The Complexities of Nurses' Pain Assessment in Hospitalized Preverbal Children.

BACKGROUND: Preverbal children are at increased risk for underassessment of pain. Pain is a social transaction involving the child in pain and the nurse assessor. However, our understanding of the nurse's part in this transaction is limited. AIMS: The aim of this study was to explore nurses' assessment of pain in hospitalized preverbal children based on self-selected clinical examples. DESIGN: Qualitative, descriptive design. SETTINGS: Five different hospital units in Canada and Norway. All units had an observational pain scale for preverbal children available for use. PARTICIPANTS/SUBJECTS: Nurses (N = 22) with ≥1 year experience caring for preverbal children. METHODS: Individual, semistructured interviews. Data were analyzed using inductive thematic analysis. RESULTS: Nurses' assessment of pain in hospitalized preverbal children emerged as a nonlinear complex process incorporating different actions and reflections in response to the child's situation and expression of distress. Information from parents was routinely included in the assessment, although further parental involvement varied considerably. Although each assessment was personalized to the individual child, the nurse used previous experiences to interpret observations of and information from the child and the parents. Few nurses described using structured pain scales, but when used, these scales were included as only one aspect of their overall assessment. CONCLUSIONS: Nurses preferred pain assessment based on clinical judgment and tailored to the individual child. Implementation strategies that aim to integrate structured pain scales with clinical judgment to assess pain may be more likely to succed. Further examination of this approach is warranted.

Health-related quality of life and orthosis use in a Swedish population with arthrogryposis.

BACKGROUND: Joint contractures are the main characteristics for children with arthrogryposis multiplex congenita. Orthoses are often used to enable or facilitate walking. OBJECTIVES: To describe health-related quality of life in children with arthrogryposis multiplex congenita and satisfaction with orthoses in those using orthoses. STUDY DESIGN: Cross-sectional study. METHODS: A total of 33 children with arthrogryposis multiplex congenita participated in the study. Questionnaires were used which measured health-related quality of life (Child Health Questionnaire-Parent Form and EQ-5D youth), mobility and self-care (Paediatric Evaluation of Disability Inventory) and satisfaction with orthoses (Quebec User Evaluation of Satisfaction with Assistive Technology 2.0). Children were divided into groups based on the use of orthoses: Ort-D were dependent on orthoses for walking, Ort-ND used orthoses but were not dependent on them for walking and Non-Ort did not use orthoses. RESULTS: Children with arthrogryposis multiplex congenita had significantly lower Child Health Questionnaire scores in 9 of 12 subscales compared to healthy controls. The children's reported perceived health with EQ-5D youth did not show any difference between children using orthoses or children using only shoes. Paediatric Evaluation of Disability Inventory showed less mobility in Ort-D than in Non-Ort. In total, both orthosis groups were 'quite satisfied' with their orthoses. CONCLUSION: Child Health Questionnaire-physical functioning was lowest in children who were dependent on orthoses (Ort-D) for walking. Both Ort-D and Ort-ND were similar satisfied with their orthoses. Clinical relevance This study contributes to knowledge about health-related quality of life in a group of ambulatory children with arthrogryposis multiplex congenita. For children using orthoses, it is relevant to capture their opinion about their orthoses but a questionnaire specifically for children should be developed.

The measurement properties of pediatric observational pain scales: A systematic review of reviews.

BACKGROUND: Valid observational pain scales are needed to assess pain and ensure sufficient treatment of pain in children that lack the verbal ability to self-report pain. Published reviews attempt to synthesize results from primary studies validating these scales and based on the findings recommendations may be given, for example which pain scales are the most appropriate for use in different pediatric populations. OBJECTIVES: The aims of this review were to describe how systematic reviews have evaluated and recommended observational pain scales for use in children aged 0-18 years and appraise the evidence underlying these recommendations. DESIGN: Systematic review of reviews. DATA SOURCES: The Cochrane Library, PubMed/MEDLINE, CINAHL, Web of Science, and PsychINFO were searched from inception to September 2016. Reference lists and gray literature were searched for additional studies. REVIEW METHODS: Study selection and data extraction were performed by two reviewers independently with a disagreement procedure in place. Methodological quality or study validity was measured using the Assessment of Multiple Systematic Reviews checklist and risk of bias or internal validity was measured using the Risk of Bias in Systematic Reviews tool. The review protocol was registered with PROSPERO: registration number CRD42016035264. RESULTS: Twelve reviews met the inclusion criteria. Together; they included 65 different observational pain scales for use in children, of which 28 were recommended at least once. Face, Legs, Activity, Cry, Consolability/revised version of Face, Legs, Activity, Cry, Consolability, COMFORT/COMFORT behavioral scale and Children's Hospital of Eastern Ontario Pain Scale were evaluated and recommended most frequently. Few of the included reviews assessed the methodological quality of the studies included in the review. The narrative analysis consisted mostly of a reiteration of the results from the primary studies. In general, more recent reviews showed a lower risk of bias than older ones. CONCLUSIONS: Included reviews exhibited low quality of evidence; thus, their recommendations regarding pain scales for use in clinical practice or research with children that lack the verbal ability to self-report pain should be interpreted with caution.

The COMFORT behavioural scale provides a useful assessment of sedation, pain and distress in toddlers undergoing minor elective surgery.

AIM: The COMFORT behavioural scale was developed to assess sedation, pain and distress in children unable to report pain. Our aims were to test construct validity of the scale in toddlers undergoing minor surgery and determine the inter-rater reliability of the scale. METHODS: We consecutively enrolled 45 children aged 12-36 months from a Norwegian surgical outpatient care unit. The level of sedation, pain and distress was assessed before and after surgery with the COMFORT behavioural scale. Inter-rater reliability was estimated and construct validity was tested based on a priori defined hypotheses. A 2.5-point (15%) change in the scale was considered clinically important. RESULTS: We obtained 307 scores covering most of the scale's range, but a floor effect was clearly present. Inter-rater reliability was high between assessors (intraclass correlation coefficient = 0.96; 95% CI 0.92-0.98). Clinically important differences were seen between baseline and light sedation (3.1 points, p < 0.001) and between light and deep sedation (4.6 points, p = 0.002). The difference between baseline and our definition of a pain/distress state was not clinically important (1.5 points, p = 0.039). CONCLUSION: The COMFORT behavioural scale can provide one aspect of an overall clinical assessment of sedation, and probably pain and distress, in toddlers before and after surgery.

Creating an environment for patient safety and teamwork training in the operating theatre: A quasi-experimental study.

INTRODUCTION: Positive safety and a teamwork climate in the training environment may be a precursor for successful teamwork training. This pilot project aimed to implement and test whether a new interdisciplinary and team-based approach would result in a positive training climate in the operating theatre. METHOD: A 3-day educational module for training the complete surgical team of specialist nursing students and residents in safe teamwork skills in an authentic operative theatre, named Co-Op, was implemented in a university hospital. Participants' (n=22) perceptions of the 'safety climate' and the 'teamwork climate', together with their 'readiness for inter-professional learning', were measured to examine if the Co-Op module produced a positive training environment compared with the perceptions of a control group (n=11) attending the conventional curriculum. RESULTS: The participants' perceptions of 'safety climate' and 'teamwork climate' and their 'readiness for inter-professional learning' scores were significantly higher following the Co-Op module compared with their perceptions following the conventional curriculum, and compared with the control group's perceptions following the conventional curriculum. CONCLUSION: The Co-Op module improved 'safety climate' and 'teamwork climate' in the operating theatre, which suggests that a deliberate and designed educational intervention can shape a learning environment as a model for the establishment of a safety culture.

Cultural adaptation of patient and observational outcome measures: a methodological example using the COMFORT behavioral rating scale.

BACKGROUND: There is little empirical evidence regarding the translation and cultural adaptation of self-report and observational outcome measures. Studies that evaluate and further develop existing practices are needed. OBJECTIVES: This study explores the use of cognitive interviews in the translation and cultural adaptation of observational measures, using the COMFORT behavioral scale as an example, and demonstrates a structured approach to the analysis of data from cognitive interviews. The COMFORT behavioral scale is developed for assessment of distress and pain in a pediatric intensive care setting. DESIGN: Qualitative, descriptive methodological study. SETTING: One general public hospital trust in southern Norway. PARTICIPANTS: N=12. Eight nurses, three physicians and one nurse assistant, from different wards and with experience caring for children. METHODS: We translated the COMFORT behavior scale into Norwegian before conducting individual cognitive interviews. Participants first read and then used the translated version of the COMFORT behavioral scale to assess pain based on a 3-min film vignette depicting an infant in pain/distress. Two cognitive interview techniques were applied: Thinking Aloud (TA) during the assessment and Verbal Probing (VP) afterwards. In TA the participant verbalized his/her thought process while completing the COMFORT behavioral scale. During VP the participant responded to specific questions related to understanding of the measure, information recall and the decision process. We audio recorded, transcribed and analyzed interviews using a structured qualitative method (cross-case analysis based on predefined categories and development of a results matrix). RESULTS: Our analysis revealed two categories of problems: (1) Scale problems, warranting a change in the wording of the scale, including (a) translation errors, (b) content not understood as intended, and (c) differences between the original COMFORT scale and the revised COMFORT behavioral scale; and (2) Rater-context problems caused by (a) unfamiliarity with the scale, (b) lack of knowledge and experience, and (c) assessments based on a film vignette. CONCLUSIONS: Cognitive interviews revealed problems with both the translated and the original versions of the scale and suggested solutions that enhanced the validity of both versions. Cognitive interviews might be seen as a complement to current published best practices for translation and cultural adaptation.

Nurses in paediatric care--self-reported professional self and perceived research utilization.

The aim was to describe how nurses in different professional levels evaluated their professional self and perceived barriers to research utilization in paediatric care. The sample consisted of three groups of nurses: control, trainee and specialists (n = 113) employed at two Paediatric University hospitals in Sweden. The control and trainee groups were nurses with a general education and the specialists had a specialist education in paediatric care. The nurses answered the two questionnaires: the Professional Self Description Form (PSDF) and the Barriers Scale. The results showed that the highest scores in the PSDF were found in sensitivity in all the three groups and consideration (in control and specialist group) and creativity (trainee group). The control group scored significantly higher in the item persistence. In the Barriers Scale, the three groups scored the greatest barriers in; 'there is insufficient time on the job to implement new ideas' and 'the nurses do not have time to read research'. The lowest barriers were found in; 'the nurse is unwilling to change/try new ideas' and 'the nurse is unaware of research'. The specialist nurses had significantly higher barriers in; 'the nurse is isolated from knowledgeable colleagues with whom to discuss the research', 'the nurse is unwilling to try new ideas' and 'administration will not allow implementation'. No correlations were found between the PSDF and the Barriers Scale. In conclusion, the self-evaluation of professional self and perceived research utilization showed few differences between the nurses. These findings indicate that the professional self is independent of educational level and work experiences while barriers to research utililization increases with competence and experience.

Professional roles and research utilization in paediatric care: newly graduated nurses experiences.

The aim of the study was to describe and analyse how newly graduated nurses perceive themselves as professionals and their perceptions of barriers to research utilization when starting to work within paediatric care. The nurses were employed in two paediatric university hospitals in Sweden and had been working as staff nurses for 1-3 months. They answered two questionnaires: The Professional Self-Description Form and the Barriers Scale. The results showed that in the assessment of their professional level the highest scores were found in consideration, ambition and sensitivity, and the lowest scores in grasp of ideas, leadership and discrimination. In perceptions of research utilization (Barriers Scale), the items with the most common barriers were 'there is insufficient time on the job to implement new ideas', 'the nurse does not have time to read research' and 'the facilities are inadequate for implementation'. These results indicate that newly graduated nurses seem to be prepared for the nursing profession when it concerns themselves as human individuals but not so prepared for the practice in the real day-to-day work. The most common barriers in the research utilization were connected to the work organization and not to themselves as individuals. The evaluation of professional self, barriers to research utilization and the relationship between these aspects indicates a need for further investigation into the significant meaning of professional self and how this influences the implementation and use of research in everyday work. The results so far also raise the question of how to best support and develop newly graduated nurses in their professional role, to help them to be the highly competent nurses that we need in providing the best and evidence-based care to those who need it.

The opinions of clinical staff regarding neonatal procedural pain in two Norwegian neonatal intensive care units.

AIM: Neonates are subjected to numerous painful procedures without sufficient pain management. The aim of this study was to describe the opinions of Norwegian physicians, nurses and nurse assistants who care for neonates, regarding procedural pain in neonates. METHODS: A replication of a previous questionnaire study was conducted in two Norwegian neonatal intensive care units (NICU's). The questionnaire aimed at evaluating procedure painfulness, the current use of pharmacological agents and comfort measures and the optimal use of both. RESULTS: Ninety members of the clinical staff participated, which is a response rate of 87%. Opinions on how procedural pain is currently and optimally managed differed significantly. Although most respondents rated a majority of the listed procedures as being more than moderately painful, pharmacological agents were rarely used, except for the insertion of a chest tube and endotracheal intubation. Comfort measures were also believed to be underutilized, but not to the same degree as pharmacological agents. CONCLUSION: Procedural pain in neonates is not sufficiently managed and both pharmacological agents and comfort measures are underutilized, according to clinicians at two Norwegian NICU's.

Sensory and affective components of pain as recorded with the Pain-O-Meter (POM) among children with acute and chronic pain.

AIM: To explore the usefulness of the Pain-O-Meter sensory and affective words scale (POM-WDS) with regard to whether children aged 6-16 who suffer from chronic and acute pain know the words and what words they chose to describe their pain. METHODS: Sixty-one children participated, mean age 11 y, suffering from acute pain (n=25) and pain associated with juvenile idiopathic arthritis (JIA, n=36). Children rated their pain intensity on the POM-VAS (visual analogue scale, 0-10 cm). Thereafter, children were asked whether each sensory and affective word on the POM-WDS was known to them, and whether each word described their pain experience. RESULTS: Seventeen out of 23 words were known to at least 70% of the sample. The least recognized word was grinding. Children age 6-16 knew fewer words than the adolescents. Age was a significant determinant for whether the children knew the words grinding (odds ratio (OR) 20.08, p<0.01), gnawing (OR 5.92, p < 0.05), unbearable (OR 8.02, p<0.05), and excruciating (OR 20.17, p<0.001). Terrible (OR 33.3, p<0.05), aching (OR 44.5, p<0.05) and sore (OR 5.4, p<0.05) were selected more often by children with acute pain than with JIA. CONCLUSION: Further studies will be required to determine the suitability of using the POM-WDS with children.