A Systematic Review of Behavioral and Environmental Interventions for Procedural Pain Management in Preterm Infants.

PROBLEM: Current research suggests behavioral and environmental interventions to prevent neonatal pain prior to an invasive procedure are rarely administered and seldom documented. The aim of this study was to systematically review findings from published randomized controlled trials that tested the effects of behavioral and environmental procedural pain management interventions on behavioral pain response in preterm infants. ELIGIBILITY CRITERIA: Randomized controlled trials examining the effects of behavioral and environmental pain management interventions on behavioral pain response in preterm infants were identified. Articles accepted for inclusion met the following criteria: English language, original, peer refereed, randomized controlled clinical trials published within the past 5 years, study sample: preterm infants, setting: neonatal intensive care units, study intervention behavioral and environmental, outcome pain measurement score from valid and reliable pain scale. SAMPLE: Fourteen randomized controlled trials from a literature search of PubMed and Medline databases were included in this review. RESULTS: Across all age groups, facilitated tucking, oral sucrose, and kangaroo care decreased behavioral and physiologic pain response alone and in combination with other behavioral and environmental interventions. CONCLUSION: Among preterm infants, facilitated tucking, oral sucrose, and kangaroo care significantly mitigates biobehavioral pain response associated with acutely painful procedures. IMPLICATIONS: Evidence suggests that behavioral and environmental interventions can decrease biobehavioral pain response associated with acutely painful procedures in preterm infants. This review highlights the need for rigorous studies to help healthcare providers to build a tailored pain treatment plan for preterm infants.

Fostering Clinical Nurse Research in a Hospital Context.

Two components of the Magnet Recognition Program® are exemplary professional practice and the generation of new knowledge through research and clinical innovation. Within Magnet® institutions, exemplary professional practice is evidenced by collaboration. Hospitals and schools of nursing can develop collaborative relationships to promote a culture of inquiry in clinical care and generate research to advance nursing practice and nursing science. The authors describe a collaborative model between clinical nurses and an academic nursing research center that promotes involvement of clinical nurses in research.

Higher Quality of Care and Patient Safety Associated With Better NICU Work Environments.

The objective of this study was to investigate the associations between the neonatal intensive care unit (NICU) work environment, quality of care, safety, and patient outcomes. A secondary analysis was conducted of responses of 1247 NICU staff nurses in 171 hospitals to a large nurse survey. Better work environments were associated with lower odds of nurses reporting poor quality, safety, and outcomes. Improving the work environment may be a promising strategy to achieve safer settings for at-risk newborns.

Factors influencing parents' decision to donate their healthy infant's DNA for minimal-risk genetic research.

PURPOSE: To examine factors that influence a parent's decision to donate their healthy infant's DNA for minimal-risk genetic research. DESIGN: Grounded theory, using semi-structured interviews conducted with 35 postpartum mother or mother-father dyads in an urban teaching hospital. Data were collected from July 2011 to January 2012. METHODS: Audiorecorded semistructured interviews were conducted in private rooms with mothers or mother-father dyads 24 to 48 hr after the birth of their healthy, full-term infant. Data-driven content analysis using selected principles of grounded theory was performed. FINDINGS: Parents' willingness to donate their healthy infant's DNA for minimal-risk pediatric genetic research emerged as a process involving three interacting components: the parents, the scientist, and the comfort of the child embedded within the context of benefit to the child. The purpose of the study and parents' perception of their commitment of time and resources determined their willingness to participate. The scientist's ability to communicate trust in the research process influenced parents' decisions. Physical discomfort of the child shaped parents' decision to donate DNA. Parental perception of a direct benefit to their child affected their willingness to discuss genetic research and its outcomes. CONCLUSIONS: Significant gaps and misunderstandings in parental knowledge of pediatric genetic research may affect parental willingness to donate their healthy child's DNA. CLINICAL RELEVANCE: Nurses knowledgeable about the decision-making process parents utilize to donate their healthy infant's DNA for minimal-risk genetic research and the factors influencing that decision are well positioned to educate parents about the role of genetics in health and illness and reassure potential research participants of the value and safeguards in pediatric genetic research.

The professional appearance of registered nurses: an integrative review of peer-refereed studies.

BACKGROUND: There is a paucity of research examining the impact of standardized uniform style and color for registered nurses (RNs). OBJECTIVE: The aim of this study was to appraise published peer-refereed studies on the effect of a standardized uniform style and color for RNs. METHODS: Seven peer-refereed studies exploring standardized uniforms for RNs were identified. Using the Oxford Centre for Evidence-Based Medicine evidence hierarchy, each study was assigned a level of evidence and overall rating. RESULTS: Data suggest that patients felt that RNs appeared professional and were easily identified by a standardized uniform style and color. No strong evidence supports a patient's preference for a specific style and color of uniform. CONCLUSIONS: Findings are inconsistent but demonstrate that a standardized uniform style and color increased the perception of professionalism and recognition of RNs among patients.

The analgesic properties of intraoral sucrose: an integrative review.

The treatment of pain is an essential component of the clinical and ethical care of infants. Despite evidence-based practice consensus statements recommending that infants receive analgesia during minor painful procedures, numerous studies have shown that procedural pain remains poorly managed in this population. Oral sucrose administration has been associated with calming effects and reductions in observed pain behaviors with preterm and term infants aged up to 1 year. The objective of this integrative review is to synthesize findings from published randomized controlled trials evaluating the efficacy and safety of oral sucrose as a preprocedural intervention for mild to moderate procedural pain in infants. Overall, studies indicate that oral sucrose is an effective, safe, convenient, and immediate-acting analgesic for reducing crying time and significantly decreases biobehavioral pain response following painful procedures with infants.

Association of Patient Acuity and Missed Nursing Care in U.S. Neonatal Intensive Care Units.

The health outcomes of infants in neonatal intensive care units (NICUs) may be jeopardized when required nursing care is missed. This correlational study of missed care in a U.S. NICU sample adds national scope and an important explanatory variable, patient acuity. Using 2016 NICU registered nurse survey responses (N = 5,861) from the National Database of Nursing Quality Indicators, we found that 36% of nurses missed one or more care activities on the past shift. Missed care prevalence varied widely across units. Nurses with higher workloads, higher acuity assignments, or in poor work environments were more likely to miss care. The most common activities missed involved patient comfort and counseling and parent education. Workloads have increased and work environments have deteriorated compared with 8 years ago. Nurses' assignments should account for patient acuity. NICU nurse staffing and work environments warrant attention to reduce missed care and promote optimal infant and family outcomes.

Parent Satisfaction With Care and Treatment Relates to Missed Nursing Care in Neonatal Intensive Care Units.

Background: The satisfaction of parents of infants in neonatal intensive care is important to parent-infant bonding and parents' ability to care for their baby, including after discharge. Given the principal caregiver role of nurses in this setting, parent satisfaction is influenced by high quality nursing care. Nursing care that is required but missed, such as counseling and support, might influence parent satisfaction. How missed nursing care relates to parent satisfaction is unknown. Objective: To describe the satisfaction of parents of infants in neonatal intensive care and to determine how satisfaction relates to missed nursing care in a sample of USA nursing units. Methods: The design was cross-sectional and correlational. Thirty neonatal intensive care units that participate in the National Database of Nursing Quality Indicators were recruited. To maximize sample variation in missed care, the highest and lowest quartile hospitals on missed nursing care, measured by nurse survey, were eligible. Ten parents of infants who were to be discharged were recruited from each site to complete a survey. Parent satisfaction was measured by the EMPATHIC-38 instrument, comprising five subscales: information, care and treatment, organization, parental participation, and professional attitude, and a total satisfaction score. Multivariate regression models were estimated. Results: Parent satisfaction was high (5.70 out of 6.00). The prevalence of missed care was 25 and 51% for low and high missed care units, respectively, and 40% for all units. On average, nurses missed 1.06 care activities; in the low and high missed care units the averages were 0.46 and 1.32. Over 10% of nurses missed activities that involved the parent, e.g., teaching, helping breastfeeding mothers, and preparing families for discharge. One standard deviation decrease in missed care activities at the unit level was associated with a 0.08-point increase in parent satisfaction with care and treatment (p = 0.01). Conclusion: Parents in USA neonatal intensive care units are highly satisfied. Neonatal intensive care nurses routinely miss care. Parent satisfaction with care and treatment is related to missed nursing care. Nursing care that is missed relates primarily to the care of the baby by the parents, which could have long term health and developmental consequences.

Sucrose decreases infant biobehavioral pain response to immunizations: a randomized controlled trial.

PURPOSE: To evaluate the effectiveness and age-related changes in analgesia of oral sucrose as a preprocedural intervention during routine immunizations in infants at 2 and 4 months of age. DESIGN: A double-blind, randomized, placebo-controlled clinical trial of 40 healthy term infants scheduled to receive routine immunizations from a pediatric ambulatory care clinic during May 2005 to July 2005. METHODS: Infants received 24% oral sucrose solution or the control solution of sterile water 2 minutes before routine immunizations at both their 2- and 4-month, well-child visits. The University of Wisconsin Children's Hospital pain scale was used to measure serial acute behavioral pain responses at baseline, 2, and 5 minutes after administration of the solution. Repeated measures ANOVA was used to examine between-group differences and within-subject variability of the effects of treatment on overall behavioral pain scores. FINDINGS: Infants receiving oral sucrose (n=20) showed a significant reduction in behavioral pain response 5 minutes after administration compared to those in the placebo group (n=20). At 2 minutes following solution administration, both sucrose and sterile water showed the highest mean pain score (4.54 and 4.39 respectively) indicating a severe amount of pain. At 5 minutes, the sucrose group returned to near normal at 0.27 while the placebo group remained at 3.02 indicating a percentage difference in mean pain scores relative to sterile water pain scores of 90.9. No statistically significant age-related change in behavioral pain response was noted between 2- and 4-month-old infants at 2 minutes and 5 minutes following treatment administration. CONCLUSION: Sucrose is an effective preprocedural intervention for decreasing behavioral pain response in infants after immunizations. CLINICAL RELEVANCE: Efforts to decrease the pain associated with immunizations can promote parental adherence to recommended immunizations schedules, prevent a resurgence of vaccine-preventable diseases and mitigate adverse neurologic outcomes in infants.

Epigenetic Modifications Following Noxious Stimuli in Infants.

PURPOSE: To recruit healthy full- and preterm infants into genetic research and determine the effectiveness of a noninvasive DNA sampling technique for comparing epigenetic modifications. BACKGROUND: Noxious stimuli during a vulnerable period of infant neuronal plasticity may trigger long-term epigenetic changes affecting neurodevelopment, pain modulation, and reactivity. Recognizing epigenetic pain findings is problematic because parents are reluctant to enroll newborns into genetic research. METHODS: Design: Within-subject change over time candidate-gene DNA methylation association study. Setting/ sample: Urban teaching hospital's neonatal intensive care unit and newborn nursery. Convenience sample of healthy full- (>37 weeks, n = 6) and preterm (<37 weeks, n = 6) infants. PROCEDURE: Parents participated in a genetic presentation prior to informed consent. Infant buccal saliva was collected after admission to the unit and prior to discharge. ANALYSIS: The methylation pattern at the 5' end of µ-opioid receptor gene ( OPRM1) was examined. DNA was treated with bisulfite to convert all cytosines to uracil residues, leaving methylated cytosines unchanged. Sequencing of untreated and bisulfite-converted DNA was carried out. The sequences of unconverted and bisulfite-converted DNA were aligned with ClustalW, fidelity of the polymerase chain reaction and the sequencing reaction evaluated, and the methylation pattern identified. RESULTS: Recruitment and assessment of a noninvasive DNA sampling technique for comparing epigenetic modifications were successful; however, infant stress did not produce a change in OPRM1 methylation expression. RELEVANCE: This study established the feasibility of recruiting healthy full-term infants into genetic research and the effectiveness of noninvasive DNA sampling for comparing epigenetic modification in infants.

Understanding Negative Predictive Value of Diagnostic Tests Used in Clinical Practice.

Nurses review, evaluate, and use diagnostic test results on a routine basis. However, the skills necessary to evaluate a particular test using statistical outcome measures is often lacking. The purpose of this article is to examine and interpret the underlying principles for use of the statistical outcomes of diagnostic screening tests (sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values, with a discussion about use of SpPIn [Specificity, Positive test = rule in], and SnNOut [Sensitivity, Negative test = rule out]) in advanced nursing clinical practice. The authors focus on NPVs because test results with high NPV are useful to practitioners when considering unnecessary, costly, and possibly risky treatments, whether using clinical assessment tool, test, or procedure or using polymerase chain reaction analysis of DNA test results. In this article, the authors emphasize the use of NPV in treatment decisions by providing examples from critical care, neonatal, and advanced forensic nursing, which become a framework for assessing decisions in the clinical arena. This commentary stresses the importance of the NPV of tests in preventing, detecting, and ruling out disease, where PPV may not be relevant for that purpose. Negative predictive value percentages inform treatment decisions when the provider understands the biology, chemistry, and foundation for testing methods used in clinical practices. The art of diagnosis, confirmed in a test's high NPV (meaning the patient probably does not have the disease when the test is negative), reassures provider treatment stewardship to do no harm.

Measurement of acute pain in infants: a review of behavioral and physiological variables.

BACKGROUND: The use of non-validated pain measurement tools to assess infant pain represents a serious iatrogenic threat to the developing neonatal nervous system. One partial explanation for this practice may be the contradictory empirical data from studies that use newborn pain management tools constructed for infants of different developmental stages or exposed to different environmental stressors. PURPOSE: The purpose of this review is to evaluate the evidence regarding the physiologic and behavioral variables that accurately assess and measure acute pain response in infants. METHODOLOGY: A literature search was conducted using PUBMED and CINAHL and the search terms infant, neonate/neonatal, newborn, pain, assessment, and measurement to identify peer-reviewed studies that examined the validity and reliability of behavioral and physiological variables used for investigation of infant pain. Ten articles were identified for critical review. PRINCIPAL FINDINGS: Strong evidence supports the use of the behavioral variables of facial expressions and body movements and the physiologic variables of heart rate and oxygen saturation to assess acute pain in infants. CONCLUSION: It is incumbent upon researchers and clinical nurses to ensure the validity, reliability, and feasibility of pain measures, so that the outcomes of their investigations and interventions will be developmentally appropriate and effective pain management therapies.

Neonatal pain: What's age got to do with it?

BACKGROUND: The neurobiology of neonatal pain processing, especially in preterm infants, differs significantly from older infants, children, adolescence, and adults. Research suggests that strong painful procedures or repeated mild procedures may permanently modify individual pain processing. Acute injuries at critical developmental periods are risk factors for persistent altered neurodevelopment. The purpose of this narrative review is to present the seminal and current literature describing the unique physiological aspects of neonatal pain processing. METHODS: Articles describing the structures and physiological processes that influence neonatal pain were identified from electronic databases Medline, PubMed, and CINAHL. RESULTS: The representation of neonatal pain physiology is described in three processes: Local peripheral nervous system processes, referred to as transduction; spinal cord processing, referred to as transmission and modulation; and supraspinal processing and integration or perception of pain. The consequences of undermanaged pain in preterm infants and neonates are discussed. CONCLUSION: Although the process and pain responses in neonates bear some similarity to processes and pain responses in older infants, children, adolescence, and adults; there are some pain processes and responses that are unique to neonates rendering them at risk for inadequate pain treatment. Moreover, exposure to repeated painful stimuli contributes to adverse long-term physiologic and behavioral sequelae. With the emergence of studies showing that painful experiences are capable of rewiring the adult brain, it is imperative that we treat neonatal pain effectively.

Infant distress: moving toward concept clarity.

Infants' inability to articulate their pain and distress and the diverse range of behavioral responses evoked by painful stimuli may partially explain the challenges associated with the treatment of pain in neonates and infants. To assist nurses in distinguishing nonspecific distress responses from specific pain responses, a concept analysis using Wilson's method was preformed. An evaluation of published, peer reviewed literature referencing distress in neonates and infants was conducted to extract meaningful information related to distress. This article examines the essential features, antecedents, and consequences of infant distress to generate an evidence-based definition that has relevance for neonatal and pediatric research and clinical practice.

Analgesic properties of oral sucrose during routine immunizations at 2 and 4 months of age.

OBJECTIVE: The purpose of this work was to evaluate the analgesic properties of oral sucrose during routine immunizations in infants at 2 and 4 months of age. PATIENTS AND METHODS: A prospective, randomized, placebo-controlled clinical trial was conducted at a pediatric ambulatory care clinic. One-hundred healthy term infants scheduled to receive routine immunizations were recruited, randomly stratified into 2- or 4-month study groups, and further randomly assigned to receive 24% oral sucrose and pacifier or the sterile water control solution. The study preparations were administered 2 minutes before the combined diphtheria-tetanus-acellular pertussis, inactivated polio vaccine, and hepatitis B vaccine. Haemophilus influenzae type b vaccine was administered 3 minutes after the combined injection, followed by the pneumococcal conjugate vaccine, 2 minutes after the H. influenzae type b injection. The University of Wisconsin Children's Hospital Pain Scale measured serial acute pain responses for the treatment and control groups at baseline and 2, 5, 7, and 9 minutes after solution administration. Repeated-measures analysis of variance examined between-group differences and within-subject variability of treatment effect on overall pain scores. RESULTS: Two- and 4-month-old infants receiving oral sucrose (n = 38) displayed reductions in pain scores 2 minutes after solution administration compared with 2- and 4-month-old infants in the placebo group (n = 45). Between-group comparisons for the oral sucrose and placebo groups showed lower pain responses at 5, 7, and 9 minutes after solution administration. The oral sucrose and placebo groups demonstrated their highest mean pain score at 7 minutes, with a mean pain score of 3.8 and 4.8, respectively. At 9 minutes, the placebo group had a mean pain score of 2.91 whereas the mean pain score for the oral sucrose group returned to near baseline, reflecting a 78.5% difference in mean pain score (oral sucrose - placebo) relative to the placebo mean. CONCLUSIONS: Oral sucrose is an effective, easy-to-administer, short-acting analgesic for use during routine immunizations.