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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 3  |  Page : 175-185

Nurses’ perception about pain assessment and management in neonatal intensive care units


1 Department of Pediatric Nursing, Faculty of Nursing, Cairo University, Cairo, Egypt
2 Department of Pediatric Nursing, Faculty of Medicine, Cairo University, Cairo, Egypt
3 Department of Neonatology, Faculty of Medicine, Cairo University, Cairo, Egypt

Date of Submission11-Mar-2020
Date of Decision05-Apr-2020
Date of Acceptance19-Apr-2020
Date of Web Publication20-Aug-2020

Correspondence Address:
Nour R Adam
Faculty of Nursing, Cairo University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_8_20

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  Abstract 


Background Pain assessment in high-risk neonates is highly challenging. In the clinical setting, neonates’ pain responses have to be observed and assessed using behavioral and physiological indicators, which can vary across premature infants and full-term infants, depending on their physiological and neurological development stages.
Aim To assess nurses’ perception about pain assessment and management in neonatal intensive care units (NICUs).
Patients and methods A descriptive exploratory research design was used on a convenient sample consisted of 60 nurses who were working in four NICUs in Cairo University Hospitals. Nurses’ perception about pain assessment and management in NICUs questionnaire was used, which included four parts regarding personal data, nurses’ perception about pain assessment, management, and barriers in NICUs.
Results Most of the nurses had high perception level about pain assessment, management, and barriers in NICUs, and the minority of the nurses had moderate perception level. There was a statistically significant relation between nurses’ perception level and their age, nursing qualifications, and years of experience.
Conclusion The results of the current study concluded that most of the NICU nurses had high perception level about pain assessment, management, and barriers. Major barriers that face nurses in NICUs include lack of time in relation to high work load, shortage of nursing staff, and lack of medication supplies.
Recommendations It is recommended to implement training programs for new nurses about neonatal pain assessment and management in all NICUs during the orientation period. Neonatal pain assessment tool should be available in all NICUs.

Keywords: barriers, high-risk neonates, nurses’ perception, pain assessment


How to cite this article:
Adam NR, Dabash SH, Hassan EF, Daihoum TH. Nurses’ perception about pain assessment and management in neonatal intensive care units. Egypt Nurs J 2019;16:175-85

How to cite this URL:
Adam NR, Dabash SH, Hassan EF, Daihoum TH. Nurses’ perception about pain assessment and management in neonatal intensive care units. Egypt Nurs J [serial online] 2019 [cited 2020 Sep 30];16:175-85. Available from: http://www.enj.eg.net/text.asp?2019/16/3/175/292500




  Introduction Top


Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage (International Association for the Study of Pain, 2017). Pain has been recognized as the ‘fifth vital sign’ that should be routinely monitored in the clinical examination (Cong et al., 2013). Continuous pain may be defined as pain lasting beyond the initial episode that causes tissue injury, mucosal stimulation, or inflammation. Attempts to define chronic or continuous pain in newborns have not led to consistent or clinically useful definitions. Identifying continuous pain is important, because it may interfere with infant growth, prolong hospitalization, alter subsequent pain perception, and impair cognitive and behavioral development (Osman et al., 2015).

High-risk neonates respond with behavioral and physiologic changes to acute pain, but they differ from term-born infants because of neurological immaturity: their reactions may be less noticeable than those of a full-term baby, or completely absent. Pain assessment in infants has been recognized to be ineffective. However, nurses’ attitudes and perceptions of this topic in the neonatal intensive care have not been widely published within the nursing science. Neonates in the neonatal intensive care unit (NICU) experience a multitude of acute and chronic painful events (Holsti et al., 2014).

Pain assessment should be comprehensive and multidimensional and include the contextual, behavioral, and physiologic indicators available to the bedside nurses. Clinical pain assessment in high-risk neonates is highly challenging. In the clinical setting, neonates’ pain responses have to be observed and assessed using behavioral and physiological indicators, which can vary across premature infants and full-term infants depending on their physiological and neurological development stages. Behavioral indicators used as pain assessment tools include body movements, facial expressions, and crying. Some pain assessments also include behavior status indicators, for example, sleep-wake state. Physiological responses to pain include, for instance, changes in heart rate, respiratory rate, blood pressure, oxygen saturation, vagal tone, and peripheral blood flow (Brummelte et al., 2014).

Procedural pain can be alleviated by pharmacological and/or nonpharmacological methods. Pharmacological methods of pain control include topical anesthetic, opioid analgesic (e.g. fentanyl and morphine), and nonopioid analgesic (e.g. acetaminophen) medications (Ohlsson and Shah, 2016). Nonpharmacological methods of pain control include oral sucrose, non-nutritive sucking, facilitated tucking, swaddling, kangaroo care, and breastfeeding or expressed breast milk. The multimodal treatment of pain combines pharmacological and nonpharmacological techniques in a safe and planned manner according to the personal need. It therefore requires observation of the baby’s physiological parameters and behavior (Stevens et al., 2016; Peng, 2017).

Nurses play a vital role in the neonates’ pain assessment. The nurses’ goal of pain assessment in neonates is to minimize the experience of pain and maximize the neonate’s capacity to cope with and recover from the many painful procedures in the NICU. The nurses must maintain a balance between pain relief and adverse effects of analgesics. This requires that the nurses have knowledge. Each nurse should complete the following head-to-toe assessment for high-risk neonates. Nurses should be responsible toward documentation of pain assessment intensity at least every 8–12 h. Nurses must observe physical characteristics such as color, muscle tone, perfusion, oxygen saturation, heart rate, and blood pressure during invasive procedure to determine pain intensity. Nurses must observe neonates’ adverse reaction to noise or handling. Nurses should assess neurobehavioral activity related to the degree of pain (Klaus et al., 2013).

Nurses must use an appropriate neonatal assessment pain tool according to the gestational age, sex, and type of pain. Nurses’ assessment of neonatal pain must be continuous during their duties and must be dynamic. The nurses must have a knowledge of the developmental stages of premature infants based on the gestational age and how this can affect the infants’ response to pain. Every neonate should have a unique set of care protocols, and the nurse must assess how well each neonate can tolerate each nursing procedure and decide what methods can be used to provide the most comfort with the least harm. With the amount of procedures each neonate in the NICU undergoes pain management (Lopez et al., 2015).

Nurses are the primary advocates for premature and critically ill neonates’ rights to adequate pain management. Neonatal nurses play a major role as a protector to neonates from prolonged pain sensation (Khoza and Tjale, 2014). Nurses are also responsible to find an effective pain management method, either pharmacological or nonpharmacological. NICU nurses must implement a strong evidence-based measurement tool to reflect accurate pain assessment to ensure optimal pain management. NICU nurses must anticipate problems and systematically evaluate the management especially pain. Nurses act as a nurturer to premature and full-term infants in NICUs (Byrd et al., 2014).

Nurses act as supporters of premature infants who spend a lot of time with them. Nurses play an important role in providing developmental care to high-risk neonates in NICUs to create a safe environment that reduces noxious stimuli, promotes positive development, and minimizes the negative effects of pain, through therapeutic handling, relaxation by tactile massage, and clustering care. Nurses play a key role in enabling and facilitating parental proximity and involvement, as well as parent–infant reciprocity, and in caregiving. Moreover, many nurses report that they believe that parents have an important role and can be effective in infant pain management (Abdel Razeq and Akuma, 2016).

The nurses’ perceptions regarding pain in neonates may have an important role in the assessment of pain and medication administration practices. The nurse may be influenced by any number of items, including the nurses’ age, educational background, and years of experience working with neonates, one’s own experience of pain, and actual knowledge of interventions employed in the treatment of pain. Many health care providers also at least subconsciously believe that they, rather than the child, can accurately judge child’s pain experience. They may attribute a child’s distractibility to the absence of pain. This perception represents a misunderstanding of the powerful roles of distraction and comforting in the attenuation or relief of pain (Ternullo, 2015).

Significance of the study

Research has continued to demonstrate that neonates can detect, process, and respond to painful stimuli, and preterm infants may actually have a 30–50% lower pain threshold than adults and a lower pain tolerance than older children. Excessive and prolonged unrelieved pain in neonates can cause adverse physiologic effects in all major organ systems, including brain structure, can be life-threatening, and can have long-term cumulative outcomes. In spite of the fast growth of knowledge and the development of pain assessment tools and management guidelines, neonatal infant pain remains unrecognized and undertreated adequately, because there are gaps between pain knowledge, evidence, and practice among neonatal nurses, which need to be addressed (American Academy of Pediatrics, Canadian Pediatric Society and Fetus and Newborn Committee, 2016).

Nurses are the most consistent caregivers for the neonates; their pain assessment skills and the relevant practices are critical for this vulnerable population. The number of studies investigating the perception of the health care providers about neonatal pain assessment and management is limited (Cong et al., 2014). It is critical that nurses are able to recognize a neonate’s pain using appropriate pain tools, which is the first step toward effective pain relief (Byrd et al., 2014). The outcomes of this study will enhance the development of guidelines for routine assessment by nurses of high-risk neonates with pain. The nursing role in ensuring holistic care and attention to problems of most concern to high-risk neonates could be strengthened. Moreover, this ensures physical and emotional well-being of high-risk neonates and provides evidence-based practice research that can develop nursing practice and research in the field of high-risk neonates.


  Patients and methods Top


Aim

The aim is to assess nurses’ perception about pain assessment and management in NICUs.

Research questions

What is nurses’ perception about pain assessment in NICUs?

What is nurses’ perception about pain management in NICUs?

What are the barriers that affecting nurses in assessing and managing pain in NICUs?

Research design

A descriptive exploratory research design was used to carry out the study. It is a research designed to gain more information about characteristics in a particular field of study. It provides a picture of a situation as it naturally happened, describes what exists, provides insights to the researcher, provides details where a small amount of information exists, establishes priorities, determines the frequency with which something occurs, and categorizes information without manipulation of variables (Grove et al., 2015).

Setting

The current study was conducted at the four NICUs. The first NICU is allocated on fifth floor of the Cairo University Specialized Pediatric Hospital. The second NICU is allocated on the third floor of Pediatric University Hospital (El Monira Hospital). The third and the fourth NICUs are allocated on the fourth floor of New Hospital of Maternity at Cairo University (Kasr El Ini). All of these units receive neonates from all over Egypt, and provide their services free of cost.

Patients

A convenience sample of all nurses (about 60 nurses) who worked in the aforementioned NICUs was taken.

Study tool

The study was the nurses’ perception about neonatal pain assessment and management questionnaire. It was developed by the researchers after reviewing the literature. It was prepared in simple Arabic language to assess nurses’ perception about neonatal pain assessment and management in NICUs. It is based on a five-point Likert scale and includes four parts:

Part I: personal and professional data about sex, age, educational level, years of experience, and attending training programs about neonatal pain assessment and management in NICUs.

Part II: nurses’ perception about pain assessment in NICUs. It includes 26 statements about perception of knowledge about pain, signs of neonatal pain, tolerance of pain, and pain assessment tool.

Part III: nurses’ perception about pain management in NICUs. It includes nine statements about the use of both approaches of pharmacological and nonpharmacological pain management and the effect of nonpharmacological approach such as massage, non-nutritive sucking, and changing position of neonate to decrease pain.

Part VI: barriers of pain assessment and management in NICUs. It includes nine statements about attending training courses of neonatal pain assessment and management during orientation of work, work load, and shortage of nursing staff.

Scoring system

Each question was scored from one to five according to the following levels: strongly agree [five score, agree (4), neutral (3), disagree (2), and strongly disagree (1)]. The total score of the questionnaire equals 220 marks and covered 44 items. It was categorized as follows: 44–88, low perception level; 89–132, moderate perception level; and 133–220, high perception level.

Tool validity

The tool was submitted to a panel of two experts in the field of pediatric nursing and one expert in the field of psychiatric nursing to test the content validity. Modifications of the tool were done according to the panel’s judgment on clarity of sentences and appropriateness of the content.

Tool reliability

Reliability of the tool was tested by using items’ analysis. It was tested to assess the internal consistency of the developed tool by Cronbach’s alpha. It is referred to the consistency, stability, and repeatability of the result. The results of the research tool for parts ІІ, ІІІ, and VІ were 0.843, 0.743, and 0.959, respectively, and it was considered reliable, because consistent results had been obtained in identical situations but different circumstances.

Procedure

An official approval was obtained from NICU administrators regarding the study settings to carry out the study. A clear explanation was given about nature, importance, and expected outcomes of the study to the nurses to gain their cooperation. The principal researcher met the nurses at NICUs of Cairo University Specialized Pediatric Hospital, Pediatric University Hospital, and New Hospital of Maternity at Cairo University where they were working, through the three shifts, during their break time. The principal researcher introduced herself to the nurses and distributed the study tool to the nurses individually, and asked each nurse to fulfill the nurse’ perception about pain assessment and management questionnaire, in the presence of the researcher. The time consumed to answer the questionnaire ranged from 15 to 20 min. The data were collected from July to September 2018.

Pilot study

A pilot study was carried out on 10% of the study sample (about six nurses) who agreed to participate in the study and working in the four NICUs of Cairo University Hospitals to test the applicability and clarity of the tool, to estimate the time needed to fill the study tool and to add or omit questions. No addition or omission was done, and the pilot nurses were involved in the study sample.

Ethical consideration

A primary and final approval was obtained from the research ethical committee in the Faculty of Nursing, Cairo University. An informed written consent was obtained from each participating nurse after explanation of purpose, the nature, and benefits of the study. Nurses who agreed to participate in the study were assured that all data gathered during the study will be confidential. They were informed that participation is voluntary. Moreover, they were assured that they have the right to withdraw at any time from the study. Each assessment sheet was coded, and nurses’ names did not appear on the sheets for the purpose of anonymity and confidentiality.

Statistical analysis

A compatible personal computer was used to store and analyze data and to produce graphic presentations for some important results. Statistical package for the social studies, version 20 (SPSS is a program for statisitics analysis, first used at 1960 and used in USA at 1970 by David Muxworthy) was used for statistical analysis of data. Descriptive statistics including frequencies and percentages for quantitative data were presented as mean±SD values. χ2 test was conducted, and correlation between nurses’ perception and personal characteristics was done. P value less than 0.05 was considered significant.


  Results Top


[Table 1] shows that nearly three-quarters of the nurses (71.7%) were females and 28.3% were males. As observed from [Table 1], the mean age of the nurses was 29.6±8.4 years, and among 65%, their age ranged from 20 to 29 years. Regarding nursing qualifications, one-third of the nurses had diploma in nursing (33.3%), and their mean years of experience was 7.4±8.2.
Table 1 Nurses’ characteristics in percentage distribution (N=60)

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It is obvious from [Table 2] that half (50%) of the nurses strongly agreed about pain affects physiological status of the neonates, and 1.67% of them strongly disagreed. Moreover, more than half (60%) of the nurses strongly agreed that pain decreases oxygen saturation in the blood, unlike the minority of them (3.33%) who disagreed. More than half (60%) of studied nurses strongly agreed that pain increases heart rate and 3.33% of the nurses disagreed. One-third (33.33%) of the nurses strongly agreed that pain increases blood pressure, and the minority of them (5%) strongly disagreed. Regarding indication of pain by rapid respiration, dilated pupils, flushed face, and cyanosis of nails and lips, less than half of the nurses (43.33%) strongly agreed, whereas the minority of them strongly disagreed (1.67, 1.67, 3.33, and 5%, respectively).
Table 2 Nurses’ perception about neonatal physiological changes as indicating pain in percentage distribution (N=60)

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[Table 3] indicates that more than half (51.67%) of the nurses strongly agreed that pain affects psychological status of the neonates, whereas 6.67% of them strongly disagreed. More than one-quarter (28.33%) of the nurses disagreed that pain affects behavior of the neonates, and a minority of them (13.33%) agreed. More than two-fifths (43.33%) of the nurses strongly disagreed, whereas 10% of them strongly agree that pain increases intensity of crying. More than half (53.33%) of the nurses strongly agreed that pain increases sleeping hours, whereas the minority of them (6.67%) strongly disagreed. In addition, [Table 3] shows that two-fifths (40%) of the nurses strongly agreed that crying is a facial expression sign that indicated pain, whereas 6.67% strongly disagree. More than half (58.33%) of the nurses strongly agreed that crying is a vocal sign of pain in neonates, whereas 1.67% strongly disagreed. Two-fifths (40%) of the nurses strongly agreed that neonates flex arms and legs during pain sensation, whereas 6.67% of them strongly disagreed.
Table 3 Nurses’ perception about neonatal psychological and behavioral changes as indicating pain in percentage distribution (N=60)

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It is clear from [Table 4] that 40% of the nurses strongly agreed that pharmacological medications are available in the unit and 3.33% of them disagreed. More than two-fifths (43.33%) of the nurses strongly agreed that pharmacological management decreases the intensity of pain for the neonates, whereas the minority of them (1.67%) strongly disagreed. Less than two-fifths (36.67%) of the nurses strongly agreed that nonpharmacological methods are applied by nurses in the NICUs, whereas 5% of them strongly disagreed. Regarding sucking decreases pain intensity, more than half (53.33%) of the nurses strongly agreed, whereas a minority of them (3.33%) disagreed.
Table 4 Nurses’ perception about pain management in neonatal intensive care units in percentage distribution (N=60)

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In relation to massage decreases pain intensity for the neonates, less than half (48.33%) strongly agreed and 3.33% of them strongly disagreed. Regarding changing position decreases pain intensity, more than half (53.33%) of the nurses strongly agreed and 1.67% of them strongly disagreed. Concerning guidelines/protocols of pain being comprehensive and clear, more than one-quarter (30%) of nurses had a neutral response, whereas the minority of them (10%) strongly disagreed. More than one-third (36.67%) of the nurses strongly agreed that they follow a protocol of care, whereas 5% of them strongly disagreed.

Apparently, [Table 5] shows that more than three-quarters (76.67%) of the nurses strongly agreed that lack of time in relation to high workloads is a barrier of neonatal pain assessment and management in NICUs, and 1.67% of them responded as neutral. Less than two-thirds (65%) of the nurses strongly agreed that shortage of nursing staff is a barrier of neonatal pain assessment and management, whereas a minority (1.67%) of the nurses strongly disagreed. More than half (55%) of the nurses strongly agreed that lack of medication supplies is a barrier of neonatal pain assessment and management, whereas a minority (3.33%) of the nurses responded as neutral. Regarding the lack of nurses’ knowledge about pain signs, half of the nurses (50%) strongly agreed, whereas 1.67% disagreed. Less than half of the nurses (46.67%) strongly agreed that lack of knowledge about pain assessment tool is a barrier of neonatal pain assessment and management, whereas a minority of them (3.33%) disagreed.
Table 5 Barriers of pain assessment and management in neonatal intensive care units in percentage distribution (N=60)

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In addition, more than half of the nurses (53.33%) strongly agreed that lack of nurses’ understanding of pain assessment tool is a barrier of neonatal pain assessment and management, whereas 3.33% of them strongly disagreed. More than half of the nurses strongly agreed that insufficient application of pain assessment tool and pain assessment is a routine care (60% each), whereas a minority of the nurses (1.67 and 3.33%, respectively) strongly disagreed. Moreover, more than two-thirds (71.67%) of the nurses strongly agreed that no-evaluation to the degree of pain, whereas 15% of the nurses disagreed.

[Table 6] reveals that regarding the nurses’ perception about neonatal pain assessment, less than two-fifths (38.3%) of the nurses strongly agreed, whereas a minority of nurses (11.7%) strongly disagreed, with a mean score of 3.88±0.54. Regarding nurses’ perception about pain management, more than two-fifths (41.7%) of the nurses strongly agreed and 6.7% disagreed, with mean score of 3.96±0.66. More than half (60%) of the nurses strongly agreed about barriers of pain assessment and management, whereas 6.7% of nurses strongly disagreed, with a mean score of 4.32±0.80.
Table 6 Total mean score of nurses’ perception about pain assessment, management and barriers in neonatal intensive care units in percentage distribution (N=60)

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[Figure 1] illustrates that more than one-quarter of the nurses (76.6%) had high perception level about pain assessment, management, and barriers in NICUs, and 23% had moderate perception level.
Figure 1 Percentage distribution of the nurses according to their perception levels.

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[Table 7] shows that there was a statistically significant relation between sex and their perception level (c2=4.29, P=0.03), and there was a highly statistically significant relation between their perception level and age, nursing qualification, and years of experience (c2=32.6, 17.9, 41.1, respectively, P<0.0001).
Table 7 Relation between nurses’ characteristics and their perception level about pain assessment and management (N=60)

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  Discussion Top


The result of the study revealed that most nurses were females. Regarding nurses’ age, less than two-third of the nurses’ age ranged between 20 and 29 years. This result was in line with Razeq et al. (2016), who conducted an assessment about pain management perceptions of the neonatal nurses in NICUs and neonatal units in Ardebil and reported that more than two-fifths of the nurses aged less than 30 years. The study results were contradicted by Cong et al. (2013), who conducted an assessment study about neonatal nurses’ perceptions of pain assessment and management in NICUs and reported that more than half of nurses’ age was more than 51 years.

The National Association of Neonatal Nurses (NANN, 2016) recommended that nurses who are working in NICUs must be graduated from college to be prepared for a highly qualified care. Findings of the current study revealed that one-third of the nurses had diploma. These results were in contradiction to Razeq et al. (2016), who found that most nurses had bachelors of nursing.

Concerning nursing experiences in NICUs, the study revealed that more than half of the nurses had experience ranging from 0 to 4 years in NICUs. These results were matched with Akuma and Abdel Razek (2017), who studied assessment about status of neonatal pain assessment and management in Jordan and found that the highest percentage of nurses working in NICUs had years of experience ranging from 1 to 5 years. This result was contraindicated by Rochefort et al. (2016), who conducted a study titled ‘Rationing of nursing care interventions and its association with nurse-reported outcomes in the NICU: a cross-sectional survey,’ and stated that the highest percentage of nurses working in NICUs had more than 11 years of experience.

Regarding physiological signs that indicated pain, Hockenberry and Wilson (2019) stated that evaluation of pain assessment in neonates must be based on physiological changes such as increased heart rate, increased blood pressure, rapid and shallow respirations, decreased transcutaneous oxygen saturation, and dilated pupils. Results of the current study revealed that more than half of the nurses strongly agreed that pain affected physiological status, such as increase in heart rate, increase in blood pressure, rapid respiration, decrease in oxygen saturation in the blood, dilated pupils, flushed face, and cyanosis of nails and lips.

The same explanation was mentioned by Nicholson et al. (2014), who evaluated the effect of music therapy to promote positive parenting and child development and concluded that pain affects physiological status such as heart rate, blood pressure, irregular breathing, decreased blood oxygen, intraocular pressure, acidosis, and increased blood glucose. Moreover, the study results are supported by Montirosso et al. (2017), who conducted a study titled ‘Promoting neuroprotective care in NICUs and preterm infant development: insights for the neonatal adequate care for the quality of life study’ and illustrated that the immediate physiologic stress response can cause fluctuations in heart rate, blood pressure, respiratory rate, and intracranial pressure, causing medical instability in the infant and an increased risk of intraventricular hemorrhage. The result of the current study was contradicted by Aymar et al. (2014), who conducted a study titled ‘Pain assessment and management in the NICU: analysis of an educational intervention for health professionals’ and explained that caregivers reported that pain did not affect vital signs.

The results of the present study showed that more than half of the nurses strongly agreed that pain affected behavioral and psychological status of neonates, increased sleeping hours, crying is a facial expression sign, crying is a vocal sign of pain, and neonates flex arms and legs during sensation of pain. This finding was supported by Hockenberry and Wilson (2019), who stated that pain affected behavioral responses such as facial expression, observe characteristics, timing, orientation of eyes and mouth, body movements and posture, observe type, quality, and amount of movement or lack of movement. Moreover, the findings were consistent with DiLorenzo et al. (2018), who conducted a study titled ‘Infant clinical pain assessment: core behavioral cues’ and found that pain changes behavior such as crying/moaning, state of arousal/alertness, arm movements, leg movements, facial expressions in general, and specific facial expressions, for example, brow bulge, eye squeeze, naso-labial furrow.

Concerning neonatal pain management, Canadian Pediatric Society Fetus and Newborn Committee (AAPSSCPSFNC) et al. (2016) reported that neonates may experience pain as a result of surgery, injuries, acute and chronic illnesses, and medical or surgical procedures. Improving pain management requires a multifactorial approach, encompassing education, institutional support, attitude shifts, change leaders, and needs multiapproach for management pharmacological management such as anesthetic, analgesics, and opiates, and nonpharmacological management, such as non-nutritive sucking with glucose, swaddling, skin to skin care, massage, and positioning.

The results of the present study were in accordance with the aforementioned empirical evidence and demonstrated that more than two-fifths of the nurses strongly agreed that pharmacological and nonpharmacological procedures were available in NICUs, and it decreases pain intensity in neonates. In the same line, Gao et al. (2015) conducted a study titled ‘Effect of repeated kangaroo mother care on repeated procedural pain in preterm infants: a randomized controlled trial’ and found that nurses strongly agreed that pharmacological and nonpharmacological management methods were necessary in NICUs. The current study contradicted Pillai Riddell et al. (2015), who conducted a study titled ‘Nonpharmacological management of infant and young child procedural pain’ and confirmed that the application of nonpharmacological pain management interventions was not always optimal in NICUs.

The current study revealed that nurses strongly agreed that nonpharmacological management such as non-nutritive sucking, massage, and change position decreased neonatal pain in NICUs. This is in the same line with Abdellah et al. (2019), who conducted a study titled ‘Effect of educational program on pediatric nurses’ knowledge and practice regarding selected nonpharmacological techniques to relieve pain in neonates in Minia’ and illustrated that nonpharmacological methods are important in relieving pain in neonates such as non-nutritive sucking, kangaroo care, swaddling, rocking, and holding. In addition, Clifford-Faugere et al. (2019) conducted a study titled ‘Nurses’ practices regarding procedural pain management of preterm infants’ and confirmed that mixing between nonpharmacological and pharmacological methods was very important in reaching optimal pain relief and not only the pharmacological method. The findings contradicted with Mahrnoush (2016), who reported that more than three-quarters of the nurses strongly disagreed that pharmacological and nonpharmacological management was not necessary in pain relief in NICUs. From the researcher point of view, nonpharmacological and pharmacological methods are necessary for relief pain and enhance physiological and psychological outcomes and should be applied in all NICUs.

Regarding guidelines/protocols of pain, Jeong et al. (2014) conducted a study titled ‘Perceptions on pain management among Korean nurses in NICUs’ and reported that vast majority of the nurses strongly agreed that guidelines and protocols of pain management in NICUs were comprehensive, clear, and available in their NICUs. These findings support the current study that more than two-fifths of the nurses agreed that guidelines and protocols of pain management in NICUs were comprehensive and clear. The researcher observed that guidelines/protocols of pain assessment and management were set and applied in NICUs.

The findings contradicted with Cong et al. (2014) who reported that the protocols were unclear, but were based on a new research evidence. It is also noticed that less than two-fifths of the nurses strongly agreed that neonates had required their own guidelines and protocols of pain management. In addition, Priscah and Mukami (2018) studied factors influencing postoperative pain management among neonates and reported that health care providers stated that there were no set guidelines and pain assessment tools in place at the NICUs.According to Sharek et al. (2016) who conducted a study titled ‘Evaluation and development of potentially better practices to improve pain management of neonates’ and stated that bedside nurses make global pain assessments or apply validated pain assessment tools before treating a newborn’s pain or discomfort, but NICU workloads may not allow bedside nurses to assess pain regularly. Many factors can influence the management of pain; poor pain care is not the result of lack of evidence, but it is more likely professional and organizational factors that limit the use of pain relieving methods.

The factors influencing the use of nonpharmacological methods in neonates include nurses’ characteristics (age, education, and work experience). However, we have a lack of knowledge on the factors associated with pain management among neonates in the NICUs. Guidelines for how to assess and manage pain may also have an influence in practice, and it was demonstrated that pain assessment and analgesic therapy were more frequently performed if written guidelines for pain management were available in the units (Marialda et al., 2019).

The present study detected that barriers included high work load, shortage of nurses, lack of knowledge, the absence of pain protocols, lack of time, and lack of trust in the pain assessment tools. The results of the present study were in accordance to the aforementioned empirical evidences and illustrated that more than half of the nurses strongly agreed that time and work load, shortage of staff, medication supplies, knowledge about pain signs, knowledge about pain assessment tool, understanding of pain assessment tool, insufficient application of pain assessment tool, pain assessment was a routinely care in the NICUs, and nonevaluation to the degree of pain were barriers of neonatal pain assessment and management in NICUs.

The current study illustrated that more than one-quarter of the nurses had high perception level about pain assessment, management and barriers in NICUs, and this finding is consistent with Cong and Mehrnoush (2013, 2016), who reported that most nurses were agreed that nurses had high perception level about pain assessment and management in NICUs.


  Conclusion and recommendation Top


The results of the current study concluded that more than one-quarter of the NICUs’ nurses had high perception level about pain assessment, management and barriers. Moreover, the study findings found that the major barriers to effective pain assessment and management that face nurses in NICUs included lack of time in relation to the high work load, shortage of nursing staff, and lack of medication supplies. The study recommends implementing training program for new nurses about neonatal pain assessment and management in all NICUs during the orientation period, as well as periodical training programs about neonatal pain assessment and management for nursing staff. Moreover, neonatal pain assessment tool should be available in all NICUs, and the barriers facing nurses should be resolved.[35]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abdellah FM, Mahmoud SE, Abd-Elaziz E, Mohamed N (2019). Studied effect of educational program on pediatric nurses’ knowledge and practice regarding selected non-pharmacological techniques to relive pain in neonates in Minia. J Neonat Nurs 25:285–292.  Back to cited text no. 1
    
2.
Akuma O, Abdel Razek MN (2017). Status of neonatal pain assessment and management in Jordan. The American Society for Pain Management Nursing. Pain Manage Nurs 17:239–248.  Back to cited text no. 2
    
3.
American Academy of Pediatrics Section on Surgery; Canadian Pediatric Society Fetus and Newborn Committee (AAPSSCPSFNC), Batton DG, Barrington KJ, Wallman C (2016). In chapter of discussion. Pediatrics 118:2231–2241.  Back to cited text no. 3
    
4.
American Academy of Pediatrics, surgery section and anesthesiology and pain medicine, Candidian Pediatric society and fetus and newborn committee (2016, Februrary). Prevention and management of procedural pain in the neonate: an update. Pediatrics 137:20152035. Retrieved from https://www.aappublications.org/news.doi:10.1542/pedd.2015.4271  Back to cited text no. 4
    
5.
Aymar CLG, Lima LS, Santos CM, Moreno AC (2014). Pain assessment and management in the NICU: analysis of an educational intervention for health professionals. J Pediatr 90:308–315.  Back to cited text no. 5
    
6.
Brummelte S, Oberlander TF, Craig KD (2014). Biomarkers of pain: physiological indices of pain reactivity in infants and children. Oxford textbook of pediatric pain. Oxford: Oxford University Press. 30:391–400.  Back to cited text no. 6
    
7.
Byrd PJ, Gonzales I, Parsons V (2014). Exploring barriers to pain management in newborn intensive care units: a pilot survey of NICU nurses. Adv Neonatal Care 9:299–306.  Back to cited text no. 7
    
8.
Clifford-Faugere G, Aita M, May S (2019). Nurses’ practices regarding procedural pain management of preterm infants. Appl Nurs Res 45:52–54.  Back to cited text no. 8
    
9.
Cong X, Delaney C, Vazquez V (2013). Neonatal nurses’ perceptions of pain assessment and management in NICUs: a national survey. Adv Neonatal Care 13:353–360.  Back to cited text no. 9
    
10.
Cong X, McGrath JM, Delaney C, Chen H, Liang S, Vazquez V et al. (2014). Neonatal nurses’ perceptions of pain management: survey of the United States and China. Pain Manage Nurs 15:834–844.  Back to cited text no. 10
    
11.
DiLorenzo MG, Pillai Riddell R, David BF, Craig DK (2018). Infant clinical pain assessment: core behavioral cues. J Pain 19:1024–1032.  Back to cited text no. 11
    
12.
Gao H, Xu G, Gao H, Dong R, Fu H, Wang D, Zhang H (2015). Effect of repeated Kangaroo Mother Care on repeated procedural pain in preterm infants: a randomized controlled trial. Int J Nurs Stud 52:1157–1165.  Back to cited text no. 12
    
13.
Grove SK, Gray JR, Burns N (2015). Understanding nurses research: building an evidence-based practice, 6th ed. Canada: Elsevier. 460–467.  Back to cited text no. 13
    
14.
Hockenberry M, Wilson D (2019). Wong’s essentials of pediatric nursing. 12th ed. Missouri, USA: Mosby. 158–160.  Back to cited text no. 14
    
15.
Holsti L, Grunau RE, Oberlander TF, Whitfield MF (2014). Specific newborn individualized developmental care and assessment program movements are associated with acute pain in preterm infants in the neonatal intensive care unit. Pediatrics 114:65–72.  Back to cited text no. 15
    
16.
International Association for the Study of Pain. (2017). IASP taxonomy. Available at: www.iasp-pain.org/Taxonomy?navItem. [Accessed March 18, 2017].  Back to cited text no. 16
    
17.
Jeong IS, Park SM, Jeon ML, Yoon JC, Joohyun L (2014). Perceptions on pain management among Korean nurses in neonatal intensive care units. Asian Nurs Res 8:261–266.  Back to cited text no. 17
    
18.
Khoza SL, Tjale A (2014). Knowledge, attitudes and practices of neonatal staff concerning neonatal pain management. Curationis 37:1–9.  Back to cited text no. 18
    
19.
Klaus H, Fanaroff A, Fanaroff J (2013). Care of the high-risk neonate. 6th ed. Elsevier. 232–235.  Back to cited text no. 19
    
20.
Lopez O, Subramanian P, Rahmat N, Theam LC, Chinna K, Rosli R (2015). the effect of facilitated tucking on procedural pain control among premature babies. J Clin Nurs 24:183–191.  Back to cited text no. 20
    
21.
Marialda M, Danielle C, Ana LuizaDorneles da Silveira LQ, Bruna N, Magesti BN, Monteiro AL, Gomes AM, Coelho AC, da Silva S (2019). Health professionals’ barriers in the management, evaluation, and treatment of neonatal pain. Brazilian J Pain 2:2595–3192.  Back to cited text no. 21
    
22.
Mehrnoush N, Ashktorab T, Heidarzadeh M, Momenzadeh S, Khalafi J (2016). Pain management perceptions of the neonatal nurses in NICUs and neonatal units in Ardebil. Iranian J Neonatol 7:23–29.  Back to cited text no. 22
    
23.
Montirosso R, Tronic ED, Borgatti R (2017). Promoting neuro protective care in neonatal intensive care units and preterm infant development: insights from the neonatal adequate care for quality of life study. Child Dev Persp 11:9–15.  Back to cited text no. 23
    
24.
National Association of Neonatal Nurses (NANN). (2016). Issues in neonatal nursing care. Available at: http://www.nannp.org. [Accessed February 15, 2019].  Back to cited text no. 24
    
25.
Nicholson JM, Berthelsen D, Abad V, Williams K, Bradley J (2014). Impact of music therapy to promote positive parenting and child development. J Health Psychol 13:226–238.  Back to cited text no. 25
    
26.
Ohlsson A, Shah PS (2016). Paracetamol (acetaminophen) for prevention or treatment of pain in newborns. Cochrane Database Syst Rev 7:CD011219.  Back to cited text no. 26
    
27.
Osman M, Elsarkawy A, Abd- Hady H (2015). Assessment of pain during application of nasal-continuous positive airway pressure and heated, humidified high- flow nasal cannula in preterm infants. J Perinatol 35:263–267.  Back to cited text no. 27
    
28.
Pillai Riddell RR, Racine NM, Gennis HG, Turcotte K, Uman LS, Horton RE, Losing DM(2015). Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev 5:CD006275, doi:10.1002/14651858.CD006275.  Back to cited text no. 28
    
29.
Ping LH, Ho SM, Leung DY, So WK, Chan CW (2016). A feasibility and efficacy randomized controlling procedural pain in preterm infant. J Clin Nurs 25:482.  Back to cited text no. 29
    
30.
Priscah M, Mukami M (2018). Factors influencing post-operative pain management among neonates at Moi Teaching and Referral Hospital, Kenya. Am J Nurs Sci 7:223–230.  Back to cited text no. 30
    
31.
Razeq NM, Akuma AO, Jordan S (2016). Status of neonatal pain assessment and management in Jordan. Offic J Am Soc Pain Manage Nurse 17:239–348.  Back to cited text no. 31
    
32.
Rochefort CM, Rathwel BA, Clarke SP (2016). Rationing of nursing care interventions and its association with nurse-reported outcomes in the neonatal intensive care unit: a cross-sectional survey. BMC Nurs 1:1–8.  Back to cited text no. 32
    
33.
Sharek PJ, Powers R, Koehn A, Anand KJ (2016) Evaluation and development of potentially better practices to improve pain managementofneonates. Pediatrics 118:78–86.  Back to cited text no. 33
    
34.
Stevens B, Yamada J, Ohlsson A, Haliburton S, Shorkey A (2016). Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev 7:CD001069.  Back to cited text no. 34
    
35.
Ternullo S (2015). Assessment and treatment ofpain in children. US Pharm 40:11–20.  Back to cited text no. 35
    


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