Nursing Theory

Original Article

From the *Department of Mother and

Child Health Nursing, School of

Nursing, University of Jordan,

Amman, Jordan; † Leicester Royal

Infirmary, Leicester, UK; ‡ Department

of Nursing, College of Human and

Health Sciences, Swansea University,

Swansea, UK.

Address correspondence to Nadin M.

Abdel Razeq, PhD, RN, Department of

Mother and Child Health Nursing,

School of Nursing, University of

Jordan, Queen Rania Street – 11942,

Amman, Jordan. E-mail: nmians@

yahoo.com

Received January 10, 2016;

Revised February 2, 2016;

Accepted February 3, 2016.

No funding was received to conduct

this study. The authors have no

financial or personal relationships

with other people or organizations

that could inappropriately influence

(bias) this work.

The study was designed by NAR,

AOA, and SJ. It was carried out by

NAR. All authors contributed to the

final version of the paper.

The questionnaire used in this study

remains available in English from

Sue Jordan (E-mail: s.e.jordan@

swansea.ac.uk), as indicated in

Akuma and Jordan, 2012. The

Arabic translation used in this study

is available from Nadin M. Abdel

Razeq, corresponding author. Those

wishing to use the Arabic

translation must contact both Dr.

Jordan and Dr. Abdel Razeq.

1524-9042/$36.00

� 2016 by the American Society for Pain Management Nursing

http://dx.doi.org/10.1016/

j.pmn.2016.02.050

Status of Neonatal Pain Assessment and Management in Jordan

- - - Nadin M. Abdel Razeq, AAUW Fellow,

NIDCAP Professional, PhD, RN,*

Akuma O. Akuma, MBBS, MSc, FRCPCH, †

and Sue Jordan, MBBCh, PhD, PGCE (FE)‡

- ABSTRACT: Current pain assessment and management in neonates need to be

fully described before neonatal pain care can be optimized. This

study’s purpose was to report neonatal nurses’ knowledge, existing

pain assessment practice, and pharmacological pain management of

neonates in Jordan. A cross-sectional descriptive study was con-

ducted. Eighteen neonatal intensive care units in Jordan were

included in the study. One hundred eighty-four neonatal nurses

participated. Questionnaires were distributed by and returned to the

neonatal intensive care units’ managers between June and August

2014. Descriptive and inferential statistics were used to present

study results. Of 240 questionnaires distributed, 184 useable re-

sponses were returned. Nurses’ knowledge regarding neonates’

neurological development, nociception, and need for neonatal pain

management was suboptimal. The analgesics most commonly used

to treat neonatal pain were acetaminophen (52%) and lidocaine

(45%). Benzodiazepines, phenobarbitone, and muscles relaxants

were also used. Most nurses (54%-97%) reported that pain

emanating from most painful procedures was never or rarely

treated. Circumcision, lumbar punctures, and chest tube insertion

were assigned the highest pain scores ($9), but were rarely

accompanied by analgesia. Pain assessment scales were more likely

to be used, and procedural pain was more likely to be treated, in

private hospitals than public hospitals. Neonates who require spe-

cial care still suffer unnecessary pain that could be avoided and

managed by following best practice recommendations. Disparities

between developed and developing countries in quality of neonatal

pain care appear to exist. Resources for education and routine care

are needed to address these discrepancies.

� 2016 by the American Society for Pain Management Nursing

Pain Management Nursing, Vol 17, No 4 (August), 2016: pp 239-248

240 Abdel Razeq, Akuma, and Jordan

BACKGROUND

Repeated exposure of neonates to stressful events, such as painful procedures, adversely affects their

physiologic and neurologic status and results in long-

term harm, including changes to brain microstructure

and function, neurodevelopment, stress systems, and

stress-sensitive behaviors (Grunau, 2013; Johnston,

Fernandes, & Campbell-Yeo, 2011). Every neonate

should be protected from pain, because neonates,

unlike adults, cannot request adequate analgesia (Guimaraes, Sanchez-Luna, Bellieni & Buonocore,

2011). Nurses are the primary advocates for premature

and critically ill neonates, and advocating for neonates’

rights to adequate pain management is a recognized re-

sponsibility of neonatal nurses (Cong, Delaney, &

Vazquez, 2013).

Nurses’ neonatal pain assessment and manage-

ment have improved over the years (Gradin & Eriksson, 2011; Lago et al., 2013). Yet, pain

management in critically ill and premature neonates,

especially during painful procedures, has been

consistently reported as inadequate and suboptimal

worldwide (Lago et al., 2013; Mosalli, Shaiba, AlFaleh

& Paes, 2012). Studies from developing countries, in

particular, indicated suboptimal uptake of pain

management guidelines, as well as less than adequate assessment and treatment of most painful daily

procedures for hospitalized neonates (Britto et al.,

2014; Khoza & Tjale, 2014; Martins, Dias, Enumo &

Paula, 2013; Stevens, Gastaldo, & Gisore, 2014). It is

a priority to describe existing practices before

attempting to translate evidence into practice and

improve the effectiveness and quality of pain

management of neonates. Jordan is a developing country in the Middle East

with a population of more than nine million

(Department of Statistics, Jordan, 2015) and an annual

birth rate of 27 per 1,000 people (The World Bank,

2010-2014). Interest in palliative care and pain manage-

ment has increased in the past few years. Most work on

pain in Jordan has covered pain among adults or cancer

patients (Al Qadire, Tubaishat & Aljezawi, 2013, 2014; Darawad, Al-Hussami, Saleh, & Al-Sutari, 2014), adult

nurses (Al Khalaileh & Al Qadire, 2012, 2014), and

nursing students (Al-Khawaldeh, Al-Hussami, & Dara-

wad, 2013). Most recent studies in Jordan indicate

that nurses demonstrate less knowledge about pain

management than their international counterparts (Al

Qadire & Al Khalaileh, 2014). Most patients who

needed pain relief received either insufficient treatment or no treatment for their pain (Al Qadire, Tubaishat &

Aljezawi, 2013). However, few studies that describe

the knowledge and practice of pain management

among neonatal nurses were located, and none was

from Jordan. Therefore, the purposes of this paper are

to: 1) assess nurses’ knowledge of neonatal pain, 2)

describe current pain management practice in Jordan’s

neonatal intensive care units (NICUs), and 3) make rec-

ommendations to improve nursing care in NICU in Jor-

dan. Specifically the study’s objectives were to:

1. Identify levels of knowledge regarding neonatal pain

among neonatal nurses.

2. Identify the most common pain indicators and pain

assessment tools used.

3. Describe nurses’ perceptions of neonates’ pain associ-

ated with clinical procedures performed in NICUs.

4. Identify the most common pain medications used to

manage pain in NICUs.

5. Evaluate the frequency of the use of local and systemic

analgesia when managing procedure- related pain.

MATERIALS AND METHODS

Design This was a cross-sectional survey, using an established questionnaire (Akuma & Jordan, 2012).

Setting and Participants Nineteen NICUs in Jordan were approached and

agreed to participate. However, one unit experienced delay in obtaining approval and questionnaires were

not received by the end of the planned data collection

period; therefore, it was excluded.

The numbers of registered nurses working in each

NICU were obtained, and the appropriate numbers of

questionnaires, with self-seal envelopes for their return

when completed, were handed to each unit manager

for distribution. In all, 240 registered nurses were em- ployed across the 18 NICUs. All nurses employed in

NICUs work full time across both day and night shifts.

All neonatal nurses and head nurses working in

the 18 NICUs were asked to complete a self-

administered questionnaire. Twelve NICUs were

located in private hospitals and two were in public

hospitals located in Amman; while four were in major

public hospitals located in north Jordan.

Data Collection Instrument Data presented in this paper are part of a larger study

designed to assess neonatal pain management reported

here and barriers to pain care practice reported else- where. Nurses were handed an invitation letter that

included study information and two questionnaires

with a section on demographic data, but not the re-

spondent’s name or institutional affiliation. The two

survey questionnaires related to neonatal pain care;

241Neonatal Pain Assessment and Management

the results of the questionnaire employed to investi-

gate pain management practice are reported here.

The questionnaire was adapted with permission from

the instrument employed in the survey by Akuma &

Jordan (2012) that was originally designed to assess

knowledge and practice of pain management among

neonatal nurses in the UK. Following Beaton, Bombardier, Guillemin and Ferraz (2000) guidelines,

the original questions were revised and rephrased to

match the practice and terminology used in Jordan

by a group of experienced neonatal nurses, including

the primary investigator. The questionnaire was

translated into Arabic and back translated by two pro-

fessional translators.

Two experienced neonatal nurses identified the most commonly performed procedures in NICUs for

inclusion in the questionnaire. These were heel lanc-

ing for glucose and capillary blood gas estimation, veni-

puncture for blood sampling, arterial puncture for an

arterial blood gases test, peripheral intravenous (PIV)

line insertion, lumbar puncture, endotracheal tube

insertion, umbilical central line insertion, chest tube

insertion, circumcision, and nasogastric tube insertion. The adapted questionnaire assessed five aspects

of neonatal pain management. First, nurses’ knowl-

edge was assessed by scoring 10 facts about neonatal

pain as true or false (two facts were added to the orig-

inal questions). Second, perceived pain intensity of

common clinical procedures performed in NICUs

was scored on a scale from 0 (not painful) to 10 (worst

pain). Third, frequency of performing painful proce- dures with local or systemic analgesia was rated on a

five-point Likert scale from 0 (never) to 5 (always).

Fourth, frequency of analgesia (local or systemic) use

for pain relief for each procedure was listed by order.

Finally, the level of agreement with the statement

that ‘‘neonates in your NICU receive less pain medica-

tion than they should during procedures listed’’ was

assessed on a Likert scale from 1 (strongly disagree) to 5 (strongly agree).

Good reliability and validity assessments of the in-

strument were reported in the original study (Akuma &

Jordan, 2012). In this study, the adapted questions of

the instrument demonstrated adequate internal consis-

tency and reliability; Cronbach’s alpha ranged from

0.71 for the ‘frequencies of treating painful proce-

dures’ questions to 0.88 for ‘procedure painfulness’ questions.

Procedures The study was granted ethical approval by one

university-based committee and three hospital-based

institutional review board committees; one of these

was the Ministry of Health, which approved the study

in all of the public hospitals visited in this study. The

questionnaires were passed to the unit managers of

each NICU for distribution to all registered nurses be-

tween June 1 and August 31, 2014. Participants placed

completed questionnaires in the self-seal envelopes

provided before passing them to the unit managers

for storage until the researcher was able to collect them. The voluntary nature of the survey was empha-

sized to the managers. The lead researcher maintained

telephone contact with the unit managers until all

questionnaires were accounted for (i.e., either

completed and returned or declined). For anonymity,

an instruction was given not to write any self-

identifiers on the questionnaires or envelopes. Ques-

tionnaires less than 75% completed were excluded.

Statistical Analysis Descriptive statistics were applied. String variables

were categorized. Ordinal responses were grouped.

The nonparametric Mann Whitney U statistic was

used to explore the differences in pain management

between public and private hospitals, and between

hospitals using and not using pain assessment tools.

Statistical significance was taken as two-sided alpha #0.05. The statistical package for social sciences for Windows version 21 (IBM SPSS, Armonk, New York,

USA) was used for data analysis.

RESULTS

Sample Description Of 240 nurses approached, 198 returned question- naires, a response rate of 82%. Fourteen questionnaires

were removed from the analysis because of consider-

able missing data, reducing the final response rate to

184/240 ¼ 76.67%. Half of the respondents were 26-35 years of age; 60% had fewer than 5 years’ experi-

ence in neonatal nursing, and 65% had spent fewer

than 5 years in the NICU from which the data were

collected. Most nurses had a bachelor’s degree in nursing (81%). Ninety-eight (53%) nurses were

employed in private and 86 (47%) in public hospitals.

Characteristics of the sample are detailed in Table 1.

Knowledge of Neonatal Pain Only 29% of the neonatal nurses reported that new-

borns can perceive pain by 26 weeks gestational age,

while 55% did not know that neonates have fully func-

tional, mature nociceptive neurological networks. More than half the nurses believed that neonates expe-

rience less pain than adults (53%), and most (79%)

believed that pain diminishes more quickly in new-

borns than in adults. Regarding pain management,

91% of nurses believed that in relation to body weight,

TABLE 1.

Sample Characteristics (N ¼ 184) Characteristics F (%)

Level of Education Diploma 29 (16%) Bachelors 149 (81%) Masters 6 (3%)

Age (years) #25 57 (31%) 26-35 90 (50%) 36-45 30 (16%) $46 7 (4%)

Neonatal nursing experience (years) #1 55 (30%) 2-4 55 (30%) 5-10 40 (22%) 10-15 20 (11%) $16 14 (8%)

Neonatal nursing experience in current NICU (years) #1 68 (37%) 2-4 52 (28%) 5-10 37 (20%) 10-15 16 (9%) $16 11 (6%)

NICU ¼ neonatal intensive care unit.

242 Abdel Razeq, Akuma, and Jordan

neonates require less analgesia than adults, while 59%

believed that analgesia is too dangerous for use in neo-

nates. Responses to the knowledge questions are

detailed in Table 2.

Pain Assessment in Practice Assessment scales for neonatal pain were used by 78 (42.4%) neonatal nurses in NICUs. Pain assessment

scales were more commonly used in private hospitals

(59/98, 60.2%) than in public hospitals (19/86,

22.1%). This difference was statistically significant

(OR 2.73, 1.78-4.18, c2 [1] 27.242, p # .001). The most commonly used pain assessment scales

for neonatal pain in the NICUs were the Neonatal-Pain,

Agitation, and Sedation Scale (N-PASS) (Hummel, Puchalski, Creech, & Weiss, 2008) and Face, Legs, Ac-

tivity, Cry, Consolability (FLACC) scale (Merkel,

Voepel-Lewis, Shayevitz, & Malviya, 1997). The most

commonly recognized response to pain by the

neonatal nurses (N ¼ 179) was crying (89%). The nurses also reported assessing pain through irritability

(52%), changes in facial expressions (31%), altered vital

signs (30%), body movement changes (22%), sleepless- ness (9%), and poor feeding (8%).

Pain and Painful Procedures When nurses were asked to rate the pain of common

painful procedures on a scale from 0 to 10, heel lancing

and nasogastric tube insertion received the lowest rat-

ings (pain level #4). Three procedures were consid- ered to cause the worst pain possible in neonates

(pain level $9): circumcision, lumbar punctures, and chest tube insertion. The median pain level of each

procedure is detailed in Table 3.

As shown in Table 4, there was consensus among respondents regarding the pain induced by some pro-

cedures. For instance, pain caused by circumcision

and chest tube insertion was rated 9 or higher by

almost 60% and 70% of nurses, respectively. In

contrast, there was less agreement for other proce-

dures. For example, the median pain of venipuncture

was rated 6 by one third of the sample (33%), 7 to 8

by 31%, and 1 to 4 by 26.6%. Similarly, variable re- sponses were observed for pain associated with arte-

rial puncture, umbilical central line insertion, and

PIV line insertion.

Analgesia Used in NICUs in Jordan Of 184 nurses, 161 listed the most common measures

used for pain management in NICU. The analgesia most

frequently used to manage pain in neonates was acet-

aminophen, both oral and suppository, followed by the local analgesic lidocaine, reported by 52% and

45%, respectively. Although it is not considered an

analgesic in neonates, Dormicium (midazolam) was

the third most common drug reported as prescribed

to manage pain in neonates, by 41% of the nurses.

Fentanyl was the fourth analgesic frequently used

to manage pain, reported by 28% of the nurses. Other

opioids such as morphine and meperidine were rarely used (<3%). Other drugs less frequently used to manage pain included phenobarbital, diazepam, and

cisatracurium besylate (a muscle relaxant). Addition-

ally, although not requested on the questionnaire,

nonpharmacologic pain relief measures were some-

times mentioned by nurses. Examples included

pacifiers, containment, and pacifiers dipped in sweet

solutions.

Adequacy of Pain Management for Painful Procedures Fifty-nine percent of the nurses confirmed that neo-

nates in their intensive care units receive less pain

treatment than they should have during painful proce-

dures. More nurses from public hospitals (72%) than

the nurses from private hospitals (37%) agreed with

this statement. When asked specifically about each procedure, pain from almost all of the painful proce-

dures in the study was never or rarely managed, ac-

cording to most neonatal nurses (Table 4). Simple

procedures that are frequently performed by nurses

such as heel lancing, PIV line insertion, and

TABLE 2.

Proportions of Correct Responses to the Knowledge Questions

Question Correct Answer Frequency (%) of Correct Answer

1. Neonates, especially preterm newborns, do not experience pain. F 169 (92%) 2. The response to pain is completely congenital. T 150 (82%) 3. Neonates experience a lesser degree of pain than adults. F 87 (47%) 4. Analgesia is not critical to the care of neonates because they do

not remember painful experiences. F 145 (79%)

5. Physiologic stress associated with pain can be more dangerous than the side effects of analgesia.

T 125 (68%)

6. Analgesia is too dangerous to use in neonates. F 76 (41%) 7. Pain diminishes quicker in newborns than in adults. F 39 (21%) 8. In relation to body weight, neonates require less analgesia than

adults do. F 16 (9%)

9. Newborns cannot feel pain before full term. F 155 (84%) 10. Term and preterm newborns respond to pain in the same way. F 110 (60%)

Questions 9 and 10 were not in the UK questionnaire.

243Neonatal Pain Assessment and Management

venipuncture were never or only rarely accompanied

by analgesia, according to almost all respondents

(96%-97%). Complex invasive procedures such as circumcision and chest tube insertion were accompa-

nied by analgesia more frequently than simpler proce-

dures. Unfortunately, neonates who undergo lumbar

puncture never receive analgesia, according to 65%

of respondents (Table 4).

As tested by the Mann Whitney U (p # .05), there were statistically significant differences between pub-

lic and private hospitals in the frequency of analgesia administration for the following procedures: lumbar

puncture, endotracheal tube insertion, and circumci-

sion (Table 5). Administration of analgesia for painful

procedures was compared in nurses using and not us-

ing pain assessment tools (Table 6). There were no

TABLE 3.

Pain From Common Procedures as Perceived by Neo

Procedure

Pain Leve

#4 5-6

Heel lancing 106 (57.6) 49 (26.6) Nasogastric tube insertion 117 (63.6) 44 (23.9) Venipuncture 52 (28.3) 61 (33.2) Umbilical line insertions 59 (32.1) 36 (19.6) Arterial puncture 29 (15.8) 40 (21.7) PIV line insertion 29 (15.8) 50 (27.2) Endotracheal tube insertion 32 (17.4) 37 (20.1) Circumcision 16 (8.7) 19 (10.3) Lumbar punctures 11 (6.0) 25 (13.6) Chest tube insertion 9 (4.9) 11(6.0)

IQR ¼ interquartile range; PIV ¼ peripheral intravenous.

differences between nurses using and not using pain

assessment tools in the frequency of analgesia adminis-

tration, except for endotracheal tube insertion.

DISCUSSION

The results of this study reflect the existing state of

neonatal nurses’ knowledge, perceptions, and practice

of pain assessment and procedural pain management

in Jordan, as reported by the neonatal nurses them-

selves. The neonatal nurses in the current study misun-

derstood the nature of pain experience in neonates,

neonates’ need for analgesia, fetal development of pain sensation, and differences in pain expression be-

tween term and preterm neonates. Inadequate knowl-

edge may lead to misjudgment of neonates’ pain and

natal Nurses on a Rating Scale of 1-10 (N ¼ 184) l f (%)

Median Pain Level (IQR)7-8 9-10

24 (13.0) 5 (2.7) 4 (2) 20 (10.9) 3 (1.6) 4 (3) 57 (31.0) 14 (7.6) 6 (3) 44 (23.9) 45 (24.5) 6 (4) 48 (26.1) 67 (36.4) 8 (4) 65 (35.3) 40 (21.7) 7 (3) 56 (30.4) 59 (32.1) 7 (4) 39 (21.2) 110 (59.8) 9 (3) 51 (27.7) 97 (52.7) 9 (3) 37 (20.1) 127 (69.0) 9 (2)

TABLE 4.

Frequency of Administration of Analgesia for Painful Procedures (N ¼ 184)

Procedure

Frequencies Reported (%)

Never Rarely Often Usually Always

Heel lancing 173 (94) 6 (3.3) 1 (0.5) 3 (1.6) 1 (0.5) Nasogastric tube insertion 165 (89.7) 10 (5.4) 5 (2.7) 4 (2.2) 0 Venipuncture 170 (92.4) 7 (3.8) 2 (1.1) 4 (2.2) 1 (0.5) Umbilical central line insertion 116 (63) 45 (24.5) 11 (6) 8 (4.3) 4 (2.2) Arterial puncture 165 (89.7) 15 (8.2) 1 (0.5) 3 (1.6) 0 PIV line insertion 168 (91.3) 11 (6.0) 1 (0.5) 2 (1.1) 2 (1.1) Endotracheal tube insertion 103 (56) 31 (16.8) 18 (9.8) 16 (8.7) 16 (8.7) Circumcision 62 (33.7) 38 (20.7) 24 (13) 22 (12) 37 (20.1) Lumbar puncture 121 (65.8) 34 (18.5) 17 (9.2) 5 (2.7) 7 (3.8) Chest tube insertion 57 (31) 49 (26.6) 20 (10.9) 30 (16.3) 27 (14.7)

PIV ¼ peripheral intravenous.

244 Abdel Razeq, Akuma, and Jordan

treatment needs, and may put premature neonates at

risk of not being assessed and treated properly for their

procedural pain.

These results contrast with nurses’ knowledge

about neonatal pain reported in studies in the UK

(Akuma & Jordan, 2012), Italy (Cong et al., 2013), Brazil (Martins et al., 2013), Finland (P€olkki et al., 2010), and India (Mathew, Mathew, & Singhi, 2011),

where nurses were more knowledgeable than neonatal

nurses in this study. Jordanian nurses who care for

TABLE 5.

Frequency of Administration of Analgesia for Painful (N ¼ 184)

Procedure

Reported Frequencies (%)

Never/Rarely Used Analgesia

Often Us Analges

Private Public Private P

Heel lancing 96 (98.0) 83 (96.5) 1 (1.0) 0 Nasogastric tube insertion 95 (96.9) 80 (93.0) 1 (1.0) 4 Venipuncture 94 (95.5) 83 (96.5) 1 (1.0) 1 Umbilical line insertions 84 (85.7) 77 (89.5) 8 (8.2) 3 Arterial puncture 95 (96.9) 85 (98.8) 1 (1.0) 0 PIV line insertion 95 (96.9) 84 (97.7) 1 (1.0) 0 Endotracheal tube insertion 56 (41.8) 78 (58.2) 14 (77.8) 4 Circumcision 43 (43.9) 58 (67.4) 22 (22.4) 2 Lumbar punctures 76 (77.6) 79 (91.9) 12 (12.2) 5 Chest tube insertion 62 (63.3) 45 (52.3) 8 (8.2) 12

% treating a specific procedure in private versus public hospitals.

Significance 2-sided alpha #.05.

*Differences between private and public hospitals. †r represents effect size.

adult patients also lacked the required knowledge to

provide optimal pain management, mainly in relation

to analgesia (Al Qadire & Al Khalaileh, 2014). In the

light of limited knowledge about pain, the adequacy

of pain assessment and treatment in general, and for

neonates in particular, is questionable. Evidence- based and well-informed nursing practice is essential

for safe neonatal care and for protecting neonates

from the harmful results of pain that could be treated

or avoided. The areas of inadequate knowledge

Procedures in Private and Public Hospitals

of Using Analgesia

Comparison between Public and Private Hospitals:

Mann Whitney U, (P)*, r†

ed ia

Usually/Always Used Analgesia

ublic Private Public

(0.0) 1 (1.0) 3 (3.5) 4151.5, (0.54), 0.05 (4.7) 2 (2.0) 2 (2.3) 4052, (0.23), 0.09 (1.2) 3 (3.1) 2 (2.3) 4188.5, (0.83), 0.02 (3.5) 6 (6.1) 6 (7.0) 4068, (0.48), 0.05 (0.0) 2 (2.0) 1 (1.0) 4134.5, (0.38), 0.06 (0.0) 2 (2.0) 2(2.3) 4184, (0.77), 0.02 (22.2) 28 (87.5) 4 (12.5) 2772, (<0.00), 0.38 (2.3) 33 (33.7) 26 (30.2) 3474, (0.02), 0.17 (5.8) 10 (10.2) 2 (2.3) 3598, (0.007), 0.20 (14.0) 28 (28.6) 29 (33.7) 3805, (0.20), 0.09

TABLE 6.

Frequency of Administration of Analgesia for Painful Procedures: Nurses Using and Not Using Pain Assessment Tools (N ¼ 184)

Procedure

Reported Frequencies (%) of Using Analgesia

Comparison between Those Who Did and Did Not Use Pain Tools

Mann Whitney U, (P)*, r†

Never/Rarely Used Analgesia Often Used Analgesia

Usually/Always Used Analgesia

Use of Pain Tools

No Use of Pain Tools

Use of Pain Tools

No Use of Pain Tools

Use of Pain Tools

No Use of Pain Tools

Heel lancing 77 (43) 102 (57) 0 (0) 1 (100) 1 (25) 3 (75) 4031.5, (0.31), 0.07 Nasogastric tube insertion 75 (42.9) 100 (57.1) 1 (20.0) 4 (80.0) 2 (50.0) 2 (50.0) 4062, (0.59), 0.04 Venipuncture 75 (42.4) 102 (57.6) 0 (0.0) 2 (100.0) 3 (60.0) 2 (40.0) 4128, (0.96), <0.001 Umbilical line insertion 64 (39.8) 97 (60.2) 6 (54.5) 5 (45.5) 8 (66.7) 4 (33.3) 3735, (0.05), 0.14 Arterial puncture 76 (42.2) 104 (57.8) 0 (0) 1 (100) 2 (66.7) 1 (33.3) 4105, (0.75), 0.03 PIV line insertion 76 (42.5) 103 (57.5) 0 (0.0) 1 (100) 2 (50.0) 2 (50.0) 4124, (0.92), <0.001 Endotracheal tube insertion 48 (35.8) 86 (64.2) 9 (50.0) 9 (50.0) 21 (65.6) 11 (34.4) 3279, (<0.001), 0.23 Circumcision 43 (42.6) 58 (57.4) 12 (50.0) 12 (50.0) 23 (39.0) 36 (61.0) 4039, (0.78), 0.02 Lumbar puncture 67 (43.2) 88 (56.8) 7 (41.2) 10 (58.8) 4 (33.3) 8 (66.7) 4007, (0.58), 0.04 Chest tube insertion 47 (43.9) 60 (56.1) 7 (35.0) 13 (65.0) 24 (42.1) 33 (57.9) 4023.5, (0.73), 0.03

% of treating a specific procedure when using versus not using pain assessment tools.

Significance 2 sided alpha #.05.

*Differences between hospitals using and not using pain tools. †r represents effect size.

2 4 5

N e o n a ta l P a in

A sse

ssm e n t a n d M a n a g e m e n t

246 Abdel Razeq, Akuma, and Jordan

identified in this study should be a focus of future inter-

ventions for nursing education and the implementa-

tion of evidence-based neonatal pain care.

Systematic use of pain assessment scales con-

tinues to be an essential recommendation in best prac-

tice guidelines for quality pain management in

neonates (Spence et al., 2010); however, no significant improvements in pain management were detected

when they were used. Pain assessment tools are avail-

able for staff but used by less than half of the NICUs

in the sample. Pain assessment scales were more likely

to be used and procedural pain was more likely to be

treated in private hospitals than public hospitals.

This improved level of pain care for neonates in private

hospitals compared with public hospitals could be ex- plained by the influence of organizational factors.

Generally, in Jordan private hospitals have higher

staff-to-patient ratios, are better equipped, and are

more committed to high-quality care. Public hospitals

are affordable (but not free), and have a higher patient

turnover. Factors related to care settings, such as staff-

ing, acuity, and training, were found to influence the

pain management of neonates in previous studies (Foster et al., 2013; Lago et al., 2013). The current

findings suggest that there is significant room for

improving pain management by introducing 1)

protocols that emphasize systematic pain assessment

and 2) staff training on neonatal pain assessment and

management.

Ideally, pain assessment tools used in the NICU

should be standardized and tested for reliability, valid- ity, clinical utility, sensitivity, and specificity to term

and preterm neonates and for acute and prolonged

types of pain (Ranger, Johnston, & Anand, 2007).

Although not fulfilling all criteria of an ideal pain

assessment tool in neonates, N-PASS is a multidimen-

sional pain measurement tool with established validity

and reliability in neonates of different gestational ages

(Hummel, Puchalski, Creech, & Weiss, 2008). Although the FLACC scale was recommended for use

in neonatal pain guidelines (The Hospital for Sick

Children, 2011), no studies were found specifically ad-

dressing the validity, reliability, and clinical utility of

the FLACC scale in the neonatal population. Neverthe-

less, it is arguable that the use of any structured pain

assessment tool is better than using no tool.

In this study, few nurses reported using physio- logic and behavioral pain signs to assess pain in neo-

nates, other than crying. This contrasts with the

reported practice of pain assessment by neonatal

nurses in other studies (Akuma & Jordan, 2012;

Gradin & Eriksson, 2011), and indicates a limited

awareness and possibly inadequate use of physiologic

and behavioral signs during pain assessment.

Although crying is a common and reliable indicator

for pain assessment in term neonates (Bellieni et al.,

2004, 2005), physiologic and other behavioral pain

indicators should also be used to accurately assess

pain in preterm neonates in particular (Sellam,

Engberg, Denhaerynck, Craig, & Cignacco, 2013).

The pain intensity levels estimated by the nurses for painful procedures in the current study are consis-

tent with other studies; in particular, the results of this

study support the finding that chest tube insertion and

lumbar puncture cause the most extreme pain

(Andersen, Greve-Isdahl, & Jylli, 2007; Cignacco

et al., 2008; Gradin & Eriksson, 2011). Interestingly,

nurses rated the pain level of a heel lance procedure

as less severe than the pain level of venipuncture. However, this finding is not supported by pain levels

indicated by objective pain measurement. A review

of trials using valid pain measures and mothers’ rated

pain found that venipuncture, when done by a

trained practitioner, appears to be the method of

choice for blood sampling in term neonates because

it causes less pain than heel lancing (Shah &

Ohlsson, 2007). The variation in pain ratings for proce- dures causing moderate-to-high pain, such as veni-

puncture, arterial puncture, umbilical central line

insertion, and PIV line insertion, might indicate that

nurses cannot determine the pain intensity provoked

by these procedures, and that the pain from these pro-

cedures is not obvious to the nurses.

There was an overall perception by the nurses

that neonatal pain management in NICUs is inade- quate, as suggested in previous studies (Akuma &

Jordan, 2012; Cong et al., 2013). The medications

reported by nurses in this study as being used to

manage pain also indicate limited evidence-based prac-

tice and limited knowledge about neonatal pain man-

agement. In this study, analgesia was frequently used

for complex, invasive procedures such as chest tube

insertion, circumcisions, and lumbar puncture, but was seldom used for routine, less-painful procedures

such as heel lancing, venipuncture, umbilical catheter

insertion, and nasogastric tube insertion, as cited in

comparable studies (Akuma & Jordan, 2012; Khoza &

Tjale, 2014; Ozawa & Yokoo, 2013). However, the

use of analgesia for invasive procedures in Jordan is

much lower than reported by nurses in developed

countries (Akuma & Jordan, 2012; Lago et al., 2013). For instance, only 10% of the nurses reported that

lumbar punctures were regularly done with

analgesia, much less than the 68% reported in Italy in

2010 (Lago et al., 2013).

Unlike lumbar puncture and chest tube insertion,

circumcision is performed on almost all male neonates

in Jordan as this is enshrined in cultural and religious

247Neonatal Pain Assessment and Management

practices. Therefore, the low rate of analgesia use dur-

ing circumcision in particular is a critically important

finding in this study. It is ethically unacceptable and

adequate analgesia should be mandatory for this proce-

dure (Guimaraes et al., 2011). In fact, the finding that

pain from almost all the painful procedures was never

or only rarely managed is critically important and alarming. Diagnostic and therapeutic procedures are

necessary but most are painful. Exposing neonates to

pain without adequate treatment may be considered

a violation of ethical codes and the patients’ rights un-

der ‘‘do no harm,’’ especially considering analgesia and

treatments for neonates are widely available

(Guimaraes et al., 2011).

These descriptions of pain assessment and man- agement from NICU nurses in Jordan allow identifica-

tion of targets for continuing professional

development. In this study, using the nurses’ reports

of neonatal pain control provided a reasonable method

for data collection, as structured pain management

tools that would have enabled documentation of pain

assessment and interventions were not used. Self-

reported questionnaires for data collection are efficient and advantageous for geographically dispersed sam-

ples, as in this study, where the hospitals were as far

as 60 miles from Amman. However, inaccuracy and

the potential for bias detract from data gathered using

self-reported instruments (Polit & Beck, 2014). There-

fore, future research should entail more comprehen-

sive evaluation of clinical practice through direct

observation, interviews, and/or audits of prospective medical documentation. The effectiveness of regularly

using structured pain assessment scales for the

treatment of pain should also be addressed in future

research. In addition, future studies should focus on

exploring the use of nonpharmacological pain manage-

ment by neonatal nurses in Jordan, as this option has

received little attention. This study has shed light on

the existing state of neonatal pain assessment and man-

agement practice in Jordan, particularly in regard to the need for improving nurses’ knowledge, assess-

ment, and evidence-based management of neonatal

pain.

CONCLUSION

The harmful consequences of pain during the neonatal

period are well documented. Systematic use of pain

assessment scales and treatment of procedural pain

are recommended to prevent these largely unneces-

sary experiences. This study demonstrated suboptimal

implementation of pain assessment as well as nurses’

significant knowledge deficit about neonatal pain,

which may lead to pain in neonates being underappre- ciated and overlooked. Nurses reported that pain from

almost all painful procedures is never or only rarely

treated in neonates. Disparities between developed

and developing countries in the quality of neonatal

pain care provided appear to exist.

Acknowledgments

The authors would like to thank the neonatal nurses who

participated in and facilitated this work. Akuma O. Akuma

& Sue Jordan (Akuma & Jordan, 2012) developed the ques-

tionnaire and granted permission for its use in this Jordan-

based research.

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