Margot Latimer

Epidemiology and management of painful procedures in children in Canadian hospitals

Background Children being cared for in hospital undergo multiple painful procedures daily. However, little is known about the frequency of these procedures and associated interventions to manage the pain. We undertook this study to determine, for children in Canadian hospitals, the frequency of painful procedures, the types of pain management interventions associated with painful procedures and the influence of the type of hospital unit on procedural pain management. Methods We reviewed medical charts for infants and children up to 18 years of age who had been admitted to 32 inpatient units at eight Canadian pediatric hospitals between October 2007 and April 2008. We recorded all of the painful procedures performed and the pain management interventions that had been implemented in the 24-hour period preceding data collection. We performed descriptive and comparative (analysis of variance, χ2) analyses. Results Of the 3822 children included in the study, 2987 (78.2%) had undergone at least one painful procedure in the 24-hour period preceding data collection, for a total of 18 929 painful procedures (mean 6.3 per child who had any painful procedure). For 2334 (78.1%) of the 2987 children who had a painful procedure, a pain management intervention in the previous 24 hours was documented in the chart: 1980 (84.8%) had a pharmacologic intervention, 609 (26.1%) a physical intervention, 584 (25.0%) a psychologic intervention and 753 (32.3%) a combination of interventions. However, for only 844 (28.3%) of the 2987 children was one or more pain management interventions administered and documented specifically for a painful procedure. Pediatric intensive care units reported the highest proportion of painful procedures and analgesics administered. Interpretation For less than one-third of painful procedures was there documentation of one or more specific pain management interventions. Strategies for implementing changes in pain management must be tailored to the type of hospital unit.

When respect deteriorates: incivility as a moderator of the stressor–strain relationship among hospital workers

AIM To test whether incivility at work exacerbates the relationship between stressors and strain for hospital workers. BACKGROUND A climate of incivility and disrespect among colleagues was expected to heighten the impact of work stressors on the mental and physical health of care providers. METHODS Members of 17 care-providing units from five hospital systems in Canada completed surveys, before and after a civility intervention (eight intervention vs. nine comparison units). Analyses tested whether (1) incivility moderated the stressor-strain relationship at baseline (n=478), and (2) the stressor-strain relationship decreased for the intervention units relative to comparison units 6 months later (n=361). RESULTS (1) Pre-intervention, individuals reporting more incivility on their unit showed a stronger stressor-strain relationship. (2) The negative relationship between work overload and mental health was mitigated among intervention group staff 6 months after the introduction of a colleague-based civility programme. CONCLUSIONS Besides being a stressor itself, incivility exacerbates the relationship between existing job role stressors and strain among health care workers. IMPLICATIONS FOR NURSING MANAGEMENT Colleague civility and respect have an important ripple effect of buffering inevitable work stressors, helping health care providers respond to stress with greater health and resiliency.

Pediatric nurses' postoperative pain management practices: an observational study

PURPOSE This study was an in-depth examination of pediatric postoperative pain care. DESIGN AND METHODS Participant observational data were collected on the care of 10 children. Particular attention was paid to actions when pain scores were ≥5 and to the relationship between pain scores and medications administered. RESULTS A pattern of care emerged of giving pain medications regularly even if they were prescribed pro re nata. Actions when pain scores were ≥5 varied. Recorded pain scores rarely guided treatment choices. PRACTICE IMPLICATIONS The use of pain scores to guide treatment choices needs further debate. Future research should explore the implications of divorcing treatment from pain scores on childrens pain experience.

Individual Nurse and Organizational Context Considerations for Better Knowledge Use in Pain Care

Nurses are involved in many of the painful procedures performed on hospitalized children. In collaboration with physicians, nurses have an exceptional responsibility to have knowledge to manage the pain; however, the evidence indicates this is not being done. Issues may be twofold: (a) opportunities to improve knowledge of better pain care practices and/or (b) ability to use knowledge. Empirical evidence is available that if used by health care providers can reduce pain in hospitalized children. Theory-guided interventions are necessary to focus resources designated for learning and knowledge translation initiatives in the area of pain care. This article presents the Knowledge Use in Pain Care (KUPC) conceptual model that blends concepts from the fields of knowledge utilization and work life context, which are believed to influence the translation of knowledge to practice. The four main components in the KUPC model include those related to the organization, the individual nurse, the individual patient, and the sociopolitical context. The KUPC model was conceptualized to account for the complex circumstances surrounding nurses knowledge uptake and use in the context of pain care. The model provides a framework for health care administrators, clinical leaders, and researchers to consider as they decide how to intervene to increase knowledge use to reduce painful experiences of children in the hospital.

Measurement of pain in children

IWK Health Centre and Dalhousie University, Halifax, Nova Scotia Correspondence: Dr Patrick J McGrath, IWK Health Centre, 5850/5950 University Avenue, PO Box 9700, Halifax, Nova Scotia B3K 6R8. Telephone 902-470-6511, fax 902-470-6767, e-mail Patrick.mcgrath@iwk.nshealth.ca Pain research in infants, children and youth has come a long way since the 1970s and 1980s, when it was seriously debated whether children, especially young children, really experienced pain. Now, there is virtually universal agreement that infants and children experience pain. Just over a decade ago, we edited a book on pain measurement in children (1). This special issue of Pain Research & Management is a reprise of this topic. This collection of papers focuses on the latest developments in pain assessment and measurement. The authors are all leading contributors on their topics and they present the latest thinking in their area. Pain is still measured by self-report, behaviour and physiology, but there are new and more sophisticated ways of obtaining behavioural and self-report measures. There has not been enough new work on physiological strategies of measuring pain to warrant a review. We believe that the development of various brain measures of pain will be an exciting area in the future. These papers are derived from the keynote addresses given October 2 to 5, 2008, at the 7th Biennial International Forum on Pediatric Pain, held at White Point Beach Resort, Nova Scotia. The authors have used the best scientific evidence to challenge our thinking about pain measurement in children, and we hope that Pain Research & Management readers find these papers interesting, helpful and provocative. Editorial

Staff Nurse Utilization of Kangaroo Care as an Intervention for Procedural Pain in Preterm Infants.

Background:Skin-to-skin contact between mother and infant, commonly referred to as Kangaroo Care (KC), has demonstrated efficacy as a pain-relieving strategy for infants, yet, it remains underutilized in clinical practice. Purpose:To evaluate changes in neonatal intensive care unit staff nurse beliefs, utilization, and challenges related to practice change in implementing KC as an intervention for management of procedural pain in preterm infants between 2 time points. Methods:Nurses who participated in a larger clinical trial examining the sustained efficacy of KC were asked to complete a questionnaire at 2 time points: 1- and 6 month(s) following study initiation. Identified benefits, expectations, frequency of use, and challenges related to practice change uptake were described using frequencies and percentages. Data from the 2 different time points were compared using &khgr;2 analysis. Results:Of the 40 nurses approached, all completed the questionnaire (19 at the 1-month and 21 at the 6-month time point). Of the sample (n = 40), 97% of participants indicated that they expected KC to provide good pain relief or better. Staff nurses reported significantly improved preconceived ideas (&khgr;2 = 22.68, P < .01) and significantly fewer concerns (&khgr;2 = 22.10, P = .01) related to using KC as a pain-relieving intervention between the 2 time points. No significant differences were seen in the frequency of using KC as an intervention between time points. Implications for Research and Practice:Despite increasingly positive preconceived ideas and reduced concerns, the frequency of using KC for procedural pain relief remained unchanged. Further research addressing ways to overcome barriers to utilizing KC as an intervention for procedural pain is warranted.

Breast-feeding Analgesia in Infants: An Update on the Current State of Evidence

To provide an updated synthesis of the current state of the evidence for the effectiveness of breast-feeding and expressed breast milk feeding in reducing procedural pain in preterm and full-term born infants. A systematic search of key electronic databases (PubMed, CINAHL, EMBASE) was completed. Of the 1032 abstracts screened, 21 were found eligible for inclusion. Fifteen studies reported on the use of breast-feeding or expressed breast milk in full-term infants and 6 reported on preterm infants. Direct breast-feeding was more effective than maternal holding, maternal skin-to-skin contact, topical anesthetics, and music therapy, and was as or more effective than sweet tasting solutions in full-term infants. Expressed breast milk was not consistently found to reduce pain response in full-term or preterm infants. Studies generally had moderate to high risk of bias. There is sufficient evidence to recommend direct breast-feeding for procedural pain management in full-term infants. Based on current evidence, expressed breast milk alone should not be considered an adequate intervention.

Neurophysiological Assessment of Acute Pain in Infants: A Scoping Review of Research Methods

A systematic scoping search to describe the neurophysiological methods used in infant acute pain assessment research was conducted. Of the 2411 abstracts screened, 19 articles were retained. Nine studies utilised near‐infrared spectroscopy (NIRS), two utilised functional magnetic resonance imaging (fMRI), and eight utilised electroencephalography (EEG). There was methodological variability in studies utilising NIRS, whereas EEG and fMRI studies reported consistent methods. Of the eight EEG studies, six identified a nociceptive‐specific event‐related potential. Conclusion: While more methodologically rigorous studies are needed, ERPs appear to hold some promise as indicators of infant nociception during clinical procedures to supplement existing measures.

Factors Affecting Korean Neonatal Infant Pain Care: Translation and Validation of Three Instruments

This study aimed to translate three English-language instruments—Pain Knowledge and Use (PKU), Collaboration and Satisfaction About Care Decisions (CSACD), and Environmental Complexity Scale (ECS)—into Korean and evaluate the equivalence of the instrument versions. Three Korean translators and two senior reviewers translated the instruments’ 56 items using a committee approach. Eight Korean experts evaluated the cultural relevance of the translated instruments using a content validity index (CVI), and 12 Korean neonatal nurses were interviewed to assess their understanding of items. In an expert panel review, the item-CVI was less than 0.78 for 14 items. Based on cognitive interviews, four items were found to be unsuitable in Korea. Based on expert panel review and cognitive interviews, unsuitable items were modified or deleted. In another expert panel review, the scale-CVI was 1.00 for the final instruments. The findings support the validity of the Korean-language PKU, CSACD, and ECS for research application.

Describing the leadership capabilities of advanced practice nurses using a qualitative descriptive study

The aim of this study is to explore advanced practice nurses’ perceptions of their leadership capabilities.