Original Article Knowledge and Attitudes Regarding Neonatal Pain Among Nursing Staff of Pediatric Department: An Indian Experience Archana S. Nimbalkar, DCH,* Ashish R. Dongara, MBBS,* Ajay G. Phatak, MPH,† and Somashekhar M. Nimbalkar, MD*,† ---
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From the *Department of Pediatrics, Pramukhswami Medical College, Karamsad, Gujarat, India; †Central Research Services, H. M. Patel Academic Center, Karamsad, Gujarat, India. Address correspondence to Somashekhar M. Nimbalkar, MD, Department of Pediatrics, Pramukhswami Medical College, Karamsad, Gujarat, India. Pin: 388325. E-mail: somu_somu@ yahoo.com Received March 18, 2012; Revised June 8, 2012; Accepted June 11, 2012. 1524-9042/$36.00 Ó 2014 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2012.06.005
ABSTRACT:
Neonates receiving care in intensive care units are highly likely to experience pain due to investigations and/or treatments carried out by the health care providers. Neonates are a vulnerable population because they are unable to vocalize their pain. Unaddressed and mismanaged pain can not only affect the child’s comfort, but also may alter the development and cognitive abilities of the child in a later part of his/her life. Therefore it is entirely the caregiver’s responsibility to accurately assess and manage neonatal pain. We assessed and compared the knowledge and attitudes regarding neonatal pain among the nurses posted in the various units of a pediatric department [pediatric ward, pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU)]. An appropriately modified Knowledge and Attitudes Survey Regarding Pain questionnaire was consensually validated, pretested, and then administered to the nursing staff of the pediatric department at a department at a hospital in Gujarat. Data were entered in Epi-Info and analyzed with the use of SPSS 14.0. The questionnaire was administered to 41 nurses working in the Department of Pediatrics, and the response rate was 97.5%. Mean age of the nurses in the study sample was 25.75 years (SD 5.513). The mean total score of the participants was 8.75 out of 17 (SD 2.549), which was unsatisfactory. The mean correct answer rate was 49.67% among the staff of NICU and 48.67% among the pediatric ward and PICU staff. The attitudes among the nurses were assessed. It was concluded that the nurses lack knowledge and that their attitudes also were hindering pain management. One of the barriers identified by the nurses was that physicians do not prescribe analgesics for managing neonatal pain. So not only the nursing staff, but all of the caregivers involved in neonatal care may be lacking in knowledge and hold perceptions and attitudes that hamper neonatal pain management. Ó 2014 by the American Society for Pain Management Nursing Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 69-75
70
Nimbalkar et al.
The International Association for the Study of Pain (IASP) defines pain as ‘‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’’ (‘‘Pain terms: A list with definitions and notes on usage,’’ 1979). The IASP definition also states that pain is always subjective and is learned through experience related to injury in early life. This definition is problematic when considering neonates who are incapable of self-report and may not have had previous experience with injury. Therefore, a new definition has been proposed that ‘‘pain perception is an inherent quality of life that appears early in development to serve as a signaling system for tissue damage’’ (Anand & Craig, 1996). From that definition, it is clear that pain is nature’s physiologic mechanism to warn the body about possible damage. Untreated and chronic pain, especially in newborns, can, in short course delay recovery, delay wound healing, impair mobility, cause sleep disturbances, etc., thereby increasing the hospital stay and in long course cause behavioral and cognition abnormality, developmental regression, and alter the development and maturation of the nervous system pertaining to perception of pain (Van Hulle Vincent, 2005). As the degree of prematurity increases, there is an increase in the sensitivity and adverse effects of pain (Anand, 1998). Pain is a side effect of clinical management. Barker and Rutter (1995), in a study of 54 babies admitted to neonatal intensive care, showed that they were jointly exposed to more than 3,000 procedures. Most of the neonates were 0.80) by repeated testing in a continuing education class of staff nurses (n ¼ 60). Internal
71
Neonatal Pain Nursing Knowledge and Attitudes
consistency reliability was established (Cronbach alpha > 0.70) with items reflecting both knowledge and attitude domains (Ferrell & McCaffery, 2008). The following modifications were made in the questionnaire: 1) Questions related to chronic/cancer related pain were deleted; 2) questions related to medications which were not routinely used in our setup were deleted; 3) the case-related questions were deleted, because nursing staff at our setup were not routinely involved in postoperative care; 4) some questions which focused on neonatal or infant pain were added. The modified tool contained 17 true/false questions and 7 multiple-choice questions. It was consensually validated. Cronbach a was >0.70 for attitudes and knowledge. This questionnaire was administered to ten randomly selected nurses outside of the pediatric department. Their responses were analyzed in a group discussion to ascertain that they understood the questions correctly and that their response reflected exactly what they meant to say. Higher scores represented better knowledge. Analysis of the data was done in terms of the percentage of total scores as well as by analyzing individual items. Isolation of questions that were answered least correctly as well as most correctly was done. Method After explaining the questionnaire, the nurses were individually administered the questionnaire. No time limit was imposed on them. After the test, all of their answers were discussed in a group discussion and their doubts and misconceptions were cleared. Analysis The data were entered into Epi-Info and then imported into Statistical Program for Social Sciences (SPSS) version 14.0, and analysis was done. Fisher’s exact test was used when required. Multiple regression analysis was performed to find out the significant contributors of the net score.
RESULTS The demographic characteristics of the participants are as shown in Table 1. A total of 40 nurses out of 41 (97.5%) returned the completed questionnaire. The mean age of the nursing population was 25.75 years with a standard deviation of 5.51 years. The median age was 24 years with a range from 21 years to 41 years. All the nurses were female. Out of the 40 nursing staff , 90% had done General Nurse Midwifery (GNM), one had a Bachelors Degree of Science (BSc) in Nursing (2.5%), three (7.5%) had done Auxillary Nurse
TABLE 1. Demographic Characteristics of the Study Sample
Sex Location Marital Status Education Has Children Nurse or family members have been hospitalized Received any training in pain management previously
n
%
Female Male Pediatric ward NICU PICU Married Unmarried ANM GNM BSc No Yes No Yes
40 0 10 22 8 16 24 3 36 1 28 12 31 9
100% 0% 25% 55% 20% 40% 60% 7.5% 90% 2.5% 70% 30% 77.5% 22.5%
No Yes
34 6
85% 15%
Midwifery (ANM). Twenty-two (55%) were NICU nurses and the remainder were PICU and pediatric ward nurses. Twenty-eight nurses (70%) did not have children, and 31 (77.5%) had previous experience with hospitalization. Thirty-four nurses (85%) did not have any formal training in pain. Yet 37 nurses (92.5%) thought that the training they had received at nursing school was useful in assessment and management of pain in neonates. Average correct response rate for NICU nurses was 49.66% and for pediatric ward and PICU nurses was 48.67%. Mean number of correctly answered questions was 8.75 with a standard deviation of 2.55. The minimum correctly answered questions was 3 and the maximum was 13 out of 17. Mean number of questions correctly answered by the NICU nurses was 9.09 (SD 2.467) and by the pediatric nurses was 8.33 (SD 2.656). The difference between them was not statistically significant (p ¼ .29; Fig. 1). Multiple regression analysis of total score and the variables previously mentioned was done. Only marital status was found to have a significant effect on knowledge and attitudes toward pain (p ¼ .029; data not shown). Statistically significant difference was not found in any other variable. For the NICU staff, the highest numbers of incorrect answers were noted in the following questions: 1) reliability of vitals as indicators of pain; 2) method of deciding subsequent dose of opiod analgesic; 3) neonates’ ability to sleep in spite of severe pain; 4)
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Nimbalkar et al.
The nurses were themselves asked to identify what according to them were barriers for effective pain management. Eighteen nurses (45%) thought that it was mistakes on the doctor’s part, i.e., not prescribing drug timely, 14 (35%) thought analgesic drugs had many side effects so were best avoided, and 10 (25%) thought that procedures were very short-lasting so no analgesic was needed.
12.50
10.00
7.50
5.00
DISCUSSION 2.50
TOTAL_SCORE
FIGURE 1. - Box plot showing the distribution of the total score of the nursing staff.
paracetamol as effective analgesic in neonates; and 5) effectiveness of breastfeeding as an analgesic. For pediatric ward and PICU staff the highest number of wrong answers were noted in: 1) method of deciding subsequent dose of opiod analgesic; 2) paracetamol as effective analgesic in neonates; 3) premature infants experiencing more pain than full terms 4) Neonates ability to sleep in spite of severe pain; and 5) nonpharmacologic methods of pain relief. Among the nurses of the NICU, 9 of 17 questions were answered correctly by fewer than 50% and among the pediatric ward or PICU 8 of 17 questions were answered correctly by fewer than 50%. Most of the nurses in the pediatric ward and PICU answered questions 1, 5, 9, and 11 correctly, whereas most nurses in NICU answered 3 and 16 correctly (Table 2). In the multiple-choice questions, nurses were allowed to select multiple options. Seventy percent correctly answered intravenous route as the route of administration of analgesic for sudden severe pain. Seventy percent of the nurses correctly mentioned that analgesic administration should be on a fixedschedule basis (Table 3). Thirty-four respondents (85%) thought that they were doing a good job of managing pain. Out of the 40 nurses who participated (70%) thought that they could accurately assess neonatal pain, although only 20 (50%) thought that they needed pain scales for assessing a neonate’s pain. The nurses were asked to identify the behavioral indicators in children that they deemed to be reliable. Thirty-four (85%) thought that a neonate’s facial expression was a reliable indicator, and 36 (90%) thought that the child’s cry, 26 (65%) limb movements, and 29 (72.5%) vitals are indicators of the child’s pain.
This study provides useful information regarding knowledge and attitudes toward neonatal pain by nurses in India. It also analyzed whether any significant difference existed between the nurses posted in the NICU, pediatric ward, or PICU. The findings show that most of the nurses lacked knowledge, and their pain management skills were far from optimal. Out of the total questions, the mean score was 8.75 with a mean correct answer rate of 49.67% among the NICU staff and 48.67% among the pediatric and PICU staff. The low score was consistent with other studies (Bernardi, Catania, & Tridello, 2007; Yildirim, Cicek, & Uyar, 2008). There was no statistically significant difference between the nurses of the NICU and the PICU and pediatric ward. Variables such as age, education (degree), marital status, previous hospitalization or painful experience, having children of their own, etc. play a role in how pain is perceived by nurses (Polkki et al., 2010; van Hulle Vincent & Denyes, 2004). But in the present study, only marital status was found to significantly affect knowledge and attitudes regarding pain. Those who were married had better knowledge regarding pain. The probable reason may be because married nurses are more empathetic and sensitive toward children’s pain. The effect of sex of the nurses on knowledge and attitude could not be analyzed, because all of the nursing staff were female. Education of the nurses was not found to have a significant effect on their knowledge and perceptions, probably because of the small sample size. The nurses thought that their nursing school education was useful in empowering them, and most of them thought that they could accurately assess and manage neonatal pain. Only 21 (52.5%) of the respondents stated that neonatal pain scales were essential for assessment of neonatal pain, and only 16 (40%) stated that they were using a pain scale supported by results of other studies (Polkki et al., 2010). This shows that pain scales were used by only a small fraction of the staff. The staff were not aware of the role and importance of pain scales and they overestimated their own
73
Neonatal Pain Nursing Knowledge and Attitudes
TABLE 2. True/False Questions Pediatric Ward Question 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Vital signs always reliable indicators of intensity of neonates pain Children
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From the *Department of Pediatrics, Pramukhswami Medical College, Karamsad, Gujarat, India; †Central Research Services, H. M. Patel Academic Center, Karamsad, Gujarat, India. Address correspondence to Somashekhar M. Nimbalkar, MD, Department of Pediatrics, Pramukhswami Medical College, Karamsad, Gujarat, India. Pin: 388325. E-mail: somu_somu@ yahoo.com Received March 18, 2012; Revised June 8, 2012; Accepted June 11, 2012. 1524-9042/$36.00 Ó 2014 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2012.06.005
ABSTRACT:
Neonates receiving care in intensive care units are highly likely to experience pain due to investigations and/or treatments carried out by the health care providers. Neonates are a vulnerable population because they are unable to vocalize their pain. Unaddressed and mismanaged pain can not only affect the child’s comfort, but also may alter the development and cognitive abilities of the child in a later part of his/her life. Therefore it is entirely the caregiver’s responsibility to accurately assess and manage neonatal pain. We assessed and compared the knowledge and attitudes regarding neonatal pain among the nurses posted in the various units of a pediatric department [pediatric ward, pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU)]. An appropriately modified Knowledge and Attitudes Survey Regarding Pain questionnaire was consensually validated, pretested, and then administered to the nursing staff of the pediatric department at a department at a hospital in Gujarat. Data were entered in Epi-Info and analyzed with the use of SPSS 14.0. The questionnaire was administered to 41 nurses working in the Department of Pediatrics, and the response rate was 97.5%. Mean age of the nurses in the study sample was 25.75 years (SD 5.513). The mean total score of the participants was 8.75 out of 17 (SD 2.549), which was unsatisfactory. The mean correct answer rate was 49.67% among the staff of NICU and 48.67% among the pediatric ward and PICU staff. The attitudes among the nurses were assessed. It was concluded that the nurses lack knowledge and that their attitudes also were hindering pain management. One of the barriers identified by the nurses was that physicians do not prescribe analgesics for managing neonatal pain. So not only the nursing staff, but all of the caregivers involved in neonatal care may be lacking in knowledge and hold perceptions and attitudes that hamper neonatal pain management. Ó 2014 by the American Society for Pain Management Nursing Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 69-75
70
Nimbalkar et al.
The International Association for the Study of Pain (IASP) defines pain as ‘‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’’ (‘‘Pain terms: A list with definitions and notes on usage,’’ 1979). The IASP definition also states that pain is always subjective and is learned through experience related to injury in early life. This definition is problematic when considering neonates who are incapable of self-report and may not have had previous experience with injury. Therefore, a new definition has been proposed that ‘‘pain perception is an inherent quality of life that appears early in development to serve as a signaling system for tissue damage’’ (Anand & Craig, 1996). From that definition, it is clear that pain is nature’s physiologic mechanism to warn the body about possible damage. Untreated and chronic pain, especially in newborns, can, in short course delay recovery, delay wound healing, impair mobility, cause sleep disturbances, etc., thereby increasing the hospital stay and in long course cause behavioral and cognition abnormality, developmental regression, and alter the development and maturation of the nervous system pertaining to perception of pain (Van Hulle Vincent, 2005). As the degree of prematurity increases, there is an increase in the sensitivity and adverse effects of pain (Anand, 1998). Pain is a side effect of clinical management. Barker and Rutter (1995), in a study of 54 babies admitted to neonatal intensive care, showed that they were jointly exposed to more than 3,000 procedures. Most of the neonates were 0.80) by repeated testing in a continuing education class of staff nurses (n ¼ 60). Internal
71
Neonatal Pain Nursing Knowledge and Attitudes
consistency reliability was established (Cronbach alpha > 0.70) with items reflecting both knowledge and attitude domains (Ferrell & McCaffery, 2008). The following modifications were made in the questionnaire: 1) Questions related to chronic/cancer related pain were deleted; 2) questions related to medications which were not routinely used in our setup were deleted; 3) the case-related questions were deleted, because nursing staff at our setup were not routinely involved in postoperative care; 4) some questions which focused on neonatal or infant pain were added. The modified tool contained 17 true/false questions and 7 multiple-choice questions. It was consensually validated. Cronbach a was >0.70 for attitudes and knowledge. This questionnaire was administered to ten randomly selected nurses outside of the pediatric department. Their responses were analyzed in a group discussion to ascertain that they understood the questions correctly and that their response reflected exactly what they meant to say. Higher scores represented better knowledge. Analysis of the data was done in terms of the percentage of total scores as well as by analyzing individual items. Isolation of questions that were answered least correctly as well as most correctly was done. Method After explaining the questionnaire, the nurses were individually administered the questionnaire. No time limit was imposed on them. After the test, all of their answers were discussed in a group discussion and their doubts and misconceptions were cleared. Analysis The data were entered into Epi-Info and then imported into Statistical Program for Social Sciences (SPSS) version 14.0, and analysis was done. Fisher’s exact test was used when required. Multiple regression analysis was performed to find out the significant contributors of the net score.
RESULTS The demographic characteristics of the participants are as shown in Table 1. A total of 40 nurses out of 41 (97.5%) returned the completed questionnaire. The mean age of the nursing population was 25.75 years with a standard deviation of 5.51 years. The median age was 24 years with a range from 21 years to 41 years. All the nurses were female. Out of the 40 nursing staff , 90% had done General Nurse Midwifery (GNM), one had a Bachelors Degree of Science (BSc) in Nursing (2.5%), three (7.5%) had done Auxillary Nurse
TABLE 1. Demographic Characteristics of the Study Sample
Sex Location Marital Status Education Has Children Nurse or family members have been hospitalized Received any training in pain management previously
n
%
Female Male Pediatric ward NICU PICU Married Unmarried ANM GNM BSc No Yes No Yes
40 0 10 22 8 16 24 3 36 1 28 12 31 9
100% 0% 25% 55% 20% 40% 60% 7.5% 90% 2.5% 70% 30% 77.5% 22.5%
No Yes
34 6
85% 15%
Midwifery (ANM). Twenty-two (55%) were NICU nurses and the remainder were PICU and pediatric ward nurses. Twenty-eight nurses (70%) did not have children, and 31 (77.5%) had previous experience with hospitalization. Thirty-four nurses (85%) did not have any formal training in pain. Yet 37 nurses (92.5%) thought that the training they had received at nursing school was useful in assessment and management of pain in neonates. Average correct response rate for NICU nurses was 49.66% and for pediatric ward and PICU nurses was 48.67%. Mean number of correctly answered questions was 8.75 with a standard deviation of 2.55. The minimum correctly answered questions was 3 and the maximum was 13 out of 17. Mean number of questions correctly answered by the NICU nurses was 9.09 (SD 2.467) and by the pediatric nurses was 8.33 (SD 2.656). The difference between them was not statistically significant (p ¼ .29; Fig. 1). Multiple regression analysis of total score and the variables previously mentioned was done. Only marital status was found to have a significant effect on knowledge and attitudes toward pain (p ¼ .029; data not shown). Statistically significant difference was not found in any other variable. For the NICU staff, the highest numbers of incorrect answers were noted in the following questions: 1) reliability of vitals as indicators of pain; 2) method of deciding subsequent dose of opiod analgesic; 3) neonates’ ability to sleep in spite of severe pain; 4)
72
Nimbalkar et al.
The nurses were themselves asked to identify what according to them were barriers for effective pain management. Eighteen nurses (45%) thought that it was mistakes on the doctor’s part, i.e., not prescribing drug timely, 14 (35%) thought analgesic drugs had many side effects so were best avoided, and 10 (25%) thought that procedures were very short-lasting so no analgesic was needed.
12.50
10.00
7.50
5.00
DISCUSSION 2.50
TOTAL_SCORE
FIGURE 1. - Box plot showing the distribution of the total score of the nursing staff.
paracetamol as effective analgesic in neonates; and 5) effectiveness of breastfeeding as an analgesic. For pediatric ward and PICU staff the highest number of wrong answers were noted in: 1) method of deciding subsequent dose of opiod analgesic; 2) paracetamol as effective analgesic in neonates; 3) premature infants experiencing more pain than full terms 4) Neonates ability to sleep in spite of severe pain; and 5) nonpharmacologic methods of pain relief. Among the nurses of the NICU, 9 of 17 questions were answered correctly by fewer than 50% and among the pediatric ward or PICU 8 of 17 questions were answered correctly by fewer than 50%. Most of the nurses in the pediatric ward and PICU answered questions 1, 5, 9, and 11 correctly, whereas most nurses in NICU answered 3 and 16 correctly (Table 2). In the multiple-choice questions, nurses were allowed to select multiple options. Seventy percent correctly answered intravenous route as the route of administration of analgesic for sudden severe pain. Seventy percent of the nurses correctly mentioned that analgesic administration should be on a fixedschedule basis (Table 3). Thirty-four respondents (85%) thought that they were doing a good job of managing pain. Out of the 40 nurses who participated (70%) thought that they could accurately assess neonatal pain, although only 20 (50%) thought that they needed pain scales for assessing a neonate’s pain. The nurses were asked to identify the behavioral indicators in children that they deemed to be reliable. Thirty-four (85%) thought that a neonate’s facial expression was a reliable indicator, and 36 (90%) thought that the child’s cry, 26 (65%) limb movements, and 29 (72.5%) vitals are indicators of the child’s pain.
This study provides useful information regarding knowledge and attitudes toward neonatal pain by nurses in India. It also analyzed whether any significant difference existed between the nurses posted in the NICU, pediatric ward, or PICU. The findings show that most of the nurses lacked knowledge, and their pain management skills were far from optimal. Out of the total questions, the mean score was 8.75 with a mean correct answer rate of 49.67% among the NICU staff and 48.67% among the pediatric and PICU staff. The low score was consistent with other studies (Bernardi, Catania, & Tridello, 2007; Yildirim, Cicek, & Uyar, 2008). There was no statistically significant difference between the nurses of the NICU and the PICU and pediatric ward. Variables such as age, education (degree), marital status, previous hospitalization or painful experience, having children of their own, etc. play a role in how pain is perceived by nurses (Polkki et al., 2010; van Hulle Vincent & Denyes, 2004). But in the present study, only marital status was found to significantly affect knowledge and attitudes regarding pain. Those who were married had better knowledge regarding pain. The probable reason may be because married nurses are more empathetic and sensitive toward children’s pain. The effect of sex of the nurses on knowledge and attitude could not be analyzed, because all of the nursing staff were female. Education of the nurses was not found to have a significant effect on their knowledge and perceptions, probably because of the small sample size. The nurses thought that their nursing school education was useful in empowering them, and most of them thought that they could accurately assess and manage neonatal pain. Only 21 (52.5%) of the respondents stated that neonatal pain scales were essential for assessment of neonatal pain, and only 16 (40%) stated that they were using a pain scale supported by results of other studies (Polkki et al., 2010). This shows that pain scales were used by only a small fraction of the staff. The staff were not aware of the role and importance of pain scales and they overestimated their own
73
Neonatal Pain Nursing Knowledge and Attitudes
TABLE 2. True/False Questions Pediatric Ward Question 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Vital signs always reliable indicators of intensity of neonates pain Children
