Hypotensive Events in Pediatric Patients Receiving Dexmedetomidine for MRI.

PURPOSE: Dexmedetomidine, the preferred pediatric sedating agent for magnetic resonance imaging (MRI), has the side effect of hypotension. Newer recommendations for reporting adverse events in pediatric procedural sedation include using a two-pronged definition. Our aim was to describe the incidence of hypotension in patients undergoing sedated MRI and to identify demographic and clinical factors associated with hypotension, applying a two-pronged definition, where a numerical threshold/clinical criterion must be met as well as at least one clinical intervention performed. DESIGN: An observational cohort study. METHODS: Medical record data were extracted for outpatients less than 18 years of age sedated primarily with dexmedetomidine for MRI in a single center for over a seven-year period. Patients who received propofol as an adjunct were also included. Hypotension was defined using a two-pronged approach, as a 20% reduction in systolic blood pressure from baseline lasting ≥10 minutes, coupled with a fluid bolus. Analysis included descriptive statistics, t tests and logistic regression using discrete-time survival analysis. FINDINGS: Of the 1,590 patient encounters, 90 (5.7%) experienced hypotension. Males were significantly more likely to have hypotension. Patients with hypotension had overall longer appointment times, including longer sedation times and recovery time. Greater blood pressure (BP) variability in the preceding 20 minutes also increased the risk of hypotension. CONCLUSIONS: Our lower incidence of hypotension is likely related to the two-pronged intervention-based definition used, as it likely more accurately reflects clinically meaningful hypotension. To our knowledge, this is the first study using this approach with this population. Research further examining the relationship between prolonged sedation, blood pressure variability, gender, hypotension, and recovery time is needed. Understanding these relationships will help interdisciplinary teams, including nurses in pediatric procedural areas, to reduce the incidence of hypotension, potentially maximize patient safety, and optimize throughput.

Using a Cascading Approach to Improve Multisite Study Procedures.

BACKGROUND: Multisite studies offer larger, more diverse samples to successfully capture populations and clinical practices of interest at the point of care. However, investigators face challenges with site recruitment and sampling, differences in clinical practices across sites, and data integrity. Addressing these issues a priori can improve the rigor and reproducibility of the research. OBJECTIVE: This article aims to describe a cascading approach to multisite research. An exemplar is provided of a study using this approach, which aimed to evaluate the prevalence of pain and the pain management practices provided to critically ill children in pediatric intensive care units in the United States. METHODS: The cascading approach includes two or more pilot study procedures with a progressively increasing number of sites prior to a full-scale study. Following each pilot, study procedures are evaluated; feedback was obtained from site personnel and content experts; procedures were revised accordingly; approvals were obtained; sites were trained; and the revised procedures are repeated with a larger, more diverse number of sites. RESULTS: In the exemplar provided, improvements in the efficiency and integrity of data collection were noted for the full-scale study following the pilots. All sites that completed the agreements and approvals for study participation were retained for the duration of the two pilots and full-scale study. DISCUSSION: Borrowing from principles of process improvement, the cascading approach allows knowledge to be gained regarding site differences and informs the revision of study procedures while potentially maximizing efficiency and data integrity, minimizing site burden, and maintaining site engagement for multisite studies.

Pain Assessment and Management for a Chemically Paralyzed Child Receiving Mechanical Ventilation.

BACKGROUND: Pain assessment in the pediatric intensive care unit (PICU) is complex, specifically for children receiving mechanical ventilation who require neuromuscular blockade (NMB). No valid pain assessment method exists for this population. Guidelines are limited to using physiologic variables; it remains unknown how nurses are assessing and managing pain for this population in practice. OBJECTIVES: To describe how PICU nurses are assessing and managing pain for children who require NMB. METHODS: A cross-sectional quantitative design was used with an electronic survey. Nurses were asked to respond to 4 written vignettes depicting a child who required NMB and had a painful procedure, physiologic cues, both, or neither. RESULTS: A total of 107 PICU nurses answered the survey. Nurses primarily used behavioral assessment scales (61.0%) to assess the child's pain. All nurses reported that physiologic variables are either moderately or extremely important, and 27.3% of nurses used the phrase "assume pain present" formally at their organization. When physiologic cues were present, the odds of a nurse intervening with a pain intervention were 23.3 times (95% CI, 11.39-53.92; P < .001) higher than when such cues were absent. CONCLUSIONS: These results demonstrate variation in how nurses assess pain for a child who requires NMB. The focus remains on behavioral assessment scales, which are not valid for this population. When intervening with a pain intervention, nurses relied on physiologic variables. Decision support tools to aid nurses in conducting an effective pain assessment and subsequent management need to be created.

Nurses' Experiences Caring for Children With Neuroblastoma Receiving 131I-Metaiodobenzylguanidine Therapy: A Qualitative Descriptive Study.

Background: Neuroblastoma, the most common extra-cranial solid tumor found in children, carries a high mortality rate due to challenges with metastatic disease at diagnoses and relapse. 131I-Metaiodobenzylguanidine (I-MIBG) therapy provides targeted radiotherapy to treat neuroblastoma, but requires children to be isolated for radiation exposure, with limited access to the healthcare team while hospitalized. There is minimal research outlining the nurses' perspectives on caring for this patient population. Therefore, the aim of this study was to describe the nurses' experiences caring for children receiving 131I-MIBG therapy, focusing on nursing care, challenges, radiation exposure, and preparation. Methods: Ten nurses were recruited using purposeful sampling for this qualitative descriptive study. Semi-structured interview guides and conventional qualitative content analysis guided the data collection and analysis. Results: Nurses overwhelmingly felt isolated from their patients and a decreased sense of connection with the child. Although nurses felt prepared, they had more anxiety with the first patient experience and identified that parent engagement was essential. Overall, nurses shared they had support from written materials outlining the protocols, and members of the multidisciplinary team. More concern for radiation exposure was expressed by nurses of childbearing age and with handling bodily fluids. Discussion: Findings suggest that nurses would benefit from simulation experiences to help prepare for radiation exposure safety, strategies to engage the family in the child's care, and interacting with a child in single-room isolation. Because programs differ around the US, additional research exploring nurses' experiences is warranted to evaluate the best successes in providing 131I-MIBG therapy.

Variability in qualifications for principal investigator status in research studies by nurses: A call for clarification.

PURPOSE: To describe existing guidance for qualifications of principal investigator s (PI s) of human subjects research and explore how they are operationalized for pediatric nurse scientists and clinical nurses in children's hospitals. DESIGN AND METHODS: After reviewing federal regulations, accreditation guidelines, and the literature, a convenience sample of members of the National Pediatric Nurse Scientist Collaborative (NPNSC). Participants completed a 33-item survey that included questions about Institutional Review Board (IRB), guidelines, and policies for PI status at their affiliated children's hospitals. RESULTS: The survey was electronically disseminated to 179 members of NPNSC through the Collaborative's listserv. Of the 39 members who responded, 90% hold a PhD and 80% practice in a free-standing children's hospital, nearly all of which (93%) are recognized as Magnet® hospitals. While the majority of respondents indicated that nurse scientists and other nurses were allowed to be PIs of research studies, educational requirements for PI status varied, with 3% requiring a PhD, 15% a baccalaureate degree, and 10% a graduate degree. 54% of respondents reported there was no degree requirement for PI status; however15% reported that even doctorally prepared nurse scientists cannot serve as PIs of research studies at their affiliated children''s hospitals. CONCLUSIONS: The survey identified substantial variability in requirements for PI status and potential barriers to pediatric nurses conducting independent research as PIs at children's hospitals. PRACTICE IMPLICATIONS: Operationalizing existing guidance will expand inclusion of nurse scientist expertise in human subjects research.

The Experience of Children With Neuroblastoma and Their Parents During Single-Room Isolation for 131I-Metaiodobenzylguanidine Therapy: A Qualitative Descriptive Study.

Background: Administration of 131I-metaiodobenzylguanidine (131I-MIBG) for neuroblastoma requires hospitalization in single-room isolation and limits caregiver physical contact due to the child's radioactive burden. Though used for decades, there is a dearth of research on the experiences of children and their parents while isolated. Methods: This qualitative descriptive study evaluated the experience of children with neuroblastoma undergoing single-room isolation for 131I-MIBG therapy and their parents. Ten nurses, nine parents, and five children were interviewed; transcripts were analyzed applying a conventional content analysis approach. Results: Child themes included overall experiences ranging from positive to negative; emotional stress was common; symptoms were common but mostly managed; the children were adequately prepared for isolation; and audiovisual technology and entertainment helped. The indwelling urinary catheter was a source of emotional stress and/or pain for several children. Parent themes included I thought it was going to be a lot worse; it gets better with time; feeling concerned and overwhelmed; prepared as much as you can be; and you feel like you're not alone. Discussion: Findings suggest that children and parents would benefit from additional coping support interventions to address emotional distress. Efforts should be made to identify other sources of technology or room designs that can maximize the child's sense of connection with parents and healthcare professionals. Additional research is needed to examine the impact of this isolation experience on the long-term psychological outcomes of children and parents.

A Secondary Traumatic Stress Reduction Program in Emergency Room Nurses.

Introduction: Secondary traumatic stress is highly prevalent among nurses, especially among nurses working within the emergency department (ED). Reducing healthcare worker secondary traumatic stress is important for ensuring the delivery of high quality, safe patient care. This paper reports on the development and implementation of a secondary traumatic stress reduction program. Methods: We used an adaption of a 5-week intervention based on the Accelerated Recovery Program to test whether there would be a reduction in secondary traumatic stress in a pilot sample of nine ED nurses. Outcomes were assessed using the Secondary Traumatic Stress Scale (STSS), Somatic Symptoms Scale (SSS), and Compassion Satisfaction subscale (CSS) measures. Results: Eight of nine nurses were able to complete at least three of the five sessions. Results indicate significant change in STSS (F[5,23] = 4.22, p = .007) and SSS (F[3,15] = 4.42, p = .02) scores, but not CSS (F[5,23] = 0.83, p = .54) scores. Pairwise comparisons revealed that the beneficial effects of the program happened early. For both STSS and SSS, scores at sessions 1 and 2 were generally higher than subsequent sessions. We also found a trend for continued effects on STSS at a four-month follow-up (t23 = 1.95, p = .064). Conclusion: Overall, results indicate the 5-week program was associated with a significant reduction in secondary traumatic stress and related somatic symptoms in healthcare workers.

Predicting Who Receives Nonpharmacologic Pain Interventions in the Pediatric Intensive Care Unit.

AIMS: The majority of patients in the pediatric intensive care unit (PICU) experience pain daily, while nonpharmacologic interventions are indicated for pain management in children, there is limited information on which nonpharmacologic interventions are provided in the PICU and which patients receive those interventions. The aim of this descriptive correlational secondary data analysis was to determine what nonpharmacologic interventions were recorded in the electronic health record of PICU patients and patterns in use by patient demographics. SETTING/SUBJECTS: All patients hospitalized in 15 participating PICUs are located within 12 unique children's hospitals across the United States were eligible for participation. METHODS: Nonpharmacologic interventions used in the PICU were identified and differences between patients who did and did not receive those interventions were examined using Fisher's exact test. A generalized linear mixed effects model was constructed to determine patient characteristics that predict nonpharmacologic pain intervention application. RESULTS: Of 220 enrolled patients, 97 (44%) had nonpharmacologic pain interventions recorded in their electronic health record. The most frequently recorded interventions included repositioning (65%), decreasing environmental stimuli (55%), caregiver presence (37%), distraction (23%), and music therapy (20%). Children who had moderate to severe pain were most likely to receive nonpharmacologic pain interventions. CONCLUSIONS: Nonpharmacologic pain management is applied inconsistently across PICUs and may be underdocumented or underutilized. Additional research is needed to determine when nurses use nonpharmacologic pain interventions, their rationale for applying these interventions across differing groups, and the effectiveness of these interventions in managing pain in critically ill children.

Surge Planning and Implementation: A Required Competency for Today's Nurse Leaders.

The ability to respond effectively and efficiently during times of crisis, including a pandemic, has emerged as a competency for nurse leaders. This article describes one institution's experience using the American Organization of Nurse Leaders Competencies for Nurse Executives in operationalizing the concept of surge capacity.

Characteristics of Critically Ill Adults With Sacrococcygeal Unavoidable Hospital-Acquired Pressure Injuries: A Retrospective, Matched, Case-Control Study.

PURPOSE: To identify characteristics of critically ill adults with sacrococcygeal, unavoidable hospital-acquired pressure injuries (uHAPIs). DESIGN: Retrospective, matched, case-control design. SUBJECTS/SETTING: Patients admitted to adult intensive care units (ICUs) at an urban academic medical center from January 2014 through July 2016. METHODS: Thirty-four patients without uHAPI were matched to 34 patients with sacrococcygeal uHAPI. Time points of interest included admission to the ICU, the week preceding the definitive assessment date, and hospital discharge status. Variables of interest included length of stay, any diagnosis of sepsis, severity of illness, degree of organ dysfunction/failure, supportive therapies in use (eg, mechanical ventilation), and pressure injury risk (Braden Scale score). RESULTS: All 34 sacrococcygeal pressure injuries were classified as uHAPI using the pressure injury prevention inventory instrument. No statistically significant differences were noted between patients for severity of illness, degree of organ dysfunction/failure, or pressure injury risk at ICU admission. At 1 day prior to the definitive assessment date and at discharge, patients with uHAPI had significantly higher mean Sequential Organ Failure Assessment (SOFA) scores (greater organ dysfunction/failure) and lower mean Braden Scale scores (greater pressure injury risk) than patients without uHAPI. Patients with uHAPI had significantly longer lengths of stay, more supportive therapies in use, were more often diagnosed with sepsis, and were more likely to die during hospitalization. CONCLUSION: Sacrococcygeal uHAPI development was associated with progressive multiorgan dysfunction/failure, greater use of supportive therapies, sepsis diagnosis, and mortality. Additional research investigating the role of multiorgan dysfunction/failure and sepsis on uHAPI development is warranted.

Predictors of pressure injury development in critically ill adults: A retrospective cohort study.

OBJECTIVE: The purpose of this research was to identify predictors of pressure injury, using data from the electronic health records of critically ill adults. METHODOLOGY: A retrospective cohort study was conducted using logistic regression models to examine risk factors adjusted for age, gender, race/ethnicity and length of stay. SETTING: The study cohort included 1587 adults in intensive care units within an urban academic medical centre. MAIN OUTCOME MEASURES: The presence or absence of a hospital-acquired pressure injury was determined during monthly skin integrity prevalence surveys. All pressure injuries were independently confirmed by two Certified Wound Care Nurses. RESULTS: Eighty-one (5.1%) of the 1587 cohort patients developed pressure injuries. After adjusting for confounders, the clinical variables associated with pressure injury development included mean arterial pressure <60 mmHg and lowest Total Braden score up to two weeks prior to the date of HAPI development or date of prevalence survey for the comparison group. CONCLUSIONS: This study provides a more comprehensive understanding about pressure injury risk in critically ill adults, identifying extrinsic and intrinsic factors associated with pressure injury development. Prospective multisite studies are needed to further examine these potential contributors to pressure injury development within the context of adherence to prevention interventions.

Improving Hospitalized Children's Sleep by Reducing Excessive Overnight Blood Pressure Monitoring.

BACKGROUND: Although required for healing, sleep is often disrupted during hospitalization. Blood pressure (BP) monitoring can be especially disruptive for pediatric inpatients and has few clinical indications. Our aim in this pilot study was to reduce unnecessary overnight BP monitoring and improve sleep for pediatric inpatients. METHODS: The intervention in June 2018 involved clinician education sessions and updated electronic health record (EHR) orders that enabled the forgoing of overnight BP checks. The postintervention period from July 2018 to May 2019 examined patient-caregiver surveys as outcome measures. These surveys measured inpatient sleep and overnight disruptions and were adopted from validated surveys: the Patient Sleep Questionnaire, expanded Brief Infant Sleep Questionnaire, and Potential Hospital Sleep Disruptions and Noises Questionnaire. Uptake of new sleep-friendly EHR orders was a process measure. Reported patient care escalations served as a balancing measure. RESULTS: Interrupted time series analysis of EHR orders (npre = 493; npost = 1472) showed an increase in intercept for the proportion of patients forgoing overnight BP postintervention (+50.7%; 95% confidence interval 41.2% to 60.3%; P < .001) and a subsequent decrease in slope each week (-0.16%; 95% confidence interval -0.32% to -0.01%; P = .037). Statistical process control of surveys (npre = 263; npost = 131) showed a significant increase in sleep duration for patients older than 2, and nighttime disruptions by clinicians decreased by 19% (P < .001). Annual estimated cost savings were $15 842.01. No major adverse events in patients forgoing BP were reported. CONCLUSIONS: A pilot study combining EHR changes and clinician education safely decreased overnight BP checks, increased pediatric inpatient sleep duration, and reduced nighttime disruptions by clinicians.

Pain Assessment Practices in the Pediatric Intensive Care Unit.

PURPOSE: Pain assessment is the first step in managing pain; however, this can be challenging, particularly in settings such as the Pediatric Intensive Care Unit (PICU). This paper reports the current pain assessment practices from a study that was conducted describing the prevalence of pain, pain assessment, painful procedures, interventions, and characteristics of critically-ill children. Specifically, this paper addresses the child's communicative ability, pain scales, and characteristics of pain. DESIGN AND METHODS: The primary study was a cross-sectional, multi-site, descriptive design. Data from a 24-hour time period were collected from medical records and bedside nurses. RESULTS: Data were collected from the records of 220 children across 15 PICUs. The average number of pain assessments per child was 11.5 (SD 5.8, range 1-28). Seven behavioral scales and five self-report scales were used. There were times when no scale was used, "assume pain present" was recorded, or a sedation scale was documented. Twelve pain scales, including the target population, scoring, psychometric properties, and clinical utility are described. CONCLUSIONS: Results of this study indicate that a wide range of pain assessment tools are used, including behavioral scales for children unable to self-report. IMPLICATIONS: Foremost, the appropriate assessment method needs to be chosen for each child to manage pain. Knowledge of the criteria for the use of each pain assessment scale will help the clinician select the appropriate scale to use for each child. The practice of "assume pain present," as well as standardization of pain scales, and clinical support tools needs further investigation.

Pain in the Pediatric Intensive Care Unit: How and What Are We Doing?

BACKGROUND: Pain management in critically ill children is complex. Epidemiological research is needed to identify how often patients in pediatric intensive care units experience pain and the practices being used to lessen pain. OBJECTIVES: To describe pain assessment and intervention practices in pediatric intensive care units, determine the prevalence of pain and painful procedures, and identify characteristics of children with moderate to severe pain. METHODS: A 24-hour observational cohort study was conducted in 15 units. Nurses completed surveys regarding patients' communicative ability. Patients' records were reviewed for pain assessments, painful procedures, and pharmacologic and nonpharmacologic interventions. RESULTS: For the 220 patients in this study, pain was assessed a median (interquartile range) of 10 (7-13) times, usually with behavioral pain scales. Sixty-eight percent of patients received pharmacologic interventions and 44% received nonpharmacologic interventions. Fentanyl was the most common analgesic provided. Repositioning was the most common nonpharmacologic intervention. Forty-five percent of patients had pain and 24% had moderate to severe pain. Patients experienced a median (interquartile range) of 7 (2-15) painful procedures in 24 hours. More frequent pain assessments and pharmacologic interventions and the ability to communicate were associated with moderate to severe pain. No patient in the moderate to severe pain category received neuromuscular blockers. CONCLUSIONS: Critically ill children experience pain and multiple painful procedures daily. Assessment and intervention practices vary considerably. Research is needed to establish best practices for pain assessment in patients with limited communicative ability and to determine which pain management strategies improve patients' outcomes.

Differentiating Deep Tissue Pressure Injury (DTPI) From Other Causes of Purpura in the Sacrococcygeal Area: A Multiple Case Series.

BACKGROUND: Recent revisions to the pressure injury staging system include guidance on differential diagnoses for deep tissue pressure injury (DTPI). Accurately identifying DTPI is critical; however, purpura in the setting of vascular disorders and systemic infectious processes can share similar features confounding diagnosis. CASES: In this three-case series, we describe suspected DTPI with an uncharacteristic shape or occurring in the presence of additional lesions distributed outside of typical pressure areas prompted further evaluation. CONCLUSIONS: The interdisciplinary approach we adapted was useful in determining the cause of purpura when the DTPI was ruled out by the certified wound care nurse.

Effectiveness of SIESTA on Objective and Subjective Metrics of Nighttime Hospital Sleep Disruptors.

We created Sleep for Inpatients: Empowering Staff to Act (SIESTA), which combines electronic "nudges" to forgo nocturnal vitals and medications with interprofessional education on improving patient sleep. In one "SIESTAenhanced unit," nurses received coaching and integrated SIESTA into daily huddles; a standard unit did not. Six months pre- and post-SIESTA, sleep-friendly orders rose in both units (foregoing vital signs: SIESTA unit, 4% to 34%; standard, 3% to 22%, P < .001 both; sleeppromoting VTE prophylaxis: SIESTA, 15% to 42%; standard, 12% to 28%, P < .001 both). In the SIESTAenhanced unit, nighttime room entries dropped by 44% (-6.3 disruptions/room, P < .001), and patients were more likely to report no disruptions for nighttime vital signs (70% vs 41%, P = .05) or medications (84% vs 57%, P = .031) than those in the standard unit. The standard unit was not changed. Although sleep-friendly orders were adopted in both units, a unit-based nursing empowerment approach was associated with fewer nighttime room entries and improved patient experience.

Association Between Room Location and Adverse Outcomes in Hospitalized Patients.

OBJECTIVE: To investigate whether a patient's proximity to the nurse's station or ward entrance at time of admission was associated with increased risk of adverse outcomes. METHOD: We conducted a retrospective cohort study of consecutive adult inpatients to 13 medical-surgical wards at an academic hospital from 2009 to 2013. Proximity of admission room to the nurse's station and to the ward entrance was measured using Euclidean distances. Outcomes of interest include development of critical illness (defined as cardiac arrests or transfer to an intensive care unit), inhospital mortality, and increase in length of stay (LOS). RESULTS: Of the 83,635 admissions, 4,129 developed critical illness and 1,316 died. The median LOS was 3 days. After adjusting for admission severity of illness, ward, shift, and year, we found no relationship between proximity at admission to nurse's station our outcomes. However, patients admitted to end of the ward had higher risk of developing critical illness (odds ratio [ OR] = 1.15, 95% confidence interval [CI] = [1.08, 1.23]), mortality ( OR = 1.16, 95% CI [1.03, 1.33]), and a higher LOS (13-hr increase, 95% CI [10, 15] hours) compared to patients admitted closer to the ward entrance. Similar results were observed in sensitivity analyses adjusting for isolation room patients and considering patients without room transfers in the first 48 hr. CONCLUSIONS: Our study suggests that being away from the nurse's station did not increase the risk of these adverse events in ward patients, but being farther from the ward entrance was associated with increase in risk of adverse outcomes. Patient safety can be improved by recognizing this additional risk factor.

Awakenings? Patient and Hospital Staff Perceptions of Nighttime Disruptions and Their Effect on Patient Sleep.

STUDY OBJECTIVES: Although important to recovery, sleeping in the hospital is difficult because of disruptions. Understanding how patients, hospital physicians, and nurses perceive sleep disruptions and identifying which disruptions are associated with objective sleep loss can help target improvement initiatives. METHODS: Patients and hospital staff completed the Potential Hospital Sleep Disruptions and Noises Questionnaire (PHSDNQ). Cutoff points were defined based on means, and responses were dichotomized. Perceived percent disrupted for each item was calculated, and responses were compared across groups using chi-square tests. Objective sleep time of patients was measured using wrist actigraphy. The association between patient-reported disruptions and objective sleep time was assessed using a multivariable linear regression model controlling for subject random effects. RESULTS: Twenty-eight physicians (78%), 37 nurses (88%), and 166 of their patients completed the PHSDNQ. Patients, physicians, and nurses agreed that pain, vital signs and tests were the top three disrupters to patient sleep. Significant differences among the groups' perceptions existed for alarms [24% (patients) vs. 46% (physicians) vs. 27% (nurses), p < 0.040], room temperature (15% vs. 0% vs. 5%, p < 0.031) and anxiety (18% vs. 21% vs. 38%, p < 0.031). Using survey and actigraphy data from 645 nights and 379 patients, the presence of pain was the only disruption associated with lower objective sleep duration (minutes) [-38.1 (95% confidence interval -63.2, -12.9) p < 0.003]. CONCLUSION: Hospital staff and patients agreed that pain, vital signs and tests were top sleep disrupters. However, pain was associated with the greatest objective sleep loss, highlighting the need for proactive screening and management of patient pain to improve sleep in hospitals.

Targeted Simulation Instructor Course for Nursing Professional Development Specialists.

Practical training for nursing professional development specialists in the facilitation of clinical simulations was implemented using a six-step curriculum development framework. General and targeted needs assessments were conducted. Methods used to apply needs assessment findings into the course design and delivery and the participant's responses via program evaluations are described. The process used to develop this training may be applied by other nursing professional development departments to prepare educators in the delivery of simulated-based learning experiences.

Nurses' Beliefs Regarding Pain in Critically Ill Children: A Mixed-Methods Study.

The purpose of this study was to provide a current and comprehensive evaluation of nurses' beliefs regarding pain in critically ill children. DESIGN AND METHODS: A convergent parallel mixed-methods design was used. Nurse beliefs were captured via questionnaire and interview and then compared. RESULTS: Forty nurses participated. Most beliefs reported via questionnaire were consistent with effective pain management practices. Common inaccurate beliefs included the need to verify pain reports with physical indicators and the pharmacokinetics of intravenous opioids. Beliefs commonly shared during interviews concerned the need to verify pain reports with observed behavior, the accuracy of pain reports, the need to respond to pain, concerns regarding opioid analgesics, and the need to "start low" with interventions. Convergent beliefs between the questionnaire and interview included the use of physical indicators to verify pain, the need to take the child's word when pain is described, and concerns regarding negative effects of analgesics. Divergent and conflicting findings were most often regarding the legitimacy of a child's pain report. CONCLUSIONS: Findings from this study regarding the accuracy of nurses' pain beliefs for critically ill children are consistent with past research. The presence of divergent and conflicting responses suggests that nurses' pain beliefs are not static and may vary with patient characteristics. PRACTICE IMPLICATIONS: While most nurses appreciate the risks of unrelieved pain in children, many are concerned about the potential adverse effects of opioid administration. Interventions are needed to guide nurses in minimizing both of these risks.