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EMPIRICAL STUDIES doi: 10.1111/scs.

12503

Nurses’ perceptions of pain assessment and management


practices in neonates: a cross-sectional survey

€ lkki RN, PhD (Adjunct Professor)1


Tarja Po , Anne Korhonen RN, PhD (Senior Researcher)2 and
Helena Laukkala MA (Lecturer)3
1
Specialist in Clinical Nursing Science, Unit of Children and Women, Oulu University Hospital, Oulu, Finland, 2Nursing Research
Foundation, Helsinki, Finland and 3Department of Research Methodology, University of Lapland, Rovaniemi, Finland

Scand J Caring Sci; 2017 but many specific facial expressions indicative of pain
were less often observed. Only a few pain assessment
Nurses’ perceptions of pain assessment and
scales were known, and they were not routinely used
management practices in neonates: a cross-sectional
in clinical practice. Most nurses reported using physical
survey
methods and giving oral sucrose along with non-
nutritive sucking. Counselling parents to continue
Aims: This study aimed to describe pain assessment and breastfeeding or guiding them to use skin-to-skin care
management practices for neonates based on nurses’ per- or music was rarely reported as used to alleviate
ceptions in neonatal intensive care units (NICUs). infants’ pain.
Design: A descriptive cross-sectional survey was con- Conclusions: Educational interventions for nurses are
ducted in Finland. needed to improve pain assessment and management
Methods: Of all nurses (N = 422) working in the NICUs in practices in the NICUs. In addition, there is a need for
the country’s five university hospitals, 294 responded to national guidelines in order to ensure the equal treat-
a questionnaire. The data were analysed by statistical ment to all neonates.
methods.
Results: Nurses agreed that pain assessment is important, Keywords: infant, neonatal intensive care units, nurses,
but over half of them reported being able to assess pain assessment, pain management, surveys and
pain in a reliable way without using pain assessment questionnaires.
scales. Physiological parameters and changes in neo-
nate’s behaviour were reported as routinely observed, Submitted 29 May 2017, Accepted 14 June 2017

pain is still under-recognised and under-treated in neo-


Introduction
nates in many countries (4–6). Thus, the scope of this
Advances in technology and treatments have facilitated issue is broad and universal.
the survival of neonates that have been extremely pre- International guidelines state that healthcare providers
mature or whose condition requires intensive care and have the responsibility for prevention, assessment and
monitoring. However, these neonates are exposed to management of pain in all neonates (7). Nurses’ role is
multiple painful procedures during their stay in the crucial for recognising and treating pain in the vulnerable
neonatal intensive care unit (NICU) (1). Many studies patients. However, knowledge of nurses’ current percep-
have reported that repeated and sustained pain in this tions and pain management practices in the care of neo-
vulnerable population has both short- and long-term nates is required to ensure high-quality evidence-based
harmful consequences contributing to altered develop- nursing practices are available and being provided for this
ment of the pain system, behaviour and cognition later vulnerable population.
in life (2, 3). Therefore, researchers and clinicians have
reached an increased awareness about the amount of Pain assessment among neonates is challenging for
pain that sick and premature neonates are experiencing healthcare providers because pain cannot be verbally
during their hospitalisation. Unfortunately, it seems that confirmed by this population of the patients. In these
cases, pain assessment is based on the nurses’ ability to
recognise the pain signs including behavioural and physi-
Correspondence to: cal changes and special facial expressions when the
Tarja P€
olkki, Vainioniementie 41, 90860 Halosenniemi, Finland. patient is experiencing pain. To this day, there are some
E-mail: tarja.polkki@nic.fi pain scales available to assess pain in preterm and full-

© 2017 Nordic College of Caring Science 1


2 T. P€olkki et al.

term infants. The most well-known scales that are valid has been an increase in awareness and use of some non-
and reliable to assess acute pain in infants include NIPS pharmacological methods among neonates in NICUs (27).
(the Neonatal Infant Pain Score) (8), PIPP (the Premature Many factors can influence the management of pain.
Infant Pain Profile) (9), CRIES (Crying, Requires As Latimer et al. (28) argue, poor pain care is not the
increased oxygen, Increased vital signs, Expression, result of lack of evidence, but it is more likely profes-
Sleeplessness) (10), NFCS (the Neonatal Facial Coding sional and organisational factors that limit the use of pain
System) (11) and NIAPAS (Neonatal Infant Acute Pain relieving methods. The factors influencing the use of
Assessment Scale) (12). In addition, the EDIN (E  chelle nonpharmacological methods in paediatric patients
Douleur Inconfort Nouveau-Ne, neonatal pain and dis- include nurses’ characteristics (age, education, work
comfort scale) (13) and the COMFORTneo scale (14), for experience), child’s age/ability to cooperate and organisa-
example, have been developed to asses prolonged pain in tional issues including the hospital where the patients are
preterm infants. treating (29). However, we have a lack of knowledge on
Despite pain scales for infants being available, they are the factors associated with pain management among neo-
rarely used in clinical practice when examining the nates in the NICUs. Guidelines for how to assess and
results, for example, from Australia (4), France (15), Italy manage pain may also have an influence in practice. The
(16), United Kingdom (5) and Japan (6). It is possible study of Gharavi et al. (30), where current pain manage-
that many tools are difficult to use (9), not sufficiently ment was explored in Austrian, German and Swiss
sensitive enough to assess specific behaviour when NICUs, demonstrated that pain assessment and analgesia
requiring intensive care (8) or perhaps do not take into therapy were more frequently performed if written
account clinical expertise (17). However, systematic pain guidelines for pain management were available in the
assessment has been reported to lead to more consistent units. In this study, we are focussing on the pain assess-
management of pain in nursing (18). ment and management practices in the neonatal inten-
Because of the nature of pain as a multidimensional sive care units in Finland and produce the updated
phenomenon, it is important to include pain manage- information to an international level in order to improve
ment via both pain medication and nonpharmacological neonatal pain care.
methods. There is an increasing interest to recommend
use of nonpharmacological interventions in the manage-
Aims
ment of pain due to their effectiveness during painful
procedures (19–22), but also because they have good tol- The aim of this study was to describe pain assessment
erance without the adverse consequences of opioids in and management practices in neonates based on the
infants (23, 24). In a Cochrane review (21), the most nurses’ perceptions in the neonatal intensive care units.
established evidence, besides the method of kangaroo The detailed research questions were as follows:
care, was for non-nutritive sucking, swaddling/facilitated 1 How do nurses assess pain in neonates?
tucking and rocking/holding in relieving pain behaviour a) How important is pain assessment considered in
among term and preterm neonates during acutely painful neonates?
procedures. b) Which parameters are observed when assessing
Another Cochrane review (25) indicated that breast- neonate’s pain?
feeding or breast milk should be used to alleviate proce- c) What kinds of pain assessment scales are well
dural pain rather than a placebo, positioning or no known and used in neonate pain assessment?
intervention, and administration of glucose/sucrose had 2 How do nurses manage pain in neonates focusing on
similar effectiveness as breastfeeding for reducing pain in the use of pharmacological methods?
neonates. In addition, some studies have shown (26) that 3 Which background factors are related to the pain
music as a nonpharmacological method is also effective assessment and management practices in neonates?
in alleviating pain in these patients.
Although, we have increasingly evidence-based knowl-
Methods
edge about the effectiveness of nonpharmacological meth-
ods in neonates’ pain alleviation, another question is how
Design
these interventions are used in clinical practice. For exam-
ple, in the study of Akuma and Jordan (5), the nurses and This was a descriptive cross-sectional survey in the Fin-
doctors reported that analgesia and comfort measures nish neonatal intensive care units.
were not usually administered for most painful proce-
dures in the neonatal intensive care units. It also seems
Participants
based on the results of other studies that current evi-
dence-based strategies to reduce procedural pain in hospi- All nurses (N = 422) working in the neonatal intensive
talised infants are used infrequently (4, 6), although there care units in the country’s five university hospitals

© 2017 Nordic College of Caring Science


Pain assessment and management practices in NICUs 3

(Helsinki, Kuopio, Oulu, Tampere, Turku) in Finland Exploratory factor analysis was employed when evalu-
were asked to participate in the study. Each hospital con- ating the construct validity of the instrument concerning
sisted of one to three units (N = 8 units), of which three section 3 of the questionnaire that dealt with the nurses’
units were designed level II and five were level III NICUs. use of nonpharmacological methods. As a result, four-
Altogether, 299 questionnaires were returned, and five of factor solutions were generated which accounted for
them were excluded for missing data. Finally, 294 nurses 63% of the total variance. The eigenvalues varied
participated in this study, resulting in a response rate of between 0.41 and 2.33, and the factor loadings between
70%. 0.61 and 0.85, while the communalities were between
0.47 and 0.73. The internal consistency was evaluated by
item analysis and Cronbach’s alpha. The alpha values
Data collection
ranged from 0.65 to 0.90 when evaluating the pain
The data were collected using a questionnaire conducted assessment practices (4 sum variables), and 0.45–0.63 in
between February 2012 and February 2013. The data col- pain management practices (4 sum variables).
lection was informed and organised via the nursing man-
agers of each neonatal intensive care unit where the
Ethical consideration
nurses worked. The questionnaires were mailed to the
nursing managers to be handed out to the nurses, and The ethics committee approval (308/13/03/09/2011) was
completed questionnaires were mailed back to the obtained for this study, and ethical permission was
researcher in prestamped return envelopes. granted by the authorities of all participating hospitals.
The questionnaire reported in the study comprised The questionnaires included a covering letter which
three sections. Section one inquired about the respon- briefly described the study, provided an affirmation of
dents’ background factors (9 items) that were dichoto- confidentiality and voluntary participation and gave the
mous or multiple-choice questions. Section 2 included researchers’ contact information. As all participants were
information about the pain assessment practices includ- competent adults and had been fully informed of the
ing (a) the importance of pain assessment (5 items), (b) study, return of the questionnaires was taken as consent
parameters when observing pain in neonates (16 items), to use the data. The respondents were able to leave the
(c) pain assessment scales that were well-known (8 questionnaires in sealed envelopes in order to avoid iden-
items) and (d) pain assessment scales that were used in tifying their anonymity at any phase of the process of
neonates by the nurses (6 items). Finally, section 3 eli- data collection.
cited information about the respondents’ pain manage-
ment practices focusing only on the use of
Data analysis
nonpharmacological methods (10 items). The replies in
sections 2 and 3 were given on a five-point Likert-type Data were analysed with PASW Statistics for Windows
scale ranging from ‘totally agree’ to ‘totally disagree’ or (version 18.0, Chicago, SPSS Inc). Descriptive statistics
‘not at all’ to ‘always’. were used to summarise the characteristics of respon-
Before the data collection, the pilot study was con- dents, as well as the pain assessment and pain manage-
ducted among RNs (n = 17) who were working in a pae- ment practices. The five dimensions of the Likert-type-
diatric intensive care unit in one of the participating scale statements were divided into three classes – ‘not at
university hospitals. Based on their comments, some all/very seldom’, ‘sometimes’ and ‘nearly always/always’
questions were specified for their more understandable – when describing nurses observing the parameters in
form. neonates’ pain assessment and their use of nonpharma-
cological methods. Four sum variables were formed from
the variables that correlated with each other using item
Reliability and validity
analysis and Cronbach’s alpha test: (a) importance of
The questionnaire for the study was developed based pain assessment (a = 0.65), (b) assessing neonates’ physi-
on the earlier research literature (5, 20, 31, 32). In ological parameters (a = 0.78), (c) behavioural changes
order to improve the content validity of the study, the (a = 0.84) and (d) specific facial expressions (a = 0.90).
expert panel (n = 9) also evaluated the questionnaire The factor analysis, using principal component analysis
consisting of five nurses specialising in paediatric pain with varimax rotation, produced a result of a total of four
management, three researchers and two specialists in factors from the nurses’ use of nonpharmacological
methodological issues in nursing science. The results methods. Sum variables were formed on the basis of that
indicated that some questions and instructions needed analysis (factor loadings ≥ 0.4, communality values
to be clarified, but no new questions were added in ≥ 0.3) and the Cronbach’s alpha values were 0.62 (physi-
the questionnaire indicating that all necessary content cal methods), 0.63 (parental counselling), 0.63 (sucrose/
was covered. non-nutritive sucking) and 0.45 (music).

© 2017 Nordic College of Caring Science


4 T. P€olkki et al.

Mann-Whitney U-test was used to assess the difference pain assessment is necessary in nursing (93.2%) and that
(sum variables) in the groups of demographics because pain assessment scales are important (86.4%). However,
the variables were not normally distributed. In addition, over half of the respondents agreed that they can assess
correlations between the groups of respondents and their the pain in a reliable way without using pain assessment
use of pain assessment scales (divided into two classes scales, and nearly fourth of them (24.8%) were uncer-
‘use’, ‘not use’) were conducted with the chi-square test. tain (‘don’t know’) that nurses can assess the pain in
p-values ≤ 0.05 were interpreted as statistically neonates consistently without the scales (Table 1).
significant.
Observing parameters when assessing neonates’ pain. Physio-
logical parameters were observed routinely (‘nearly
Results
always/always’) by the nurses when assessing pain in
neonates, except the blood pressure was observed by
Background factors
38.4% of the respondents. Changes in neonate’s beha-
The study participants ranged in age from 23 to 64 years viour, such as crying and state of arousal, were also well
(Mean = 37.7 years, SD = 11.1). Almost all of them were observed. When examining the specific facial expression,
female (99%). The majority were RNs (90%) with there were many indicators that were less observed: only
2.5 4.5 years of education, and 10% were children’s half of the nurses reported routinely observing the neo-
nurses/practical nurses with 1.5 2.5 years of education nate’s taut tongue (15.3%), naso-labial furrow (22.2%),
who had completed a lower-level training course than lip pursing (34.8%) and mouth stretch (47.6%)
that required of RNs in Finland. Slightly over half of the (Table 2).
nurses (55%) had more than 5 years of experience in
neonatal intensive care nursing ranging from 1 month to Pain assessment scales. There were many pain assessment
39 years (Mean = 10.0 years, SD = 9.9). scales with which nurses mostly reported being unfamil-
Sixty per cent of the respondents had children of iar. Only NIPS (93.5%), VAS (79.3%) and Faces Pain
their own, and 22% of them had been in the NICU Scale (79.1%) were the pain assessment scales that the
with their own children. Most nurses (74%) reported nurses knew ‘fully or to some extent’ (Fig. 1).
that they have in their unit written instructions on Most nurses reported to use ‘not at all/very seldom’ the
pain assessment (with responses ‘yes’ 74%, ‘no’ 6% pain assessment scales in neonates. Only a few pain assess-
and ‘don’t know’ 15%) and written instructions on ment scale were used ‘nearly daily/daily’ by the nurses,
nonpharmacological methods (with responses ‘yes’ such as NIPS (23.0%) and NIAPAS (10.2%) (Fig. 2).
65%, ‘no’ 8% and ‘don’t know’ 28%) for healthcare
providers.
Pain management practices
Using nonpharmacological methods in alleviating neonate’s
Pain assessment practices
pain. Most nurses reported using physical methods
Importance of pain assessment. Most of the nurses agreed (range from 79.0 to 93.5%) ‘nearly always/always’, as
(‘totally agree/agree to some extent’) that pain assess- well as giving oral sucrose along with non-nutritive suck-
ment in neonates affects the implementation of pain ing (79.8%) or alone (54.8%) to alleviate neonates’ pain.
management (95.2%), that systematic documentation of However, counselling parents to continue breastfeeding

Table 1 Nurses’ perceptions of the importance of pain assessment in neonates

Totally Agree to Don’t Disagree to Totally


agree some extent know some extent disagree
Items f (%) f (%) f (%) f (%) f (%)

Pain assessment in neonates affects the implementation 175 (59.9) 103 (35.3) 8 (2.7) 4 (1.4) 2 (0.7)
of pain management.
Pain assessment scales are important when assessing pain 112 (38.1) 142 (48.3) 29 (9.9) 9 (3.1) 2 (0.7)
in neonates.
I can assess the neonate’s pain in a reliable way without 21 (7.1) 160 (54.4) 47 (16.0) 58 (19.7) 8 (2.7)
using pain assessment scales.
Nurses assess the pain in neonates consistently without 9 (3.1) 81 (27.6) 73 (24.8) 101 (34.4) 30 (10.2)
pain assessment scales.
Systematic documentation of pain assessment in neonates 1 (0.3) 9 (3.1) 10 (3.4) 99 (33.7) 175 (59.5)
is not necessary in nursing.

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Pain assessment and management practices in NICUs 5

Table 2 Nurses’ observations of the parameters when assessing pain


in neonates

Not at
all/very Nearly
seldom Sometimes always/always
Items f (%) f (%) f (%)

Physiological parameters
Heart rate 7 (2.4) 47 (16.0) 240 (81.6)
Breathing 7 (2.4) 45 (15.4) 240 (82.2)
Blood pressure 90 (30.7) 91 (31.0) 113 (38.4)
Oxygen saturation 8 (2.7) 27 (9.2) 259 (88.1)
Behavioural changes
Crying/moaning 1 (0.3) 2 (0.7) 290 (98.9)
State of arousal/alertness 5 (1.7) 9 (3.1) 280 (95.3)
Arm movements 4 (1.4) 23 (7.8) 267 (90.8) Figure 2 Pain assessment scales that are used in neonates (%).
Leg movements 5 (1.7) 26 (8.8) 263 (89.5)
Facial expressions 2 (0.7) 12 (4.1) 280 (95.3) who were over 40 years old (Mann–Whitney test,
in general
Mean = 4.02, SD = 0.63, 95% CI: 3.901–4.148) used this
Specific facial expression
method more than nurses who were 40 years old or less
Brow bulge 7 (2.4) 55 (19.0) 227 (78.6)
Eye squeeze 5 (1.7) 66 (22.8) 218 (75.4)
(Mean = 3.70, SD = 0.70, 95% CI: 3.601–3.807)
Naso-labial furrow 144 (50.0) 80 (27.8) 64 (22.2) (p < 0.001). In addition, children’s nurses/practical
Mouth stretch 69 (23.9) 82 (28.5) 137 (47.6) nurses (Mean =2.54, SD = 0.92, 95% CI: 2.178–2.893)
Lip pursing 100 (34.9) 87 (30.3) 100 (34.8) counselled the parents more than RNs (Mean 2.10,
Taut tongue 183 (64.9) 59 (20.6) 44 (15.3) SD = 0.72, 95% CI: 2.017–2.194) (p = 0.001), including
Chin quiver 33 (11.5) 74 (25.9) 179 (62.6) use of breastfeeding and kangaroo care. Instead, RNs
(Mean = 4.05, SD = 0.69, 95% CI: 3.964–4.130)
observed physiological parameters more than the other
nurses (Mean = 3.40, SD = 0.73, 95% CI: 3.121–3.688)
(p < 0.001) when assessing pain in neonates. In addition,

Table 3 Nurses’ use of nonpharmacological methods in relieving pain


in neonates

Nearly
Not at all/very always/
seldom Sometimes always
Items f (%) f (%) f (%)

Physical methods
Touching 7 (2.4) 12 (4.1) 272 (93.5)
Positioning 7 (2.4.) 29 (9.9) 256 (87.7)
Figure 1 Pain assessment scales that are well-known among the Holding 11 (3.8) 50 (17.2) 229 (79.0)
nurses (%). Facilitated tucking 2 (0.7) 44 (15.1) 246 (84.2)
Parental counselling
Encourage mother to 217 (74.1) 69 (23.5) 7 (2.4)
(74.1%) or guiding them to use kangaroo care (56.0%) continue breastfeeding
were reported to occur ‘not at all/very seldom’. In addi- Guide parents to use 164 (56.0) 104 (35.5) 25 (8.5)
tion, music was not used among the nurses because only kangaroo care
a few respondents routinely used recorded music (2.1%) Sucrose/non-nutritive sucking
or live music (0.7%) in neonate’s pain relief (Table 3). Giving sucrose p.o. 33 (11.3) 99 (33.9) 160 (54.8)
Non-nutritive sucking 1 (0.3) 58 (19.9) 233 (79.8)
together with sucrose p.o.
Background factors related to pain assessment and pain Music
management practices in neonates Recorded music 202 (70.4) 76 (26.5) 9 (2.1)
Live music 272 (95.8) 10 (3.5) 2 (0.7)
The nurses’ age was significantly related to their use of
(singing or humming)
sucrose/non-nutritive sucking. It appeared that nurses

© 2017 Nordic College of Caring Science


6 T. P€olkki et al.

the number of well-known pain assessment scales were (Mean = 3.11, SD = 0.80, 95% CI: 2.957–3.271,
higher in RNs (Mean = 3.14, SD = 1.74, 95% CI: 2.930– p = 0.048 and Mean 2.73, SD = 1.73, 95% CI: 2.390–
3.30) than in children’s nurses/practical nurses 3.070, p = 0.034, respectively). In addition, the written
(Mean = 1.54, SD = 1.07, 95% CI: 1.120–1.950) instruction on nonpharmacological methods correlated
(p < 0.001), and RNs also used more scales when assess- significantly with the nurses’ use of pain assessment
ing neonates’ pain in NICU (v2 test, 58.1 vs. 35.7%, scales in neonates (v2 test, 61.5 vs. 44.1%, p = 0.005).
p = 0.023). The number of the respondents’ own children or ear-
Nurses with more than 5 years of work experience in lier experiences of hospitalisation of their children did
neonatal intensive care nursing used sucrose/non-nutri- not significantly correlate with any of the pain assess-
tive sucking (Mean = 3.93, SD = 0.63, 95% CI: 3.82– ment and management practices.
4.02) and physical methods (Mean = 4.25, SD = 0.55,
95% CI: 4.159–4.4.333) more than nurses with 5 years
Discussion
or less of experience (Mean = 3.69, SD = 0.74, 95% CI:
3.558–3.814, p = 0.022 and Mean = 4.40, SD = 0.49, Our study aimed to describe pain assessment and man-
95% CI: 4.315–4.488, p = 0.022, respectively). It also agement practices in neonates based on the nurses’ per-
appeared that more experienced nurses used pain assess- ceptions in Finnish neonatal intensive care units. The
ment scales more than less experienced nurses in neona- results indicated that nurses found neonates’ pain assess-
tal intensive care nursing (v2 test, 62.7 vs. 49.6%, ment important in their units. Over half of them, how-
p = 0.026). ever, agreed that they can assess an infant’s pain in a
The hospital where the respondents worked related sig- reliable way without using the scales. The reason for this
nificantly to many nonpharmacological methods used by finding might be that nurses trust their own ability to
the nurses: sucrose/non-nutritive sucking (Mann–Whit- recognise and assess pain without the objectivity indica-
ney test, p < 0.001), physical methods (p = 0.014) and tors, and they probably have become accustomed to
parental counselling (p < 0.001). In addition, there were doing so because pain assessment scales are not routinely
differences between the hospitals concerning the nurses’ used in their units. This discovery may procedure new
perceptions of the importance of pain assessment in neo- understanding for not using the scales; perhaps the scales
nates (p = 0.001) and how to observe the physiological do not provide meaningful information for nurses in
parameters when assessing pain in the children practice. In addition, nurses may not be familiar with all
(p = 0.001). There were also hospitals where the pain the scales if only a few are used at their institutions.
assessment scales were used more than in the others (v2 Anyway, it seems that there is an obvious need for
test, range from 24.6 to 85.0%, p < 0.001). arranging educational sessions for nursing staff. Although
Nurses who reported that they have written instruc- the nurses believe that pain assessment is important, it is
tions on pain assessment used significantly more sucrose/ not evident that any pain assessment tools are used (18).
non-nutritive sucking (Mann–Whitney test, Only a few nurses used the pain assessment scales such
Mean = 3.860, SD = 0.70, 95% CI: 3.764–3.954) and as NIPS and NIAPAS routinely, whereas the other scales
music (Mean = 1.65, SD = 0.66, 95% CI: 1.559–1.737) including EDIN, CRIES, NFCS and PIPP were used even
than nurses who reported not having the instructions in more rarely or not at all. The results are consistent with
their unit (Mean = 3.69, SD = 0.64, 95% CI: 3.538– the earlier studies in Europe (4, 5, 15, 16) and Asian (6),
3.837, p = 0.037 and Mean = 1.42, SD = 0.54, 95% CI: although we have available valid and reliable pain scales
1.298–1.549, p = 0.010, respectively). In addition, these for infants, they are rarely used in practice. For example,
nurses claimed to observe neonates’ behavioural changes in the study of Japan, more than 60% of neonatal inten-
(Mean 4.68, SD = 0.41, 95% CI: 4.625–4.736) more than sive care units did not use pain scales; 12% used scales
nurses without written instructions on pain assessment such as PIPP, NIPS and NFCS, but no units used the
(Mean = 4.51, SD = 0.59, 95% CI: 4.370–4.646) CRIES (6). In addition, in the updated study of Aus-
(p = 0.040). It also appeared that nurses reporting to tralian NICUs, a pain assessment tool was only used in
have the written instructions used the pain assessment 11% of the units, and there had only been a small
scales more than nurses without the instructions in their increase in the number of neonatal units undertaking
unit (v2 test, 61.7 vs. 39.2%, p = 0.001). pain assessment (27).
We also found that, in units where the written instruc- Despite not knowing and using the pain assessment
tions on nonpharmacological methods were available, scales in neonates, most physiological parameters and
the nurses observed more specific facial expressions changes in neonate’s behaviour were observed routinely
among neonates (Mann–Whitney test, Mean = 3.33, by the nurses in our study. However, the specific facial
SD = 0.86, 95% CI: 3.202–3.453) and reported to know expression, such as a neonate’s taut tongue, naso-labial
more pain assessment scales (Mean = 3.11, SD = 1.77, furrow and lip pursing, was less often observed. The
95% CI: 2.860–3.370) than units without the instructions results may indicate that these actions may be lessened

© 2017 Nordic College of Caring Science


Pain assessment and management practices in NICUs 7

in infants who are very sick or in infants with mechani- or earlier experiences of hospitalisation of their children.
cal ventilation or other equipment that make it difficult However, more research is needed on these factors in
to observe the facial movements. Contrary to our study, order to make conclusions. In addition, children’s nurses/
the Swedish follow-up study of neonates’ pain assess- practical nurses provided more counselling for the par-
ment demonstrated that most commonly used individual ents to use breastfeeding and kangaroo care than RNs,
pain indicators were facial actions following body move- whereas RNs observed physiological parameters and used
ments in observing the infant’s pain (33). However, there scales more than the other nurses. This result may indi-
is a lack of earlier international studies where the nurses cate the different roles of nurses with different educa-
had been asked in more detail about their observations tional levels in Finland.
of neonates’ pain expressions, but because the neonates The most considerable finding of our study was proba-
are in monitor, it is natural that their physiological bly that the hospital where the respondents’ work related
parameters are also followed in the NICU. Physiological significantly to many nonpharmacological methods, as
indicators provide complementary information, but they well as the using of pain assessment scales in infants. The
lack sensitivity and specificity when they cannot be used results could reflect different levels of NICUs, but also
independently (34). demonstrates that depending on the hospital, the infants
Most nurses reported using physical methods (e.g. may have unequal treatment when relieving their pain
touching, positioning, holding and facilitated tucking) as in the NICU. Therefore, our results recommend that
well as giving oral sucrose, along with non-nutritive there is a need for national guidelines in the Finnish hos-
sucking or alone, in alleviating neonate’s pain. Based on pitals. There is probably the same challenge in some
earlier studies, there is strong evidence to support the countries because earlier studies have also indicated that
effectiveness of these methods in pain reduction among neonatal units have no articulated pain policies to guide
neonates (19, 21, 25). However, efforts to counsel par- pain management (4, 6).
ents to continue breastfeeding or guide them to use kan- However, most nurses reported that they have in their
garoo care were rarely used. These results may indicate unit written instructions on pain assessment and non-
that some infants are too ill for kangaroo care and breast- pharmacological methods for healthcare providers, but
feeding, and these methods are probably implemented they were compiled for their local needs. It appeared that
for supporting the mother–child relationship and close- nurses who reported that they have written instructions
ness rather than purpose of relieving the pain. In addi- used more nonpharmacological methods (i.e. sucrose/
tion, music as pain alleviation intervention was not used non-nutritive sucking), observed more of neonates’
among infants in the NICUs, although, based on the ear- behavioural changes or facial expressions and used more
lier study (35), the Finnish nurses’ expectations towards pain assessment scales than nurses not to have the
using music were positive. instructions in their unit. This demonstrates that any
Our results are partly consistent with the earlier studies instructions on pain assessment and management in
which found that there is a need for improving pain these patient groups may have positive effects on the
management by using versatile nonpharmacological practice, and it is therefore recommendable. In the
methods (4, 6, 36), because the methods in which the updated study of Lago et al. (36), the national guidelines
nurses had an active role were mostly well implemented. on pain control and prevention will improve the prac-
Clinicians in the NICUs of the United Kingdom agreed tices in neonatal pain care. However, Akuma and Jordan
that both medicines and comfort measures should be (5) reported in their study that although pain manage-
used more frequently than they have been (5). In addi- ment guidelines were available to most of the nurses,
tion, most units in Japan offered behavioural interven- gaps between knowledge and practice remained. They
tions during painful procedures, although a few units argue that if neonatal pain is not measured, and pain
used sucrose, and parental involvement in neonatal pain policies and protocols are not audited, neonatal pain may
management was extremely low (6). Regardless, in the be discounted.
future, there is an obvious need to strengthen the par-
ents’ role in their infants’ pain management in which the
Study limitations
parent’s counselling will be emphasised.
There were many background factors, including There are some limitations that should be considered in
nurses’ age, education, work experience, hospital and interpreting the results and generalisability of the find-
written instructions available in the unit that were signif- ings in our study. First, we used questionnaires that are
icantly related to the pain assessment and management probably vulnerable to bias. Because of concerns of its
practices in neonates. It appeared that some nurses’ per- social desirability, nurses may have over-reported the
sonal characteristics such as nurses’ age and long work pain management and assessment practices in their
experience might promote their use of nonpharmacologi- units. Second, as the survey was anonymous, we have
cal methods, but not the number of their own children no information about the characteristics of the nurses

© 2017 Nordic College of Caring Science


8 T. P€olkki et al.

who did not respond. Nonresponders may have had dif- involvement in their infants’ pain alleviation. The results
ferent perceptions on the research topic. Third, although of our study indicate that educational interventions for
all nurses working in the neonatal intensive units of the nurses are needed to improve pain assessment and man-
country’s university hospitals were asked to participate agement practices in the future. In addition, there is a
in the study, the generalisability of the results are need for national guidelines in the NICUs in order to
restricted only to these units, not to the Central hospitals ensure equal treatment of all neonates.
of Finland that also treat neonates requiring intensive
care. In addition, the response rate was 70% in our
Acknowledgements
study. Finally, nurses’ use of nonpharmacological meth-
ods may differ during various painful procedures and We would like to thank the nurses who participated in
based on the infant’s condition, and these background this study.
factors were not considered in this study. However,
when comparing the results with earlier literature, our
Author contributions
study may well reflect contemporary practice in the Fin-
nish NICUs. It seems that there are similar challenges in TP and AK contributed to study conception/design; TP,
neonatal pain assessment and management across the AK and HL performed data collection/analysis; TP per-
world. formed drafting of manuscript; AK and HL performed
critical revisions for important intellectual content; HL
performed statistical expertise. In addition, all the authors
Conclusions
have given their approval for the manuscript to be sub-
The study provided new knowledge on the nurses’ per- mitted in its present form.
ceptions of pain assessment and management practices in
the vulnerable patient group in Finnish NICUs. Although
Ethical approval
nurses agreed that pain assessment is important, pain
assessment scales were not routinely used in practice. We Ethical permission was granted by the authorities of the
likely need to discuss which scales are most feasible based participating hospitals, and the study was also approved
on the nurses’ experience. Most nurses reported using by the Regional Ethical Review Board. (308/13/03/09/
physical methods and giving oral sucrose along with 2011).
non-nutritive sucking when alleviating infants’ pain dur-
ing the painful procedure. However, more attention
Funding
should be paid to counselling parents to continue breast-
feeding or guide them to use kangaroo care or music. The study was supported by grants from the Signe and
This means that parents should have more active Ane Gyllenberg Foundation, Finland.

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