Effect of Educational Program on Pediatric Nurses' Knowledge and Practice Regarding Selected Nonpharmacological Techniques to Relive Pain in Neonates

Introduction

Pain is a universal experience and it is one of the oldest symptoms in the history of medicine; it is an unpleasant sensation that everyone is going to experience throughout life, and that can be aggravated by a disease or during certain procedures performed in hospital stays. The American Pain Society (1995) has labeled it "the fifth vital sign" to emphasize the importance of assessing pain frequently and providing appropriate treatment. The goal is to encourage health care professionals to assess pain every time that temperature, pulse, respiration and blood pressure are assessed and to institute measures to manage time (Syan, 2014; Dames, et al., 2016). It is extensively documented that newborn infants admitted to neonatal units are regularly exposed to painful experiences; both term, and preterm newborns experience pain and have the right to receive safe, efficient, and effective pain relief (Ottawa Neonatal Pain Interest Group, 2015; Wallace & Jones, 2017).

Pain is a complex phenomenon whose nature is, at best, elusive in the neonate. The rationalization for inadequate treatment of pain has resulted in unnecessary suffering for these fragile infants. Research has shown that the unchecked release of stress hormones by untreated pain may exacerbate injury, prevent wound healing, lead to infection, prolong hospitalization, and even lead to death. These fragile neonates are simply too sick to not have their pain treated. Healthcare professionals are responsible for influencing positive change in clinical practice about neonatal pain (Gardner, et al., 2012).

All newborns undergo at least one painful procedure during their first few days of life as newborn screening and sometimes heel lancing for bilirubin (Ottawa Neonatal Pain Interest Group, 2015). All neonates are exposed to pain at levels ranging from trivial to excruciating even normal healthy neonates experience pain after birth related to heel lancing, venipuncture, vitamin K injection or intramuscular (IM) vaccination. However, although normal healthy neonates experience limited amounts of pain, premature or critically ill neonates are exposed to various painful procedures such as mechanical ventilation, suctioning, intravenous (IV) access for the nutritional supplement or drug administration, chest tube insertion or lumbar puncture  (Jeong, et al., 2014).

Newborn infants experience pain just as older children, however, clinicians' ability and approach to assessing and managing neonatal pain is inadequate and controversial. Pain management is a very important aspect of nursing care of the pediatric patient. Since 2001, pain management standards require that providers be educated in the assessment and management of pain and that they recognize the right of patients to appropriate assessment and management of pain (Stanley & Pollard, 2013).

Neonatal pain is an emotive issue and nurses can help alleviate pain and suffering through careful assessment and ensuring appropriate interventions are provided by having an understanding of the mechanisms of neonatal pain pathways, nurses should be able to demonstrate effective assessment skills which in turn contribute to best practice. It is envisaged that nurse who learns about pain in the newborn will be empowered to provide interventions to relief neonatal pain. Pain assessment and management remain controversial. There are many assessment tools available for acute pain; however, the assessment of pain remains underused in the neonatal intensive care and special care units (Boxwell, 2010). Nurses working in Neonatal Intensive Care Units are responsible for applying the best-proven pain reduction methods in the most effective ways (Kostak, et al.,  2015).

Pain control in Neonatal Intensive Care Unit (NICU) yet remains suboptimal which suggests a gap between research evidence and the translation of knowledge into clinical practice this highlights the importance of exploring the clinical feasibility of implementation of nonpharmacological intervention through translational research (Ho, et al., 2016). Although there is a significant improvement from a decade ago, particularly with an increase in the use of nonpharmacological interventions, nevertheless, about one-third of procedures were unmanaged and furthermore, the longer an infant remains in the NICU, the more procedures they will experience (Fernandes, et al., 2011).

Several nonpharmacological interventions have been recommended as efficacious to manage acute neonatal pain in NICU during minor procedures such as oral sucrose and/or pacifier, kangaroo care, and swaddling. Evaluation of such care showed reduction in pain among neonates during medical or nursing procedures as measured by physical and behavioral outcomes (Ho, et al., 2016).

Nursing care of the infant with pain includes nursing assessment, nursing diagnosis, planning, interventions, and evaluation. Each step of this process must be individualized for each infant. A general understanding of the physiology of pain, factors that influence pain and effective pain management techniques can help to individualize the infant's plan of care. When assessing pain in infant, the nurse must be mindful that the infant's response to the painful stimulus may not be immediate (AboEl-Maged, 2011; Kyle & Carman, 2013).

In general the appearance of painful sequelae fact which requires the development of strategies directing health professional actions to its correct and adequate control. In this sense, nursing is an important element of teaching pain as the fifth vital sign, by applying specific care science interventions (Romanek & Avelar, 2014).

Significance of the study

Pain in newborns is a common phenomenon and all infants are regularly exposed to pain early in their lives. In a study by Simons carried out on 151 neonates, an average of 14±4 painful interventions/day was recorded for the first 14 days of life (Noghabi, et al., 2014). Research has continued to demonstrate that neonates can detect, process, and respond to painful stimuli, and preterm infants may actually have a 30% to 50% lower pain threshold than adults and a lower pain tolerance than older children. Effective pain prevention and treatment have been recommended as the standard of care at NICUs nowadays, yet both pharmacologic and nonpharmacologic pain interventions are still underused (Cong, et al., 2013).

Neonates are often more sensitive to adverse effects of medication due to the immaturity of many systems including the renal, hepatic and central nervous systems (Wilson-Smith, 2011). Non-pharmacological pain intervention is a prophylactic and complementary approach to alleviate pain. A number of non-pharmacological therapies have shown to be effective in the management of mild to moderate pain in neonates (Noghabi, et al., 2014). Kostandy, Anderson, and Good (2013) conducted an in-hospital randomized controlled trial among healthy, full-term newborns examining the impact of skin to skin contact infant cry time and consolability among infants receiving a hepatitis B vaccine within the first hour of life. Thirty-six mother-infant dyads were randomized to either routine (infant placed supine in bassinet) or skin to skin contact (prone on mother's chest) vaccine administration. Skin to skin contact infants had shorter cry times and calmed more quickly after vaccine administration (Hockenberry & Wilson, 2015).

Another prospective, randomized and controlled study compared the effectiveness of two non-pharmacological pain relief strategies – non-nutritive sucking and facilitated tucking with routine care in preterm newborns. The study showed nonnutritive sucking and facilitated tucking reduced pain scores in the PIPP scale (Premature Infant Pain Profile) more effectively than routine care during the heel puncture, and non-nutritive sucking represented an even greater reduction in pain (MottaI & Cunha, 2015). The results of some studies demonstrate that there is still a gap between scientific knowledge on neonatal pain, as well as its consequences, and the use of methods for pain assessment and management (Aymar, et al., 2014).

Studies in Jamaica14 and in Australia15 also showed that nurses and physicians lacked knowledge of measuring pain and using effective pharmacologic and nonpharmacologic analgesia in neonates. The results of these surveys raised a suspicion of similar knowledge deficits among the US nurses (Cong, et al., 2013). Therefore developing and applying educational program for nurses about nonpharmacologic techniques to relieve pain in the neonatal units are very important and beneficial in terms of quality of care to decrease morbidity and mortality, in addition, to lessen the burden on families, hospitals, and the community as well.

Operational Definitions:

Kangaroo Care:

Skin to skin contact and is operationally defined as the upright prone positioning of the diaper-clad infant skin-to-skin and chest-to-chest with an adult.

Nonnutritive sucking:

Nonnutritive sucking means any repetitive oral activity in which there is no response to food stimuli.

Swaddling:

Swaddling is defined as securely wrapping neonates in a blanket to prevent their limbs from moving around excessively.

Rocking and Holding:

Rocking, holding or both are defined as an infant is held or gently moved up and down or side to side (or both) by a care-giver.

Aim of the study:

This study aimed to:

• Assess the pediatric nurses' knowledge and practices regarding selected nonpharmacologic techniques to relieve pain in neonates.
• Apply the educational program on pediatric nurses regarding selected nonpharmacologic techniques to relieve pain in neonates.
• Assess the effect of educational program on pediatric nurses' knowledge and practices regarding selected nonpharmacologic techniques to relieve pain in neonates.

Research Hypotheses:

• Pediatric nurses who received the educational program will have higher mean score of knowledge regarding selected non-pharmacological techniques to relive pain in neonates than before.
• Pediatric nurses who received the educational program will have higher mean score of practice regarding selected non-pharmacological techniques to relive pain in neonates than before.

Research Design:

Quasi- experimental research design was utilized to meet the aim of this study.

Subjects:

A convenient sample of 41 nurses (14 nurses from Minia University for Obstetric and Pediatric Hospital and 27 nurses from Minia General Hospital).

Setting of the study:

This study was conducted at Minia University for Obstetric and Pediatric Hospital and Minia General Hospital at neonatal units. Minia University for Obstetric and Pediatric Hospital neonatal unit is located on the third floor and contains two rooms, the first room for septic cases with a capacity of 13 incubators and the second room for clean cases with a capacity of 9 incubators. Minia General Hospital neonatal unit is located on the third floor and contains only one room with a capacity of 20 incubators.

Tools of data collection:

Two tools were developed by the researchers for collecting data which are:

Tool I: A structured interview questionnaire sheet in an Arabic language it was developed by the researcher after reviewing of the related literature. Tool I consist of two parts:-

Part (1): Personal data of nurses includes sex and age of nurses, qualification, years of experience … etc.

Part (2): Knowledge assessment sheet (Pre and post- test) about pain was developed by the researcher that was adapted from (Mahfoz, 2008; Srouji, et al., 2010; Bowden & Greenberg, 2012; Hockenberry & Wilson, 2015).

Tool II: Observational checklist (Pre and post -test) was developed by the researchers that was adapted from (Healthy children org., 2013; MottaI & Cunha, 2015; Basavanthappa, 2015) to assess the nurses' practices including: (pain assessment tools as CRIES scale and the neonatal infant pain scale (NIPS), hand washing and nonpharmacologic techniques to relieve pain in neonatal units as (non-nutritive sucking, skin to skin contact with the mother (kangaroo care), rocking and holding  and swaddling). CRIES scale consists of 8 steps , neonatal infant pain scale (NIPS) consists of 7 steps, Hand Washing  consists of 11 steps, Nonpharmacologic techniques (non-nutritive sucking consists of 4 steps, skin to skin contact with the mother (kangaroo care)  consists of 8 steps, rocking and holding consists of 6 steps and swaddling consists of 10 steps).

Scoring system

Nurses' knowledge: a score of one was given for right answer and a zero for incorrect answer. The nurses' knowledge was considered satisfactory if the percent score was 60% or more and unsatisfactory if scored less than 60%. 

Nurses' practice: a score 2 done completely, 1 done incompletely and zero not done. The nurses' practice was considered proper if the percent score is 60% or more and improper if scored less than 60%.

Pilot study:

After developing the tools, a pilot study was conducted on 4 nurses (10% of the total sample). A pilot study was conducted for purpose to testing clarity, completeness and to determine the time involvement. Results of the pilot study illustrated that no any refinements and modifications needed so the subjects were include to the actual sample.

Tools Validity:

The tool was tested for content validity by a jury of five experts in the field of the pediatric nursing and neonatology and necessary modifications were done. The tool was tested for internal consistency after developing the tools.

Tools Reliability:

Reliability of the tools was performed to confirm its consistency by using Cronbach's alpha test. The reliability scores of the tools as above 0.87, which indicates the tool internal consistency of the used tool.

Ethical Considerations:

A written initial approval was obtained from the research ethical committee of the Faculty of Nursing, Minia University. The purpose of this study was explained for every nurse each nurse has right to agree or refuse participation in the study. Oral informed consent was obtained from nurses who participated in this study. They also informed that the information obtained will be confidential and will be used only for the purpose of the study. Each assessment sheet was coded and nurses' name did not appear on the sheets in the purpose of anonymity and confidentiality.

Procedure:

An official permission to conduct the proposed study was obtained by the researcher from the manager of Minia University for Obstetric and Pediatric and General Hospitals. Also the official approval for data collection was obtained from the medical consultant of the study setting after explanation of the purpose of the study. Also verbal consent was obtained from each nurses participated in the study. Clarification of the nature and purpose of the study was done on initial interview with each nurse.

Collection of data was started from the beginning of June 2017 to the end of august 2017, every day except Friday during 2 shifts, the first shift is from (8am: 2pm), and the second shift is from (2pm: 8pm). Nurses are divided into 10 groups according to work and place conditions, each group consists of 4 nurses except one group which consists of 5 nurses. Each group was trained an hour per day, so the number of nurses who are interviewed per each day varies between (8-9 nurses) as one group per shift.

Total time of the program was 3 months, two groups are trained every 14 days (6 days\week), and total time of the educational program for each group was 14 hours in a total number of sessions equal 14 sessions and each session takes about an hour, including one hour for the editorial and presentation of the topic, 6 hours for theoretical content and 7 hours for practical content.

The theoretical content included information about pain (definition, causes, clinical manifestations, assessment (NIPS & CRIES scales), management and role of nurse toward neonatal pain), information about selected nonpharmacological techniques; non-nutritive sucking, skin to skin contact with the mother (kangaroo care), rocking and holding  and swaddling (definition, benefits, mechanism of action in relieving pain and steps for each of them). The practical content included clinical application of the pain assessment tools (NIPS & CRIES scales) and selected nonpharmacological techniques (non-nutritive sucking, skin to skin contact with the mother (kangaroo care), rocking and holding and swaddling).

Educational information and training practices about pain, pain assessment and selected nonpharmacological techniques to relieve pain in neonates were included in a booklet and given to each participant. Methods of teaching were through a modified lecture, demonstration and re-demonstration and group discussion. Post test was conducted immediately after application of the program by interviewing and observing each participant alone. A follow up test was conducted 3 months later at the same manner of posttest.

Limitations/difficulties of the study:

Work load of nurses was an obstacle as the researcher was waiting for a long time to start the session with participants, also this caused some participants to be tired to listen and has low concentration and need continuous repetition, which required a lot of time and effort. Interruptions during conducting sessions by other staff members.

Statistical analysis of data:

Data were collected, revised, verified, coded, then entered PC for statistical analysis done by using IBM SPSS statistical package version 20. Data were analyzed and expressed using descriptive statistics, for qualitative data: number (N) and percentage (%), for quantitative data: mean (X~) and standard deviation (SD) and Kolmogorov- Smirnov for normality test was used to differentiate between parametric data and non-parametric data. The independent quantitative continuous data were compared by using Mann-Whitney U test. The dependent Quantitative continuous data were compared by data by Wilcoxon sign ranked test. The dependent Qualitative data were compared by Mc-Nemar test. ANOVA test was used to compare quantitative data with sample characteristics.

Results:

Table (1): Distribution of the studied nurses according to their personal characteristics (n=41)

Table (1) illustrates the personal characteristics of the studied nurses. It was found that the majority (87.8%) of them were ages 21-30 years, with a mean age 24.15 ± 5.22 years. As regards qualification of the studied sample it was found that more than two thirds (70.7%) of them were having Clinical Institute of Nursing. As regards the nurses' years of experience, it was noticed that the majority (87.8%) were having work experience less 5 years. Regarding marital status, 61% of nurses were married. Regarding taking previous courses about pain and pain relief methods in neonates the vast majority of the studied sample (97.6%) did not take previous courses. Regarding to the place of work, it was found that 34.1% of nurses were working at Minia University for Obstetric and Pediatric Hospital and (65.9%) at Minia General Hospital.

Table (2): Frequency distribution of pediatric nurses' knowledge regarding pain and selected non-pharmacological techniques to relive pain (n=41)

Mc-Nemar test for comparison of paired qualitative data

Probability (p) was considered significant if ≤ 0.05, highly significant if < 0.01, very highly significant if <0.001

* F=Frequency of proper answer

Table (2) demonstrates frequency distribution of pediatric nurses' knowledge regarding pain and selected non-pharmacological methods to relive pain. It was found that the most pain indicator to be known by nurses in pretest phase is newborns feel pain with a percentage of 63.4% and 85.3% pain resulting from medical and nursing procedures. There was an increase in the nurses' knowledge after conducting the program as about all nurses (100%) identified CRIES scale and Neonatal Infant Pain Scale as neonatal pain assessment tool and the same percent (100%) for Nonnutritive sucking, kangaroo care, holding and rocking and swaddling as nonpharmacological neonatal pain relief techniques with a very highly significant difference (p<0.001).

Fig. (1) Total mean scores of pediatric nurses' knowledge regarding pain and selected non-pharmacological methods to relive pain.

Figure (1) presents total mean scores of pediatric nurses' knowledge regarding pain and selected non-pharmacological methods to relive pain. An increase in the mean scores in all knowledge areas was observed at the post and follow up program phase compared with pretest phase (12.76±2.7, 30.27±1.2, 29.24±2.13); respectively.

Table (3): The relation between total mean scores of pediatric nurses' knowledge and their personal characteristics regarding pain and selected non-pharmacological techniques to relive pain (n=41)

Mc-Nemar test for comparison of paired qualitative data

ANOVA test to compare quantitative data with sample characteristics

Probability (p) was considered significant if ≤ 0.05, highly significant if < 0.01, very highly significant if <0.001

Table (3): illustrates that there was a significant improvement in pediatric nurses' knowledge after implementing the program regardless of their personal characteristics. Regarding qualification of nurses, there were a significant variations in the mean scores of knowledge between nurses in the pretest phase only; as nurses with Bachelor in Nursing Science has higher scores mean (15±1.852) compared with mean of Clinical Institute of Nursing (12.38±2.718) and mean of Diploma of Secondary Nursing School (11±2.160) with a significant statistical difference (P. 0.019).

 Table (4): Total mean scores of pediatric nurses' practice regarding pain assessment tools and selected non-pharmacological techniques to relive pain (n=41)

Dependent Quantitative data by Wilcoxon sign ranked test

Probability (p) was considered significant if ≤ 0.05, Highly significant if < 0.01, Very highly significant if <0.001

Table (4): presents total mean scores of pediatric nurses' practice regarding pain assessment tools and selected non pharmacological techniques to relive pain. There was an obvious increase in the total mean scores of practice in post and follow up program phase compared with pretest phase (9.07±2.58, 101.07±4.86, 86.41±6.65); respectively had a very highly significant difference (p<0.001).

Table (5): The relation between total mean scores of pediatric nurses' practice and their personal characteristics regarding selected non-pharmacological techniques to relive pain (n=41)

Mc-Nemar test for comparison of paired qualitative data

ANOVA test to compare quantitative data with sample characteristics

Probability (p) was considered significant if ≤ 0.05, highly significant if < 0.01, very highly significant if <0.001

Table (5) illustrates that there was a significant improvement in pediatric nurses' practice after implementing the program regardless of their personal characteristics. Regarding qualification of nurses there were significant variations in the mean scores of practice between nurses in the follow-up phase only; as nurses with Bachelor in Nursing Science has higher mean scores (92.25±4.713) compared with the mean of Clinical Institute of Nursing (85.14±6.457) and the mean of Diploma of Secondary Nursing School (84±5.944) had significant difference (P.0.017).

Fig. (2): Correlation between total mean scores of knowledge and practice in (pre/post/follow up program) among all studied nurses.

Fig. (3): Correlation between total mean scores of knowledge and practice in (pre/post/ follow up program) among all studied nurses.

Figures (2, 3) show the correlation between the total scores of pediatric nurses' knowledge and practice in the selected hospitals. It is evident that the highest strong positive statistical significant correlation was found between the total scores of knowledge and practice of nurses who were working at Minia General Hospital MGH (r= 0.665) with a p-value of (p. <0.001**) and the lowest strong positive statistically significant correlation was found between the total scores of knowledge and practice of nurses who were working at Minia University for Obstetric and Pediatric Hospital MUOPH (r= 0.312) with a p-value of (p. 0.278). In general moderate positive statistical significant correlation was found between the total scores of knowledge and practice of all nurses (r=0.562) with a very highly significant difference from the pretest (p. <0.001**).