Assessment and management of pediatric pain based on the opinions of health professionals

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Psychology & Neuroscience, 2014, 7, 1, DOI: /j.psns Assessment and management of pediatric pain based on the opinions of health professionals Maria Beatriz Martins Linhares 1, Nátali
Psychology & Neuroscience, 2014, 7, 1, DOI: /j.psns Assessment and management of pediatric pain based on the opinions of health professionals Maria Beatriz Martins Linhares 1, Nátali C.A.C. Oliveira 1, Fernanda N.P. Doca 2, Francisco E. Martinez 1, Ana Paula P. Carlotti 1, and Gordon Allen Finley 3 1. Universidade de São Paulo, Ribeirão Preto, SP, Brazil 2. Universidade de Brasília, Brasília, DF, Brazil 3. University of Dalhousie, Halifax, NS, Canada Abstract The present study characterized the opinions of health professionals about strategies for assessing and managing pediatric pain in a public teaching hospital. The sample consisted of 92 health professionals who worked in pediatric wards, pediatric intensive care, and neonatal intensive care. The sample included 45 doctors, 18 nurses, 16 psychologists, eight physiotherapists, and five occupational therapists. Data were collected through a self-administered questionnaire that included 22 open questions on the following topics: pain assessment, pharmacological management, and non-pharmacological interventions. Each area was analyzed with regard to actions, resources, gaps, and needs. The questionnaire was developed based on the principles of Strategic Planning. Two trained researchers analyzed the thematic content of all of the responses. With regard to actions and resources, 33% of the respondents mentioned the use of instruments for pain assessment, 73% reported that they prescribed pharmacological treatments for symptoms of pain, and 2 reported the use of non-pharmacological interventions for the relief of pain. The professionals predominantly reported a lack of training for pain assessment and management, standardized protocols, and human and material resources. Consequently, 9 of the professionals reported the necessity for educational training and standardized implementation guidelines for pain assessment services. These findings provide a baseline of the health professional s opinions of pain issues, which are essential for implementing and increasing pain assessment and management policies institutionally. Keywords: pediatric pain, hospitalization, healthcare professionals, assessment, management. Received 08 March 2013; received in revised form 29 June 2013; accepted 01 July Available online 07 March Introduction Pain constitutes a health problem, the relief and treatment of which are recognized as human rights by several organizations, especially the World Health Organization and International Association for the Study of Pain (1997). Despite increasing scientific evidence Maria Beatriz Martins Linhares, Department of Neurosciences and Behavior, Ribeirão Preto Medical School, University of São Paulo. Nátali C.A.C. Oliveira, Hospital of Clinics, Ribeirão Preto Medical School, University of São Paulo, and master s degree in Mental Health Program, Ribeirão Preto Medical School, University of São Paulo. Fernanda N.P. Doca, Brasília University Hospital and Distrito Federal Base Hospital, Institute of Psychology, University of Brasília. Francisco E. Martinez and Ana Paula P. Carlotti, Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo. Gordon Allen Finley, Department of Anesthesiology, Pediatric Pain Research Center, University of Dalhousie, Canada. Correspondence regarding this article should be directed to: Profa Dra Maria Beatriz Martins Linhares, Avenida Tenente Catão Roxo 2650, Prédio da Saúde Mental (salas 52/53), Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Campus Universitário Monte Alegre, Ribeirão Preto, SP, CEP , Brasil. Phone: Fax: that pain is experienced by newborns and children, the translation of scientific knowledge to clinical practice has not occurred to the same degree. Audit studies on the prevalence, assessment, and management of pain in hospitals showed that pain is under-assessed and under-treated in pediatric inpatients (Taylor, Boyer, & Campbell, 2008; Stevens et al., 2011; Linhares et al., 2012). Few investments have been made in training professionals and improving clinical practice with regard to pain evaluation and management. Consequently, newborns and children continue to experience unnecessary pain during hospitalization (Karling, Renstrom, & Ljungman, 2002; Harrison, Loughman, & Johnston, 2006; Taylor et al., 2008; Stevens et al., 2011). With regard to health professionals, studies have found problems related to pain evaluation and management. Disagreements exist between the caretakers of patients and children with regard to the evaluation of pain intensity (Elias, Guinsburg, Peres, Balda, & Santos, 2008; van Dijk, van Wiljck, Kappen, Peelen, Kalkman, & Schuurmans, 2012). Nurses and physicians report limitations in evaluation tools and methods for pediatric pain management, and pain is 44 Linhares et al. consequently under-treated during invasive and painful procedures (Chermont, Guinsburg, Balda, & Kopelman, 2003; Prestes et al., 2005; Kulkamp, Barbosa, & Bianchini, 2008; Schultz, Loughran-Fowlds, & Spence, 2010). Professionals also have a lack of knowledge and misconceptions about the prescription of analgesics and opioids (Kulkamp et al., 2008; Daudt, Hadlich, Facin, Aprato, & Pereira, 1998). Pediatric pain is inadequately managed pharmacologically with regard to scheduling, doses, and intervals (Kulkamp et al., 2008; Daudt et al., 1998). A high incidence of medical mistakes is associated with the prescription of pain medicines (Lerner, Carvalho, Vieira, Lopes, & Moreira, 2008). Nurses in training and less-experienced physicians (i.e., 5 years since undergraduation) have little knowledge about pain (Barros, Pereira, & Almeida Neto, 2011; Schultz et al., 2010). Based on the principles of the ChildKind International Initiative (Schechter, Finley, Bright, Laycock, & Forgeron, 2010), the HC Criança Sem Dor project was initiated at the Hospital das Clínicas at Ribeirão Preto Medical School, University of São Paulo (HCFMRP/USP) involving a collaboration between Brazil and Canada with financial support initially from the Canadian Institutes of Health Research (CIRH). This project was subsequently expanded to the Fernandes Figueira Institute at the Hospital CuidaDOR with support from the Ministry of Health of Brazil. The first step of the HC Criança Sem Dor project was to conduct a survey to examine the prevalence of pain in 121 hospitalized pediatric patients (i.e., newborns, babies, and children) and the actions taken for pain evaluation and pharmacologic and non-pharmacologic pain management according to the perceptions of patients, families, and health professionals (Linhares et al., 2012). The second step of this project was undertaken in 2011, which was the subject of the present study. We characterized the opinions of health professionals about the evaluation strategies and management of pediatric pain adopted in infirmaries and intensive care units in an educational public hospital. The opinions were related to four axes: (1) pain evaluation, (2) pharmacological management, (3) non-pharmacological management, and (4) continuing education. Each axis included actions, human and material resources, gaps, and needs in different services that cater to hospitalized pediatric patients. Methods Participants The sample was composed of 92 professionals who worked in two different units of the HCFMRP/ USP complex (Campus Unit, n = 67; Emergency Unit, n = 25). Health professionals with different pediatric specialties who worked in infirmaries and intensive care units were included, representing the fields of Medicine, Nursing, Psychology, Physiotherapy, and Occupational Therapy. Each professional category had a representative and significant number of participants based on the criterion of directly working with patients or working in coordination to allow decision-making in different services. A professor physician (i.e., service coordinator), two hired physicians, and two residents for each pediatric specialty were included. Head nurses, psychologists, physiotherapists, and occupational therapists who worked in pediatric sectors were also included. The potential sample for the study included 110 participants, but the sample size decreased by 17% because 17 physicians and one nurse did not complete the questionnaire. The final sample included 92 health professionals (45 physicians, 18 nurses, 16 psychologists, eight physiotherapists, and five occupational therapists). The professionals mean time working in their respective field was 10 years (±9.17 years). Twenty-seven percent of the sample consisted of service coordinators. Ethical aspects The project was approved by the Research Ethical Committee of Hospital of Clinics, Ribeirão Preto Medical School, University of São Paulo. Instrument For data collection, a questionnaire was developed by two pediatric psychologists and trained researchers in the field of pediatric pain who are members of the Pain in Child Health Program in Canada (i.e., the first and third authors). The final questionnaire was reviewed by a third Canadian researcher with expertise in pediatric pain (sixth author). The questionnaire included 22 open questions that were organized in four axes: pain evaluation, pharmacological management, non-pharmacological management, and continuing education. Each axis included questions related to the following topics: actions, human/material resources, and gaps/needs (see Appendix). The coverpage of the questionnaire presented the goals of the study and instructions for completing the form. The questionnaire was developed based on Strategic Planning principles (Almeida, 2010). Procedure For data collection, the questionnaires were placed in individual envelopes that were personally given to the eligible participants in the study. The questionnaires were self-administered. The researchers gave the respondents 15 days to complete and return the questionnaires. For data analysis, the participants responses were categorized based on the quantitative interpretative method of Biasoli-Alves (1998) for the analysis of thematic content. Two independent researchers applied the categorical system to code the responses. Finally, the data were quantified, organized into database sheets, and analyzed using Statistical Package for Social Sciences software, version 19.0 (Chicago, IL, USA). A descriptive statistical analysis was performed to calculate frequencies and percentages. Pediatric pain assessment and management 45 Results Sample characteristics Table 1 shows that the majority of the professionals belonged to the Campus Unit (73%), which has the most pediatric services and beds in HCFMRP/USP. With regard to professional fields, physicians, nurses, and psychologists constituted the majority of the sample (8), which was expected based on the criteria of the composition of the hospital team and consequent study sample. Table 1. Sample characteristics: hospital units and professional categories Sample characteristics n % Hospital Units HC Campus HC Emergency Profession Physician Nurse Psychologist Physiotherapist Occupational therapist Table 2 shows that the professionals worked specifically in different pediatric specialties or pediatrics in general. Sixteen pediatric specialties were included in the study, predominantly neonatology and pediatric intensive care. Table 2 also shows that the majority of the professionals worked in pediatric infirmaries (49%) or neonatal or pediatric intensive care units (23%). The remaining 2 of the professionals were distributed into different sectors including burn unit (), child neurology and neurosurgery (7%), infectious diseases (5%), nursery (5%), pediatric surgery (2%), and orthopedics (1%). Table 2. Sample characteristics: health professionals in pediatric specialties Sample characteristic n % Pediatric Specialty General pediatrics Neonatology Pediatric intensive care Burn unit 7 8 Gastroenterology 6 7 Rheumatology 5 5 Neurology 5 5 Infectology 5 5 Endocrinology 4 4 Nephrology 4 4 Oncology 3 3 Pneumology 3 3 Immunology 2 2 Cardiology 2 2 Pediatric surgery 2 2 Orthopedics 1 1 Neurosurgery 1 1 Evaluation of pediatric pain Figure 1 illustrates the actions related to pain evaluation. A total of 84% of the participants reported that they performed pain evaluation in their hospital routine using clinical evaluations (e.g., anamnesis and physical examinations), pain measurement tools or reports, and behavioral observations. Among these methods, the professionals predominantly used clinical evaluations (32%). Notably, only 29% of the professionals reported the use of standard measurement tools (e.g., Faces Scale-Revised, Comfort Scale, Neonatal Facial Coding System Scale, and Neonatal Infant Pain Scale) for pain evaluation, although 43% of the professionals reported that they had pain measurement tools available in their work sector. Of the respondents, 37% reported that they did not have materials for pain evaluation or did not know about the existence of these resources. With regard to gaps in pain evaluation, the professionals highlighted a lack of standardized service protocols and professional training (43%) in both separate and combined categories, a lack of communication between professionals, and a lack of resources. The lack of human and material resources was reported by 25% of the professionals. A total of 69% of the professionals indicated that protocol standardization and training are the main necessities related to the evaluation of pediatric pain. Pharmacological management With regard to pharmacological pain management, Figure 2 shows that the use of medications was mentioned by a majority of the professionals (7). Of these, 49% were aware of the specific type of medication used for pain relief in their work sector. Complementing these findings, the analysis of only the physicians responses (n = 45) revealed that 47% reported the use of specific medications for pain in their routine, and 3 were able to precisely specify the schedule or procedure for prescribing these medications. With regard to material resources for pharmacological management, the vast majority of the professionals (91%) reported that their work sector had pain medications for use with children, and 20% reported the specific names of the medications that were available by prescription. Concerning the gaps in the proper management of pediatric pain, the professionals reported a lack of professional training (1), difficultly accessing certain medications (14%), lack of anesthesiologists in clinical pediatric care sectors (11%), and lack of standardized service protocols (). Notably, a high number of responses either ignored these gaps (13%) or did not identify them (12%). This may indicate that some health professionals in the sample did not directly work with medications in their clinical practice (e.g., psychologists, physiotherapists, and occupational therapists). The professionals needs were similar to the reported gaps. The professionals highlighted the need for professional training in pain management (2), 46 Linhares et al. Assessment - Actions Assessment - Material Resources Pain assessment through clinical evaluation (n= 29) 32% Pain assessment tools (n= 34) 43% Pain assessment through tools (n= 26) Pain assessment report and behavioral observation (n= 21) 23% 29% No resources for assesment available (n= 20) Unknown (n= 10) 12% 25% Do not use assessment (n= 5) None (n= 4) Referred assessment with no specification (n= 3) Unknown (n= 3) 4% 3% 3% Monitor or other physiological parameters (n= 8) Clinical examination (n= 4) Other resources with no specification for assessment (n= 4) 0% 5% 10% 15% 20% 25% 30% 35% 0% 10% 20% 30% 40% 50% 5% 5% 10% Assessment - Gaps/Barriers Assessment - Demands Standardization (n= 14) 17% Training (n= 11) 13% Human resources (n= 11) 13% Material resources (n= 11) 12% Information (n= 7) Limitations of clinical condition (n= Commitment (n= 6) 7% Unknown (n= 5) Standardization and training (n= 4) 5% Standardization and communication 5% Resources and training (n= 3) 3% 0% 5% 10% 15% 20% Standardization (n= 24) Training team (n= 23) Standardization and training (n= 12) Material resources (n= 9) Unknown (n= 6) Human resources (n= 5) Material and human resources (n= 3) Commitment of team staff (n= 3) 4% 3% 7% 11% 14% 2 27% 0% 5% 10% 15% 20% 25% 30% Figure 1. Opinion of health professionals about pain assessment: actions, material resources, gaps/ barriers and demands standardized pharmacological protocols (22%), improved accessibility to medications (13%), and the availability of anesthesiologists in the context of pediatric care and support for invasive and painful procedures (). Non-pharmacological management With regard to non-pharmacological management actions taken by the professionals, Figure 3 shows that only 25% of the professionals adopted this type of intervention in the hospital context, and 2 reported the use of strategies to comfort the patient. Importantly, a high proportion of respondents disregarded or did not use this type of management (1). With regard to material resources for non-pharmacological pain management, 65% of the professionals reported the existence of any resource in their work place. Toys and distraction objects were the most identified resources (2). With regard to gaps, the professionals reiterated a lack of training in the pain field (25%), outdated human resources (22%), and difficulty communicating and integrating actions between health professional teams (1). The needs reported by the participants followed a similar pattern including human and material resources (3), professional training (35%), and the creation of standardized protocols (10%). Discussion The goal of the present study was to characterize the opinions of health professionals who work in the hospital context with regard to strategies for the evaluation and management of pediatric pain that are adopted in infirmaries and intensive care units in a public teaching hospital. The main findings showed that few professionals practices used standardized, validated, and specific tools for pain evaluation. Therefore, the evaluations were predominantly performed using clinical evaluations. Similar findings were reported by Schultz et al. (2010), who analyzed the responses of recently graduated physicians and found that tools for pain evaluation were seldom used in their healthcare routine. For the evaluation of children, especially newborns who do not verbally communicate, the use of tools that operationalize symptoms of pain is critical. Silva, Balda, & Guinsburg (2012) analyzed photographs of babies in situations of pain and no pain. They found that medical Pediatric pain assessment and management 47 Pharmacological Management - Actions Pharmacological Management - Material Resources Medications with no specifications (n= 44) 49% Nonspecific medication (n= 52) 63% Medication specific for pain management (n= 26) Describes routine of clinical service (n= 12) 13% 29% Specific medications for pain management (n= 16) 20% None (n= 5) Referred material resources with no specifications (n= 7) 9% Not done/ lack of information (n= 3) 3% Unknown/no materials (n= 7) 0% 10% 20% 30% 40% 50% 60% 0% 50% 100% Pharmacological Management - Gaps/Barriers Pharmacological Management - Demands Team training (n= 13) 1 Professional training (n= 20) 2 Medications and difficulties accessing (n= 10) Unknown (n= 10) Unindentified gaps (n= 9) Pediatric anesthesiologist in ward (n= 8) Standardization of medication (n= 6) Difficulties admnistering medications (n= 6) Difficulty in integrating the team (n= 4) None (n= 4) 5% 14% 13% 12% 11% Unknown/unidentified demands (n= 19) Standardization of medications (n= 17) Available medications (n= 10) Pediatric anesthesiologists in ward (n= 7) Team to implement integrative actions (n= 3) 9% 13% 22% 25% Professionals and qualified team (n= 3) 4% 4% 0% 5% 10% 15% 20% 0% 5% 10% 15% 20% 25% 30% Fig
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