependent on nurses to acknowledge their needs. It is assumed that children should be approached from a holistic perspective in the caring situation to meet their caring needs. The aim of the study was to unfold the meaning of nursing care through nurses' concerns when caring for children in the pediatric intensive care unit. To investigate the qualitative aspects of practice embedded in the caring situation, the interpretive phenomenological approach was adopted for the study. The findings revealed three patterns: medically oriented nursing--here, the nurses attend to just the medical needs, and nursing care is at its minimum, leaving the children's needs unmet; parent-oriented nursing care--here, the nursing care emphasizes the parents' needs in the situation, and the children are viewed as a part of the parent and not as an individual child with specific caring needs; and smooth operating nursing care orientation--here, the nursing care is focused on the child as a whole human being, adding value to the nursing care. The conclusion drawn suggests that nursing care does not always respond to the needs of the child, jeopardizing the well-being of the child and leaving them at risk for experiencing pain and suffering. The concerns present in nursing care has been shown to be the divider of the meaning of nursing care and need to become elucidated in order to improve the cultural influence of what can be seen as good nursing care within the pediatric intensive care unit.

Neuropathic pain management in children

There are difficulties in assessing, managing, and evaluating neuropathic pain in dying children, particularly those with neurological impairment. Neuropathic pain in children often presents differently to how it presents in the adult population. Comprehensive assessment as well as pharmacological and non-pharmacological interventions are crucial to its successful management and frequently require input from an interdisciplinary team. Notwithstanding the need for further research, this paper brings together research papers, reviews, and clinical guidelines to present an exploration of existing evidence regarding care for children with neuropathic pain and their families.

Balancing truth-telling in the preservation of hope: a relational ethics approach

Truth-telling in healthcare practice can be regarded as a universal communicative virtue; however, there are different views on what consequence it has for giving or diminishing hope. The aim of this article is to explore the relationship between the concepts of truth-telling and hope from a relational ethics approach in the context of healthcare practice. Healthcare staff protect themselves and others to preserve hope in the care of seriously sick patients and in end-of-life care. This is done by balancing truth-telling guided by different conditions such as the cultural norms of patients, family and staff. Our main conclusion is that the balancing of truth-telling needs to be decided in a mutual understanding in the caring relationship, but hope must always be inspired. Instead of focusing on autonomy as the only guiding principle, we would like to propose that relational ethics can serve as a meaningful perspective in balancing truth-telling.

[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.