Nursing Theory

MiniBetty17

Neonataltheory.pdf

Home >Nursing homework help >Nursing Theory

Original Research Donna Dowling, PhD, RN ❍ Section Editor

Advances in Neonatal Care • Vol. 13, No. 5 • pp. 353-360 353

Neonatal Nurses’ Perceptions of Pain Assessment and Management in NICUs A National Survey

Xiaomei Cong, PhD, RN; Colleen Delaney, PhD, RN, AHN-BC; Victoria Vazquez, MS, RN

ABSTRACT PURPOSE: The purpose of this survey was to investigate neonatal nurses’ perceptions of knowledge and practice in pain assessment and management. METHODS: A convenience sample consisted of 237 neonatal nurses with a membership in National Association of Neonatal Nurses (NANN) and neonatal nurses in Connecticut who were not NANN members. A researcher-developed questionnaire, including 36 questions with Likert scale and 2 open- ended questions, was used. RESULTS: The nurses were knowledgeable, and about 50% felt that they received adequate training and continuing education on pain. Participants reported the use of pain assessment tools (81%) and felt confident in uses of pharmacologic (83%) and nonpharmacologic interventions (79%). More than half felt that the pain tool used in their unit was appropriate for neonates (65%) and was an accurate measure (60%). Fewer than half reported that pain was well managed (44%) and that their pain protocols were research evidence based (43%). CONCLUSIONS: Nurses’ perceptions of well-managed pain were significantly correlated with training, use of appropriate and accurate pain tools, and clear and research-based protocols. Barriers to effective pain management emerged as resistance to change, lack of knowledge, perceived fear of side effects of pain medication and incorrect interpretation of pain signals, lack of time, and lack of trust in the pain assessment tools. Gaps exist in knowledge, evidence, and practice in neonatal assessment and management. Key Words: neonatal pain assessment, nurses’ perceptions, pain management

Author Affiliations: University of Connecticut School of Nursing, Storrs. The authors declare no conflict of interest. Correspondence: Xiaomei Cong, PhD, RN, University of Connecticut School of Nursing, 231 Glenbrook Rd, U-4026, Storrs, CT 06269 ([email protected]). Copyright © 2013 by The National Association of Neonatal Nurses DOI: 10.1097/ANC.0b013e31829d62e8

H igh-risk neonates in the neonatal intensive care unit (NICU) are subjected to numerous invasive procedures as part of their care.

Studies showed that infants in the NICU, especially preterm neonates, had a mean of 10 to 16 painful procedures per day during their early lives.1-4 Research has continued to demonstrate that neo- nates 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.5-7 Excessive and prolonged unrelieved pain in the infant causes adverse physiologic effects in all major organ systems including brain structure, can be life-threatening, and can have long-term cumulative outcomes.6,8,9 In spite of the fast growth of knowledge and the devel- opment of pain assessment tools and management guidelines, neonatal infant pain remains unrecog- nized and undertreated adequately.3,10 The gaps between pain knowledge, evidence, and practice among neonatal nurses need to be addressed.

Nurses are consistent caregivers for neonates, and their assessment of pain and pain practice is invalu- able. Limited studies were found on healthcare pro- viders’ knowledge and attitudes toward neonatal pain. The NICU nurses in California were reported aware of sensitivity of newborns to pain stimuli and

ANC200393.indd 353ANC200393.indd 353 20/08/13 4:32 PM20/08/13 4:32 PM

354 Cong et al

METHODS

Design and Sample A cross-sectional descriptive survey design was used in the study. Neonatal nurses were invited via the National Association of Neonatal Nureses (NANN) membership Web site or direct e-mail to complete a Web-based questionnaire developed using SurveyMonkey software (Palo Alto, California). A convenience sample of participants included in this study consisted of neonatal nurses with a member- ship to NANN and neonatal nurses in Connecticut who were not NANN members. Inclusion criteria were registered nurses who were working with the neonatal population, English-speaking, and were willing to participate in the online survey.

Instruments The questionnaire was designed to focus on 5 aspects of nurses’ perceptions of neonatal pain: (1) knowl- edge and beliefs; (2) use of assessment tools; (3) use of pharmacologic and nonpharmacologic interven- tions; (4) guidelines/protocols and family involve- ment; and (5) barriers and strategies. The question- naire items were developed by a group of graduate students who were in the neonatal practitioner pro- gram and then validated and revised by 2 doctorally prepared neonatal nursing experts. A 5-point Likert scale was used in 36 questions pertaining to neona- tal pain knowledge, assessment, intervention, and guidelines. Two open-ended questions were devel- oped to explore potential barriers to pain manage- ment and strategies that could be used to raise the awareness of effective pain intervention in the clinical units. Demographic characteristics were also collected regarding gender, age, race/ethnicity, education background, practice setting, and years of experience in the NICU. The survey was accompa- nied by an information sheet that explained anonymous and voluntary participation.

Procedure The study protocol was approved by the university institutional review board. The survey was adminis- tered electronically using SurveyMonkey.com. A list of e-mail addresses was obtained from the NANN membership Web site and from neonatal nurses’ contact information including 5 hospitals in Connecticut. The NANN members and Connecticut nurses without the NANN membership were e-mailed an introductory letter and a link to the elec- tronic survey. The survey was available online for 3 months, and 2 reminders were sent, 1 month apart, following the initial invitation.

Data Analysis All data results were downloaded from the SurveyMonkey Web site into an Excel spreadsheet

of adverse sequelae of repetitive pain.11 Canadian NICU nurses scored moderately high on the knowl- edge of pain care instruments.12 However, a study in Finland found that nurses were not aware that pre- mature infants are more sensitive to pain than full- term counterparts.13 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.

Neonates cannot speak and advocate for them- selves when they experience pain, which makes nurses face enormous challenges because self-report is the gold standard for pain measurement. It is crit- ical that nurses are able to recognize a neonate’s pain using appropriate pain tools; that is the first step toward effective pain relief. Although most California nurses surveyed stated that they consis- tently use pain tools, some nurses were concerned about the accuracy of the pain tools, and they tend to rely on their own instincts to assess infant pain.11 Another study also showed that more than half of the respondents in Finland assessed premature infant pain without pain scores.13 Studies in Australia16 and the United Kingdom17 found that only 6% of the units and 2.5% of surveyed nurses and physicians reported using pain tools regularly. The use of a structured pain assessment tool was shown to have increased from 1993 to 2008 in Sweden18 and from 2004 to 2010 in Italy19; still, only some NICUs rou- tinely assess pain during mechanical ventilation and after surgery. Inadequate staff training regarding pain assessment has been identified as one of the barriers in using pain tools.11,17

Effective pain prevention and treatment have been recommended as the standard of care at NICUs nowadays,10,20 yet both pharmacologic and nonpharmacologic pain interventions are still unde- rused.3,17,19 More than half of the surveyed nurses in California felt that pain was not managed adequately within the NICUs, and lack of evidence- based pain management protocols/guidelines has been identified as one of the barriers to implemen- tation.11 Another study showed that the majority of Australian NICUs had no articulated policy to guide pain management.16 Nurse-physician collab- oration and nurses’ work assignments may also predict evidence-based pain care in Canada.12 The discrepancies and gaps between nurses’ knowledge and practice remain within neonatal pain manage- ment world-wide, and a national population of US nurses needs to be included in the investigation. The aim of this study was to investigate neonatal nurses’ perceptions, knowledge needs, and practice related to pain assessment and management in a national survey.

ANC200393.indd 354ANC200393.indd 354 20/08/13 4:32 PM20/08/13 4:32 PM

Advances in Neonatal Care • Vol. 13, No. 5

Pain Management in NICUs 355

Knowledge and Beliefs About Neonatal Pain The majority agreed that neonates are capable of experiencing pain. Some nurses disagreed that pre- term infants are more sensitive to pain than older children and adults and that neonatal pain has long- term adverse effects. Nearly half of the nurses reported that they received training when they were oriented to the unit and received further continuing education of pain management (Table 2).

Neonatal Pain Assessment The majority reported that they used pain assess- ment tools regularly and that they felt confident in recognizing pain indicators. Nonetheless, some nurses disagreed that the assessment tool used in their unit was appropriate for neonates and dis- agreed that the tool was an accurate measure of neo- natal pain (Table 3).

Neonatal Pain Intervention The majority agreed that pharmacologic/nonphar- macologic interventions are necessary even though many invasive procedures can be completed quickly, and they felt confident in uses of these pain inter- ventions. However, less than half reported that the neonatal pain in their units was well managed (Table 4).

Neonatal Pain Guidelines/Protocols and Family Involvement The majority were aware of the pain management guidelines/protocols on their units. Yet nearly half felt that the protocols were unclear, and less than half felt that the protocols were based on new research evidence. Most of the nurses agreed that parents should be involved with their infants’ pain care (Table 5).

In addition, Spearman correlation coefficients were conducted to investigate the relationships of perceived pain management with training and education, use of pain tools and interventions, and pain protocol utilization. Nurses’ perceptions of well-managed pain in their units were positively cor- related with adequate training during orientation and continuing education (r = 0.50-0.45, P < .001), use of appropriate and accurate pain tools (r = 0.50-0.40, P < .001), and use of clear and research- based protocols (r = 0.52-0.53, P < .001).

Barriers and Strategies The majority acknowledged that it is the responsi- bility of NICU nurses to be advocates in improve- ment of pain care (90.7%), but less than half felt that making changes can be initiated easily. Content analysis of narrative data from 161 respondents revealed 5 main themes of perceived barriers to effective pain management: (1) resistance to change by nurses and physician (44%); (2) lack of

and then imported into SPSS 19.0 (SPSS, Inc, Armonk, NY) for analysis. Descriptive and correla- tional statistical methods were used to analyze responses to the survey. Responses to open-ended questions were analyzed using Krippenndorff’s the- matic content analysis method21 and categorized into recurring themes. One doctoral student and 1 under- graduate student independently conducted the cod- ing process of the content analysis, and the first author audited the procedure to validate the analysis.

RESULTS

A total of 237 neonatal nurses participated in the study (Table 1). The majority of the participants have completed higher levels of education with a bache- lor’s or master’s degree, worked at a level III NICU, and had more than 15 years’ working experience.

TABLE 1. Demographic Characteristics of Neonatal Nurses (N = 237)

Frequency %

Gender

Female 235 99.2

Male 2 0.8

Age, y

<40 46 19.6

41-50 68 29.0

>51 122 51.5

No response 1 0.4

Ethnicity

White 223 94.2

African American 4 1.9

Asian 6 2.4

American Indian or Alaska Native

1 0.5

Hispanic 3 1.3

No response 2 0.8

Education

Diploma/associate’s 39 16.5

Bachelor’s 110 46.4

Master’s 86 36.3

Doctoral degree 2 0.8

Neonatal practice, y

<5 43 18.3

6-10 23 9.9

11-15 20 8.4

>15 151 63.7

ANC200393.indd 355ANC200393.indd 355 20/08/13 4:32 PM20/08/13 4:32 PM

356 Cong et al

DISCUSSION

To the best of our knowledge, this is the first study to investigate neonatal nurses’ perceptions of knowl- edge and pain care nationwide in the United States. The majority of the participants in the survey were experienced NICU nurses with high levels of educa- tional background and were members of NANN. The survey findings may reflect contemporary prac- tice pertinent to neonatal pain in the United States and across the world.

knowledge (23%); (3) fear of side effects of pain medication and incorrect interpretation of pain signals (15%); (4) lack of time or excessive turn- around time from pain recognition to medication (13%); and (5) lack of trust in the pain assessment tools (13%). Three main perceived strategies to improve pain management emerged from 147 respondents’ data: (1) providing education (45%); (2) using/disseminating current research (15%); and (3) having more open/ongoing communication within the treatment team (6.6%).

TABLE 2. Knowledge of and Beliefs About Neonatal Pain (N = 237)

Questions

Strongly Agree, n (%)

Agree, n (%)

Neutral, n (%)

Disagree, n (%)

Strongly Disagree,

n (%)

No Response,

n (%)

Neonates are capable of experiencing pain.

208 (87.8) 19 (8.0) 0 1 (0.4) 9 (3.8) 0

Minor procedures can cause pain. 85 (35.9) 126 (54.4) 16 (6.8) 9 (3.8) 0 1 (0.4)

Preterm neonates are at a greater risk of neurodevelopmental impairment due to repeated painful procedures.

112 (47.3) 93 (39.2) 24 (10.1) 6 (2.5) 2 (0.8) 0

Neonates, especially preterm infants, are more sensitive to pain than older children and adults.

127 (53.6) 63 (26.6) 6 (2.5) 17 (7.2) 24 (10.1) 0

Neonatal pain has long-term adverse effects.

107 (45.1) 79 (33.3) 28 (11.8) 7 (3.0) 16 (6.8) 0

TABLE 3. Nurses’ Perceptions of Pain Assessment in the Neonatal Intensive Care Unit (N = 237)

Questions

Strongly Agree, n (%)

Agree, n (%)

Neutral, n (%)

Disagree, n (%)

Strongly Disagree,

n (%)

No Response,

n (%)

My unit uses a neonatal pain assessment tool regularly.

127 (53.6) 66 (27.9) 23 (9.7) 9 (3.8) 7 (2.1) 5 (2.1)

I feel confident with my skills in recognizing the physiologic/ behavioral indicators of neonatal pain.

101 (42.6) 92 (38.8) 28 (11.8) 9 (3.8) 5 (2.1) 2 (0.8)

I am confident in my ability to interpret scores obtained from pain assessment tools.

63 (26.6) 124 (52.3) 24 (10.1) 14 (5.9) 2 (0.8) 10 (4.2)

I feel confident in my use of the neonatal pain assessment tool in my unit.

89 (37.6) 92 (38.8) 26 (11.0) 14 (5.9) 8 (3.4) 8 (3.4)

The pain assessment tool available in my unit is appropriate for neonates.

38 (16.3) 116 (49.0) 38 (15.9) 34 (14.3) 5 (2.1) 6 (2.5)

The pain assessment tool in my unit is an accurate measure of neonatal pain.

38 (16.0) 104 (43.9) 55 (23.2) 26 (11.0) 8 (3.4) 6 (2.5)

ANC200393.indd 356ANC200393.indd 356 20/08/13 4:32 PM20/08/13 4:32 PM

Advances in Neonatal Care • Vol. 13, No. 5

Pain Management in NICUs 357

TABLE 4. Nurses’ Perceptions of Pain Interventions in the Neonatal Intensive Care Unit (N = 237)

Questions

Strongly Agree, n (%)

Agree, n (%)

Neutral, n (%)

Disagree, n (%)

Strongly Disagree,

n (%)

No Response,

n (%)

Pharmacologic/nonpharmacologic interventions are necessary even though many invasive procedures can be completed quickly.

144 (60.8) 63 (26.6) 22 (9.3) 1 (0.4) 1 (0.4) 6 (2.5)

I am aware of pharmacologic treat- ments available for neonatal pain.

76 (32.1) 110 (46.4) 33 (13.9) 4 (1.7) 4 (1.7) 10 (4.2)

I feel confident with my skills in pain management using pharmacologic interventions.

74 (31.2) 122 (51.4) 28 (11.8) 3 (1.3) 4 (1.7) 6 (2.5)

Nonpharmacologic pain manage- ment is effective to manage neo- natal pain.

41 (17.3) 104 (43.9) 60 (25.3) 20 (8.4) 2 (0.8) 10 (4.2)

I feel confident with my skills in pain management using nonpharmaco- logic interventions.

78 (32.9) 110 (46.4) 30 (12.7) 6 (2.5) 4 (1.7) 9 (3.8)

I feel that the neonatal pain in my unit is well managed.

17 (7.2) 88 (37.1) 59 (24.9) 58 (24.5) 8 (3.4) 7 (3.0)

TABLE 5. Guidelines/Protocols and Parental Involvement in Pain Management (N = 237)

Questions

Strongly Agree, n (%)

Agree, n (%)

Neutral, n (%)

Disagree, n (%)

Strongly Disagree, n

(%)

No Response,

n (%)

I am aware of the pain management guidelines/ protocols on my unit.

87 (36.7) 101 (42.6) 29 (12.2) 8 (3.4) 4 (1.7) 8 (3.4)

The pain management guidelines/protocols in my unit are clear and comprehensive.

44 (18.6) 82 (34.6) 70 (29.5) 26 (11.0) 5 (2.1) 10 (4.2)

The pain management guidelines/protocols in my unit are based on new research evidence.

24 (10.1) 77 (32.5) 93 (39.2) 27 (11.4) 7 (3.0) 9 (3.8)

I feel that making changes in relation to pain management in my unit can be initiated easily.

30 (12.7) 83 (35.0) 69 (29.1) 36 (15.2) 10 (4.2) 9 (3.8)

Parents are emotionally affected by the pain their infant may be experiencing.

140 (59.1) 62 (26.2) 20 (8.4) 6 (2.5) 0 9 (3.8)

The prevention of pain in neonates is an expectation of parents.

103 (43.5) 83 (35.0) 28 (11.8) 6 (2.5) 5 (2.1) 12 (5.1)

Parents should be involved with the care and comfort of their infant during painful procedures.

67 (28.3) 79 (33.3) 53 (22.4) 12 (5.1) 4 (1.7) 11 (4.6)

ANC200393.indd 357ANC200393.indd 357 20/08/13 4:32 PM20/08/13 4:32 PM

358 Cong et al

a shift from acute to ongoing or chronic pain.24 Although more than 40 pain tools for use in both term and preterm infants have been published, many of them were devised solely for the purposes of research, and many newly developed tools largely overlap with existing tools.25 The integration of pain assessment and measurement into daily practice still remains problematic.26 Novel instruments, espe- cially targeting pain biomarkers and measures of cortical responses to pain, may need to be further developed.25,27 Studies are also necessary to examine the clinical feasibility of pain tools during different pain conditions, that is, ongoing pain, and within varying neonatal populations.24

Neonatal Pain Intervention The majority of surveyed nurses were aware of the pharmacologic treatments and felt confident in use of them. Regarding the nonpharmacologic interven- tions, fewer nurses acknowledged their effective- ness compared with pain medications, despite the large body of evidence demonstrating the analgesic effects of nonpharmacologic treatments, for exam- ple, kangaroo care,28-30 breastfeeding,31 and multi- sensorial stimulation method.32 Similar results have also been reported that nonpharmacologic inter- ventions were less frequently recognized as useful.15,16 This low awareness may be a result of a lack of hands-on training, of resources, and of time required for clinicians to learn and perform these interventions, which have been identified as barri- ers to pain management supported by the content analysis in this study.

Another significant finding was that less than half of the participants felt that neonatal pain in their units was well managed, which is similar to the result of the study in California.11 Furthermore, par- ticipants’ perception of how well pain was managed on their units was significantly correlated with staff training, the use of a valid pain tool, and the use of research-based guidelines. These contributing factors to pain management seemed inadequate from our survey and suggest that these factors must be considered in promoting practice change within NICUs.

Neonatal Pain Guidelines/Protocols and Family Involvement Absence of evidence-based pain guidelines in the NICU has been found in previous studies.11,16,17 Neonatal nurses need to effectively institute evidence- based interventions in the NICUs, especially to include parent involvement in the pain protocol. In this study, the majority of nurses acknowledged that parents are emotionally affected by the pain their infants experience and readily agreed that parents should be involved with care during painful proce- dures. A longitudinal study found that preterm

Knowledge and Beliefs About Neonatal Pain The surveyed nurses were generally knowledgeable about and positive toward pain care, which is con- sistent with findings in California,11 Europe13,17 and Australia15 and demonstrates that care providers’ knowledge and perceptions of neonatal pain have changed dramatically in the past several decades.22 However, the survey revealed that some nurses still disagreed about the capability of neonates to feel pain and the long-term adverse effects of pain. A similar finding has been reported that one-fourth of the participants were unaware that a premature infant could be more sensitive in sensing pain than a full-term counterpart.13 Although these rates are relatively small, the fact that they are present at all is disturbing. Misunderstanding these crucial concepts, nurses may not be able and/or willing to assess pain in their most vulnerable patients and take measures to treat it appropriately.

Neonatal Pain Assessment Pain has been recognized as the “fifth vital sign” that should be monitored routinely in the clinical prac- tice.23 The majority of the surveyed nurses reported that they used assessment tools regularly and felt confident in their ability to recognize and interpret pain indicators. In comparison with other studies in which pain assessment tools were used only by a small proportion of clinicians and NICUs,13,16,17 our findings reflected a high rate of pain tool use in United States. The results may be attributed to the experience level of the survey sample, suggesting that with the increase in amount of years worked, the neonatal nurse builds confidence and is more apt to recognize and intervene in various neonatal cues to painful situations. A longitudinal increase of units adopting a structured method for pain assessment was reported in Sweden, from 2% in 1993 to 83% in 2008.18 The increases might be related to interna- tional and national guidelines being published; nevertheless, concerns were expressed that no evidence showed that pain assessment was actually performed in daily clinical practice.18

Another finding in our study was that about 60% of the nurses felt that the pain assessment tool in their units was appropriate and accurate for neo- nates. A similar result was reported in an Australian study that about half of the respondents believed pain assessment tools to be reliable and valid.15 Measuring pain in infants, especially in preterm infants, is an enormous challenge for practitioners because no “gold standard” instrument exists, and attention also needs to be given to confounding fac- tors such as age, severity of illness, behavioral state, and previous painful experiences. The controversies about infant pain assessment also include dissoci- ated biobehavioral response systems, lack of observ- able indicators due to depleted energy sources, and

ANC200393.indd 358ANC200393.indd 358 20/08/13 4:32 PM20/08/13 4:32 PM

Advances in Neonatal Care • Vol. 13, No. 5

Pain Management in NICUs 359

imperative that nurses are empowered with knowl- edge of neonatal pain and with the ability to disseminate and employ current research to fill out the gaps between knowledge and practice.

References 1. Evans JC, McCartney EM, Lawhon G, Galloway J. Longitudinal com-

parison of preterm pain responses to repeated heelsticks. Pediatr Nurs. 2005;31:216-221.

2. Lago P, Guadagni A, Merazzi D, Ancora G, Bellieni CV, Cavazza A. Pain management in the neonatal intensive care unit: a national survey in Italy. Paediatr Anaesth. 2005;15:925-931.

3. Carbajal R, Rousset A, Danan C, et al. Epidemiology and treatment of painful procedures in neonates in intensive care units. JAMA. 2008;300:60-70.

4. Simons SH, van Dijk M, Anand KS, Roofthooft D, van Lingen RA, Tibboel D. Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates. Arch Pediatr Adolesc Med. 2003;157:1058-1064.

5. Fitzgerald M. The development of nociceptive circuits. Nat Rev. 2005;6:507-520.

6. Slater R, Fabrizi L, Worley A, Meek J, Boyd S, Fitzgerald M. Premature infants display increased noxious-evoked neuronal activity in the brain compared to healthy age-matched term-born infants. NeuroImage. 2010;52:583-589.

7. Slater R, Worley A, Fabrizi L, et al. Evoked potentials generated by noxious stimulation in the human infant brain. Eur J Pain. 2010;14:321- 326.

8. Anand KJ. Effects of perinatal pain and stress. Prog Brain Res. 2000;122:117-129.

9. Brummelte S, Grunau RE, Chau V, et al. Procedural pain and brain development in premature newborns. Ann Neurol. 2012;71:385-396.

10. American Academy of Pediatrics CoFaNaSoS, Canadian Paediatric Society and Fetus and Newborn Committee. Prevention and manage- ment of pain in the neonate: an update. Pediatrics. 2006;118:2231- 2241.

11. Byrd PJ, Gonzales I, Parsons V. Exploring barriers to pain manage- ment in newborn intensive care units: a pilot survey of NICU nurses. Adv Neonatal Care. 2009;9:299-306.

12. Latimer MA, Johnston CC, Ritchie JA, Clarke SP, Gilin D. Factors affecting delivery of evidence-based procedural pain care in hospital- ized neonates. J Obstet Gynecol Neonatal Nurs. 2009;38:182-194.

13. Polkki T, Korhonen A, Laukkala H, Saarela T, Vehvilainen-Julkunen K, Pietila AM. Nurses’ attitudes and perceptions of pain assessment in neonatal intensive care. Scand J Caring Sci. 2010;24:49-55.

14. Young J, Barton M, Richards-Dawson MA, Trotman H. Knowledge, perception and practices of healthcare professionals at tertiary level hospitals in Kingston, Jamaica, regarding neonatal pain manage- ment. West Indian Med J. 2008;57:28-32.

15. Schultz M, Loughran-Fowlds A, Spence K. Neonatal pain: a compari- son of the beliefs and practices of junior doctors and current best evidence. J Paediatr Child Health. 2010;46:23-28.

16. Harrison D, Loughnan P, Johnston L. Pain assessment and procedural pain management practices in neonatal units in Australia. J Paediatr Child Health. 2006;42:6-9.

17. Akuma AO, Jordan S. Pain management in neonates: a survey of nurses and doctors. J Adv Nurs. 2012;68:1288-1301.

18. Gradin M, Eriksson M. Neonatal pain assessment in Sweden: a fifteen- year follow up. Acta Paediatr. 2011;100:204-208.

19. Lago P, Boccuzzo G, Garetti E, et al. Pain management during invasive procedures at Italian NICUs: has anything changed in the last five years? . J Matern Fetal Neonatal Med. 2013;26(3):303-305.

20. Anand KJ, Aranda JV, Berde CB, et al. Summary proceedings from the neonatal pain-control group. Pediatrics. 2006;117:S9-S22.

21. Krippendorff K. Content Analysis: An Introduction to Its Methodology. Thousand Oaks, CA: Sage; 2004.

22. Anand KJ, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med. 1987;317:1321-1329.

23. Anand KJ. Consensus statement for the prevention and manage- ment of pain in the newborn. Arch Pediatr Adolesc Med. 2001;155:173- 180.

24. Ranger M, Johnston CC, Anand KJ. Current controversies regarding pain assessment in neonates. Semin Perinatol. 2007;31:283-288.

25. van Dijk M, Tibboel D. Update on pain assessment in sick neonates and infants. Pediatr Clin North Am. 2012;59:1167-1181.

26. Hummel P, van Dijk M. Pain assessment: current status and chal- lenges. Semin Fetal Neonatal Med. 2006;11:237-245.

27. Holsti L, Grunau RE, Shany E. Assessing pain in preterm infants in the neonatal intensive care unit: moving to a “brain-oriented” approach. Pain Manage. 2011;1:171-179.

infants from NICUs with a high degree of parent involvement had fewer signs of stress than infants from NICUs with a low degree of parent involve- ment, when controlling for other pain management factors.33 These findings suggest that in addition to other pain management practices, parent involve- ment independently contributes to improve neurobe- havioral outcomes in high-risk infants. Given the fact that many nonpharmacologic interventions such as kangaroo care and massage are parent-oriented interventions and have been demonstrated as effec- tive in reducing neonatal pain response, parent involvement should be addressed in the pain manage- ment guidelines.

Barriers and Strategies The content analysis identified major barriers to effective pain management in the NICUs including perceived resistance, lack of knowledge, fear, lack of time, and lack of trust in the pain tools, which are consistent with the California study.11 Ignorance of current knowledge and uncertainty about pain tools might result in perceptions of resistance and fear during pain practice. Not surprisingly, then, nurses identified education, use of current research, and communication within the treatment team as main strategies that could remove the barriers and improve neonatal pain management. Other studies have also considered the need for neonatal clinicians’ future education in pain assessment and practice11,15 and promotion of nurse-physician collaboration.12

Limitations Because the majority of the participants were NANN members with access to the Internet and the NANN Web site, representative bias may exist. They might have higher education levels, more clinical experi- ence in NICUs, and less diverse racial and ethnic backgrounds than the entire population of US neo- natal nurses. Also, for the purpose of anonymity, we did not collect extended demographic data, such as geographic locations and rural or urban practice, which made the representativeness of the partici- pants unknown. Studies using self-report question- naires may also be vulnerable to bias from social desirability. However, given that we used an anonymous online survey and that we only collected a minimum amount of demographic data, the social desirability bias could be low.

Nurses acknowledged that it is the responsibility of NICU nurses to be advocates in pain manage- ment. Even though there has been substantial research and progress in neonatal analgesia, our sur- vey findings reveal valuable insights that further action is required to solve the issues of inadequate training and education, resistance to change, the lack of clinically feasible and valid pain tools, and the absence of evidence-based guidelines. It is

ANC200393.indd 359ANC200393.indd 359 20/08/13 4:32 PM20/08/13 4:32 PM

360 Cong et al

28. Cong X, Cusson RM, Walsh S, Hussain N, Ludington-Hoe SM, Zhang D. Effects of skin-to-skin contact on autonomic pain responses in preterm infants. J Pain. 2012;13:636-645.

29. Cong X, Ludington-Hoe SM, McCain G, Fu P. Kangaroo care modifies preterm infant heart rate variability in response to heel stick pain: pilot study. Early Hum Dev. 2009;85:561-567.

30. Johnston CC, Filion F, Campbell-Yeo M, et al. Kangaroo mother care diminishes pain from heel lance in very preterm neonates: a cross- over trial. BMC Pediatr. 2008;8:13.

31. Gray L, Miller LW, Philipp BL, Blass EM. Breastfeeding is analgesic in healthy newborns. Pediatrics. 2002;109:590-593.

32. Cignacco E, Hamers JP, van Lingen RA, et al. Pain relief in ventilated preterms during endotracheal suctioning: a randomized controlled trial. Swiss Med Wkly. 2008;138:635-645.

33. Montirosso R, Del Prete A, Bellu R, Tronick E, Borgatti R. Level of NICU quality of developmental care and neurobehavioral performance in very preterm infants. Pediatrics. 2012;129: e1129-e1137.

ANC200393.indd 360ANC200393.indd 360 20/08/13 4:32 PM20/08/13 4:32 PM