Original Article Turkish Pediatric Surgical Nurses’ Knowledge and Attitudes Regarding Pain Assessment and Nonpharmacological and Environmental Methods in Newborns’ Pain Relief Emine Efe, PhD,* S¸ evkiye Dikmen, RN,† Nuray Altas¸, RN,‡ and Cem Boneval, PhD‡

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From the *Child Health Nursing Department, School of Health, Akdeniz University; †Pediatric Surgical Unit; ‡Pediatric Surgical Department, Akdeniz University Hospital, Antalya, Turkey. Address correspondence to Emine Efe, PhD, Akdeniz University, School of Health, 07058, Campus, Antalya, Turkey. E-mail: [email protected] Received August 12, 2011; Accepted August 12, 2011. 1524-9042/$36.00 Crown Copyright Ó 2013 Published by Elsevier Inc. on behalf of the American Society for Pain Management Nursing doi:10.1016/j.pmn.2011.08.003

ABSTRACT:

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

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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. Crown Copyright Ó 2013 Published by Elsevier Inc. on behalf of the American Society for Pain Management Nursing

Infants in the neonatal intensive care unit (NICU) are routinely subjected to various diagnostic, surgical, and therapeutic procedures that can result in pain (Evans, McCartney, Lawhon, & Galoway, 2005; Lago, Guadagni, Merazzi, Ancora, Bellieni, Cavazza, & Pain Study Group of the Italian Society of Neonatology, 2005). There are numerous reports of invasive procedures being routinely performed in the NICU without analgesia (Carbajal, 2006; Harrison, Loughnan, & Johnston, 2006) despite well established neonatal pain guidelines (American Academy of Pediatrics, 2000). Infants in pediatric surgery in the neonatal intensive care units are subjected to pain in the same way. Stevens, McGrath, Gibbins, Beyene, Breau, Camfield,..., Yamada, (2003) reported that all neonates underwent more than ten painful procedures per day; those at the highest risk for neurologic impairment had more procedures and received the least amount of analgesia during the first days of life. Repeated pain in neonates results in specific pain behaviors (Stevens, Yamada, Beyene, Gibbins, Petryshen, Stinson, Narciso, 2005; Grunau & Tu, 2007), sensory cortex activation (Bartocci, Bergqvist, Lagercrantz, & Anand, 2006), neuroendocrine and physiologic stress responses (Ladd, Huot, Thrivikraman, Nemeroff, Meaney, & Plotsky, 2000), altered clinical outcomes (Anand et al., 2004; Peters, Schouw, Anand, van Dijk, Duivenvoorden, & Tibboel, 2005), heightened peripheral sensitivity (Schmelzle-Lubiecki, Campbell, Howard, Franck, & Fitzgerald, 2007), and significant risk in learning and for cognitive, behavioral, and motor sequelae (Grunau & Tu, 2007). Therefore, it is of crucial importance to find effective ways to relieve pain in newborns. Pain management is one of the most frequent interventions implemented by nurses (Brown, Bowman & Eason, 1999). Nurses have a key role in effective pain management; therefore, nurses’ knowledge is of critical importance in the care of newborns with procedural pain. The nurse’s accurate assessment, prompt intervention, and adequate evaluation of pain relief measures are necessary for better clinical outcomes (Plaisance & Logan, 2006). Despite these realities, many nurses may not be prepared to assume a critical role, because

of lack of knowledge and individual attitudes on pain. The American Academy of Pediatrics (AAP) and American Pain Society attribute the lack of effective pain management to myths and insufficient knowledge of caregivers and inadequate application of knowledge (American Academy of Pediatrics 2001). Moreover, children have an ethical right to pain relief (Kankkunen, Vehvilainen-Julkunen, & Pietila, 2002). Therefore, it is of crucial importance to find effective ways to relieve newborn’s pain. Behavioral and physiologic indicators can be more beneficial in the evaluation of short term pain in the newborn (Choules 1999, Chiswick 2000). Physiologic indicators used in the assessment of acute procedural pain in infants include heart rate, heart rate variability (or vagal tone), oxygen saturation, arterial PaO2, respiratory rate, intracranial pressure, blood pressure, and palmar sweat. Behavioral indicators are important markers of pain in infants. Three categories of behaviors—facial expression, vocalizations, and motor activity—have been consistently identified in the evaluation of pain for all infants (Stevens, Johnston, & Gibbons, 1998). Body movements have been studied as indicators of pain in older infants and include such behaviors as kicking, thrashing, trunk, arm, and leg rigidity, and withdrawal of the affected extremity (Craig, Whitfield, Grunau, Linton, & Hadjistavropoulos, 1993). Research indicates that nurses are inconsistent in their practices of assessing infant pain and in using available assessment tools (Twycross, 1999). The nonpharmacologic methods for relieving pediatric pain consist of a wide variety of approaches that do not involve the use of drugs but make pain more tolerable and give the children a sense of control over the situation (Pederson, Alster, Lundeberg, & Uvnas-Moberg, 1996). Nonpharmacologic pain relief methods that have been tested in neonates with varying degrees of efficacy can be categorized as sensory stimulation (positioning or swaddling, vestibular action or rocking, nonnutritive sucking, music), nutritive (oral sweet solutions), and maternal interventions (maternal odor and voice, breastfeeding, and skin-to-skin contact or kangaroo care) (Brown et al., 1999). Many studies have highlighted the efficacy of selected nonpharmacologic pain methods, but few studies have examined pediatric nurses’ actual use of such techniques in their clinical practice (Broome, Richtsmeier, Maikler, & Alexander, 1996; Salantera, Lauri, Salmi, & Helenius, 1999). Carbajal et al. (2008) recently reported that only 2% of 42,413 painful procedures were performed with pharmacologic interventions, 18% with nonpharmacologic interventions, and 0.4% with combined interventions; 79% were undertaken without analgesia. The ill neonate may be bombarded with visual, auditory, and

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tactile stimuli that can easily overwhelm the infants’ ability to calm and organize his/her physiologic and behavioral state (Stevens, Gibbins, & Franck, 2000, Canadian Paediatric Society, 2000). Providing a more quite environment with an organized day-night cycle promotes sleep and normal circadian rhythms and reduces heart rate and cortisol levels (Stevens et al. 2000). Research focused on nurses’ use of nonpharmacologic methods for relief of children’s pain has increased in recent years. However, research evidence seems to be inconsistent. Some European investigators (Salantera et al., 1999; P€ olkki et al., 2001) report that nurses frequently use these methods. He, P€ olkki, Julkunen, and Pietil€a, (2005) report that nurses use nonpharmacologic methods for children’s postoperative pain relief. However, another study (Byrne, 1997) shows that nurses rarely use these methods to relieve pain. Several studies have examined nurses’ pain assessment and documentation practices in children (Salantera et al., 1999; Manworren, 2000; Vincent & Denyes, 2004; Rieman & Gordon, 2007; Twycross, 2007; Huth Polkki, Julkunen, & Pietila, 2010) and newborns (Brown & Timmins, 2005; Harrison et al., 2006). Other studies have investigated nurses’ use of nonpharmacologic methods for pain relief (Pederson & Harbaugh 1995, P€ olkki et al., 2003; He et al., 2010). In Turkey, there are several studies related to the knowledge and beliefs of nurses on the nature, assessment, and management of pain (Aslan & Badir, 2005; Ozer & B€ ol€ ukbas¸ı, 2001; Yıldırım et al., 2008; Efe, Altun, C ¸ etin, & I_¸s ler, 2007; Akbas¸ & Oztunc¸, 2008; Ozyazıcıo glu & C ¸ elebio glu, 2008; Beytut et al., 2009; T€ ufekci, € u, Arslan, Canbulat, & Ozkan, € Ozl€ 2010). However, regarding this topic, there are not any earlier studies about pediatric surgical nurses in Turkey. The purpose of the present study was to determine Turkish pediatric surgical nurses’ knowledge and use of pain assessment and nonpharmacologic and environmental methods for relieving newborns’ pain.

Instruments The data were collected using a questionnaire form. The questionnaires were web based and had to be completed electronically. All data from questionnaires were collected by the researcher via the internet. The questionnaire consisted of knowledge and attitudes regarding pain assessment and nonpharmacologic and environmental pain management and demographic information.

MATERIALS AND METHODS

Permissions and Ethics Permission to conduct the study was obtained from the Director of Nursing Services, Clinical Director, and Lead Clinician. Each of the questionnaires for nurses was accompanied by a cover page, which briefly described the study, provided an affirmation of anonymity, indicated voluntary participation, and gave the researchers contact information. The research data were analyzed using the SPSS for Windows 11.1 program using percentage.

Sample Four hundred Turkish pediatric surgical nurses employed in pediatric surgical units in 15 university hospitals in Turkey composed the sample. Two hundred eighty-nine of them refused to participate or did not return the questionnaire, mainly because of current workload requirements. Consequently, the sample of the study consisted of 111 nurses.

Demographic Questionnaire The demographic questionnaire of five questions was developed by the authors to obtain data related to the pediatric surgical nurses’ sociodemographic and job characteristics, such as gender, age, level of nursing education, years of nursing experience, and region of working. Nurses’ Knowledge and Attitudes Regarding Pain Assessment and Nonpharmacologic and Environmental Pain Management The knowledge and attitudes questionnaire of 11 questions was developed by the authors on the basis of earlier research literature regarding pain assessment and nonpharmacologic and environmental methods for newborn pain relief (American Academy of Pediatrics, 2000; Harrison et al., 2006; Czarnecki, Turner, Collins, Doellman, Wrona, & Reynolds, 2011; Cignacco, Hamers, Stoffel, Lingen, Gessler, McDougall, & Nelle, 2007; Salantera et al., 1999; P€ olkki et al. 2010). It included, first, general attitudes toward the importance of pain assessment (six items) and second, knowledge about and use of pain assessment and nonpharmacologic and environmental methods (five items). For the purpose of determining whether or not the language of the questions could be understood, the questionnaire was given to 20 nurses in a pilot study. In that pilot study, it was determined that the questions could be understood, and no changes were made. The instrument’s reliability and validity were also confirmed in the pilot study before using it.

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RESULTS Sample Characteristics The demographics of the 111 nurses who responded to the questionnaire are presented in Table 1. As shown, of the nurses participating in the study, 98.2% were female, 83.8% were aged 20-35 years, 54.1% had a bachelor degree, and 75.7% had nursing experience #10 years. Nurses’ Knowledge and Attitudes Regarding Pain Assessment and Nonpharmacologic and Environmental Pain Management Methods The percentages of answered items regarding pain assessment in the newborn are presented in Table 2. As shown, 36.9% of the nurses stated that physiologic indicators to pain in the infants include change of temperature, rising of heart rate, rising of respiratory rate, rising of muscle tone, rising of intracranial pressure, rising of blood pressure, lowering of oxygenation, and lowering of arterial oxygen saturation; 52.3% stated that behavioral indicators to pain in the infants include crying, grimacing, quivering chin, screwing up of eyes, finger clenching, arching of back, writhing, and thrashing of limbs; 50.5% stated that they used physiologic and behavioral indicators in the assessment of pain in infants. Table 3 presents pediatric surgical nurses’ knowledge and use of nonpharmacologic

TABLE 1. Demographic Characteristics of Participating Pediatric Surgical Nurses Characteristic Gender Male Female Age, y 20-35 >35 Education level Associate degree Bachelor degree Vocational health high school Nursing experience, y #10 11-15 $16 Region of working Mediterranean Aegean Marmara Black Sea Central Anatolia East and Southeast Anatolia

n

%

2 109

1.8 98.2

93 18

83.8 16.2

29 60 22

26.1 54.1 19.8

84 14 13

75.7 12.6 11.7

26 14 30 7 28 6

23.4 12.6 27.0 6.3 25.2 5.4

and environmental methods: 55.9% stated that skin-toskin contact, holding, breastfeeding, and nonnutritive sucking as nonpharmacologic methods are used for newborn pain relief; 87.3% stated that they used nonnutritive sucking, skin-to-skin contact, and holding as nonpharmacologic methods for newborn pain relief in daily practice; 85.6% stated that they used avoiding loud talking close to the baby, minimal holding, careful opening and closing of incubator openings, avoiding the noise of using the wardrobe, drawers, trash, and nearby devices such as radio and television, avoiding use of sharp fragrances such as perfume and alcohol, and reducing light sources as environmental methods to be used for newborn pain relief.

DISCUSSION Despite recommendations arising from the ‘‘Consensus Statement for the Prevention and Management of Pain in the Newborns’’ (Anand & Maze, 2001), pain assessment tools and articulated pain management policies, as well as effective nonpharmacologic interventions during minor painful procedures, are not widely used in neonatal units in Turkey. Although several studies have been made of the knowledge about pain in newborn infants among pediatricians and pediatric nurses in Turkey in the past (Efe et al., 2007, Ozyazıcıoglu & C ¸ elebioglu, 2008, Beytut et al., 2009, T€ ufekci et al., 2010), this is the first study to evaluate pediatric surgical nurses’ knowledge and use of newborn pain assessment and nonpharmacologic and environmental methods in this country. The results of the present study reflected the pediatric surgical nurses’ knowledge and use of pain assessment and nonpharmacologic and environmental interventions in pediatric surgical units in Turkish university hospitals. According to our results, it was determined that the majority of nurses have insufficient information about physiologic indicators used in the assessment of acute procedural pain in infants. It was determined that one-half of the nurses had sufficient information about behavioral indicators used in the assessment of acute procedural pain in infants (Table 2). As a result, pediatric surgical nurses did not have enough knowledge about infant’s pain assessment. Inadequate pain assessment can lead to underestimation and undertreatment of pain in the pediatric population (Merkel & Malviya, 2000). Several guidelines have recently been developed to improve pain assessment in infants. These include the National Association for Neonatal Nurses assessment guidelines for neonates, titled ‘‘Pain Assessment and Management: Guidelines for Practice’’ (Walden& Gibbins, 2001), the joint statement of the AAP and the Canadian Pain Society (2001), titled

347

Turkish Pediatric Surgical Nurses’ Knowledge and Attitudes

TABLE 2. Pediatric Surgical Nurses’ Knowledge and Assessment of Pain Variable Nurses’ knowledge about physiologic indicators Heart rate[, respiratory rate[, muscle tone[, intracranial rate[, oxygenationY Change of temperature, heart rate[, respiratory rate[, muscle tone[, intracranial pressure[, blood pressure[, oxygenationY, arterial oxygen saturationY Heart rate[, blood pressure[, respiratory rate[, muscle tone[, intracranial rate[, oxygen consumption[, transcutaneous oxygen tensionY, arterial oxygen saturationY, oxygenationY, skin color, pallor, or flushing, change of temperature, sweating in the palm, pHY þ pupilla expansion Nurses’ knowledge about behavioral indicators Crying, grimacing, quivering chin, screwing up of eyes, opening mouth, taking the shape of a square Crying, body bending, writhing, taking the shape of a square, finger clenching, thrashing of limbs Crying, grimacing, quivering chin, screwing up of eyes, finger clenching, arching of back, writhing, thrashing of limbs Nurses’ assessment of pain in neonates Behavioral and physiologic responses Neonatal pain scales Behavioral and physiologic responses þ neonatal pain scales

‘‘Prevention and Management of Pain and Stress in the Neonate,’’ and the Joint Commission guidelines for pain assessment in infants and children (1999). Current recommendations for pain assessment in infants include the use of reliable, valid, sensitive, and developmentally appropriate tools that include both physiologic and behavioral indicators of pain. Infants respond to pain with behavioral and physiologic indicators that can be observed by caregivers. Nurses play a key role

n

%

35 41

31.5 36.9

35

31.5

28 25 58

25.2 22.5 52.3

56 5 50

50.5 4.5 45.0

in the assessment and management of infant pain. Many tools are available to measure pain in the pediatric population (Conlon, 2009). As such, in the present study one-half of the nurses claimed to be able to assess newborn pain with observation of physiologic and behavioral indicators. As a result, one-half of the nurses did not have knowledge about pain scales (Table 2). The results indicate that knowledge about areas such as pain assessment was rated as poor by one-half of

TABLE 3. Pediatric Surgical Nurses’ Knowledge and Use of Nonpharmacologic and Environmental Methods Variable Nursing knowledge about nonpharmacologic methods Skin-to-skin contact, holding, breastfeeding, nonnutritive sucking Skin-to-skin contact, holding, breastfeeding, sucrose solution, kangaroo care Skin-to-skin contact, holding, breastfeeding, sucrose solution, nonnutritive sucking, nonnutritive sucking with sucrose solution, breastfeeding Skin-to-skin contact, holding, breastfeeding, breastmilk, use of manual lancet, kangaroo care Skin-to-skin contact, holding, breastfeeding, sucrose solution, nonnutritive sucking, nonnutritive sucking with sucrose solution, breastmilk, use of manual lancet Nursing using nonpharmacologic methods for newborn pain relief Nonnutritive sucking, skin-to-skin contact, holding, glucose solution Nonnutritive sucking, skin-to-skin contact, holding Not using Nursing using environmental methods for newborn pain relief Not talking loudly close to the baby, avoiding noise using wardrobe, drawers, trash Not talking loudly close to the baby, minimal holding, care when opening and closing of the incubator, avoiding noise using wardrobe, drawers, trash, not using nearby devices such as radio and television or sharp odors such as alcohol, perfume, and fragrances, reducing light sources

n

%

62 16 10

55.9 14.4 9.0

11 12

9.9 10.8

11 97 3

9.9 87.3 2.7

16 95

14.4 85.6

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Efe et al.

the pediatric surgical nurses. Lack of knowledge is reported also in various studies conducted on nurses (Salantera et al., 1999; Salantera & Lauri, 2000, Reyes, 2003, Harrison et al., 2006, Twycross, 2007). Effective pain management in newborn requires knowledge of both nonpharmacologic and pharmacologic methods. In the present study, it was determined that the majority of the nurses were aware that skinto-skin contact, holding, breastfeeding, and nonnutritive sucking, can be used as nonpharmacologic interventions for newborn pain relief. The results showed that more than one-half of the pediatric surgical nurses expressed that they used nonnutritive sucking, skin-to-skin contact, and holding (Table 3). These results are similar to findings of Cignacco et al. (2007), Griffin et al. (2007), and Dodds (2003). Minimal use of nonpharmacologic methods was found in several other studies (Jacop & Puntillo, 1999, Salantera et al., 1999, Kwekkeboom, 2008). Earlier research showed that the nurses have insufficient knowledge about using nonpharmacologic methods (Rieman & Gordon, 2007). Some studies (Vincent & Denyes, 2004, Twycross, 2007) suggested that children nurses are not using their theoretical knowledge in practice. Findings of the present study demonstrate that pain is recognized in infants with behavioral and physiologic indicators and that pain is treated with nonpharmacologic methods in pediatric surgical units by pediatric surgical nurses. In our study, most of the nurses expressed that they used not talking loudly close to the baby, minimal holding, careful opening and closing of incubator openings, avoiding noise while using wardrobe, drawers and trash, not using noise generating devices such as radio and television nearby, avoiding usage of alcohol and heavy perfumes and fragrances, and reducing light intensity as environmental interventions for newborn pain relief. Our study demonstrated that a majority of the pediatric surgical nurses used environmental methods for newborn pain relief. The present findings contradict the results of some earlier studies (Jacop & Puntillo 1999, Gelinas, Fortier, Viens, Fillion, & Puntillo, 2004). We considered that this difference

may be that pediatric surgical nurses should know environmental methods and willing to use these methods for newborn pain relief. The present study, which is the first survey of pediatric surgical nurses’ knowledge and use of pain assessment and nonpharmacologic and environmental methods in newborns’ pain relief in Turkey, provides important information about knowledge deficits in pain assessment and nonpharmacologic and environmental pain management of newborns. Pain is a neglected topic in nursing educational programs. When major medical and pediatric nursing textbooks published worldwide are examined, it is seen that pain makes up a small part of the content. We think that pain management issues in baccalaureate and master nursing programs are insufficient in Turkey as well. National and local course programs about pain management are also insufficient. Nurses generally try to increase their knowledge about pain management by means of participating in inservice training programs. The present study has a limitation in that the sample size was relatively small and may not represent all pediatric surgical nurses in Turkey. Despite this limitation, the findings support that pain assessment and nonpharmacologic and environmental pain management issues should be further considered and that nursing textbooks and nursing curricula should include further content about these issues to provide effective pain management. We also think that continuing education programs developed by official institutions may improve the knowledge level about pain management in nursing. This study provided new knowledge on pediatric surgical nurses’ knowledge and use of pain assessment and nonpharmacologic and environmental methods in newborns. There is a need to develop systematic and evidence-based guidelines for pain assessment practices and use of nonpharmacologic and environmental methods in pediatric surgical units. An observational study is required to draw conclusions from the nurses’ actions during pain assessment and their use of nonpharmacologic and environmental methods in newborns at the pediatric surgical unit.

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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 pedi...
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