Knowledge, attitude and practice of pediatric critical care nurses towards pain: Survey in a developing country settingPJ Mathew1, JL Mathew2, S Singhi2
1 Departments of Anesthesia & Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0022-3859.85203
Source of Support: None, Conflict of Interest: None
Background : Nurses' knowledge, sensitivity and attitudes about pain in children and its management affect their response and therefore management of pediatric pain. Children in critical care units undergo more painful procedures than those in general wards. Aims : To study the knowledge, attitude and practice of nursing personnel catering to critically ill children in a developing country. Settings and Design : Prospective questionnaire-based survey. Materials and Methods : The survey was carried out in a tertiary care teaching hospital on nursing personnel in three pediatric/neonatal intensive care units. The domains studied were: i. Training and experience, ii. Knowledge of pediatric pain, iii. Individual attitude towards pain in children, iv. Personal practice(s) for pain alleviation, v. Pain assessment, and vi. Non-pharmacological measures adopted. Statistical Analysis : Descriptive statistics and logistic regression. Results : Of the 81 nursing personnel working in the three critical care units, 56 (69.1%) responded to the questionnaire. Only one-third of them had received formal training in pediatric nursing. Fifty percent of the respondents felt that infants perceive less pain than adults. Training in pediatric nursing was a significant contributing factor in the domain of knowledge (P=0.03). Restraint and distraction were the common modalities employed to facilitate painful procedures. Scientific approaches like eutectic mixture of local anesthetic and the judicious use of sedatives were not adopted routinely. Observing a child's face and posture were widely used parameters to assess pain (83%). None of the three critical care areas used a scoring system to assess pain. Conclusions : There are several lacunae in the knowledge and practice of nurses in developing countries which need to be improved by training.
Keywords: Attitude, critical care, knowledge, nursing personnel, pediatric pain, practice
Improved understanding of the pathophysiology of pain in children has led to major changes in management strategies over the past two decades, especially in intensive care units. However, these improvements vary widely across institutions, countries and cultures. Though pain management strategies are largely determined by the clinician(s) caring for sick children, nursing personnel play a vital supportive role. In most hospital settings, nurses are the first medical personnel approached by admitted patients requiring assistance. In addition, many (painful) procedures in critical care units are routinely performed by nursing staff. In developed countries, training programs have been shown to improve the response of nurses to pain in children.  On the other hand, limited data from some developing countries suggests that nurses lack training in pain management ,, for a variety of reasons. In the absence of formal training in pain management, the knowledge, sensitivity and attitudes of individual nurses towards pediatric pain become even more important, as they can directly affect the management of critically sick children. , At present, there is hardly any information available on this issue. Therefore, this study was carried out to determine the knowledge, attitude and practice of nursing personnel looking after critically ill children in a developing country.
The prospective questionnaire-based survey was initiated after obtaining approval from the Institutional Ethics Committee. All nursing personnel working in three intensive care units for children were invited to participate; those who gave written informed consent were included. The three intensive care areas included Pediatric Intensive Care Unit (PICU) (12 beds), Neonatal Intensive Care Unit (NICU) (six beds) and Pediatric Surgical Intensive Care Unit- neonatal and pediatric (SICU) (10 beds).
A semi-structured questionnaire was pre-tested on 10 anesthesiology registrars, and modified based on the inputs received. The finalized questionnaire [Appendix][Additional file 1] contained 47 items in six domains: i. Training and experience (five items), ii. Knowledge (four items), iii. Attitude towards pain (14 items), iv. Pain assessment (five items), v. Practice of pain alleviation (six items), vi. Non-pharmacological measures adopted for pain alleviation (10 items). The first domain dealt with training and experience in the nursing profession in general and specifically in pediatric and critical care nursing. The domain on knowledge tested the participants' awareness about pain in infants and preterm infants. The next domain enquired about the individual's perception of the degree of pain experienced by children when subjected to various procedures in the ICU. The fourth, fifth and sixth domains covered the various practices adopted for assessment and alleviation of pain. The participants could give multiple responses in these three areas.
The questionnaire was distributed among nurses in the three critical care areas, through the Nursing Sister In-charge of each area. Participation was on a purely voluntary basis and anonymity of the participants was guaranteed. A collection box for responses was placed for nurses to drop their responses at their convenience.
Descriptive statistics were used to summarize the results in the six domains. Logistic regression analysis was performed to explore the contribution of the type of ICU, training and experience on the knowledge and practice of nurses. A P<0.05 was considered statistically significant. SPSS Version 11 was used for statistical analysis.
Of the 81 nursing personnel working in the three critical care units, 56 (69.1%) responded to the questionnaire. The mean duration of professional experience was similar in the three areas, viz. 14.5±9.9 years in nursing and 5.2±4.8 years in pediatric critical care nursing. Only one-third of the personnel had formal training in either pediatric or critical care nursing [Table 1].
Almost half the participants believed that infants perceive pain less than adults and the majority felt that infants forget pain faster [Table 2]. Regarding attitude to pain [Table 2]: Lumbar puncture, urinary catheterization, endotracheal intubation and suction, blood sampling, removal of sticking tape and insertion/removal of infant feeding tube were considered painful. Chest physiotherapy was not deemed painful by almost half of them. Squeezing of muscles during blood sampling was the only intervention where observations from the three ICUs were not concordant.
Regarding parameters to assess pain [Table 3], asking the child about pain seemed to be in vogue in the PICU and SICU-noticeably, these areas cater to children of an older age group and this difference was statistically significant (P=0.01). Use of physiological measurements to assess pain were used by less than two-thirds of the staff in the NICU and SICU and even less (28.6%) in the PICU. None of the three critical care areas had used a scoring system to assess pain in children.
Restraint was the most common modality employed to facilitate a painful procedure in the NICU and SICU [Table 3], whereas distraction was most common in the PICU. This difference in practice was significantly different (restraint: P=0.022, distraction: P=0.015). More scientific approaches like Eutectic Mixture of Local Anesthetic (EMLA), local anesthetic infiltration and judicious use of sedatives seemed unpopular.
The non-pharmacological measures used in various ICUs were similar in the three ICUs. Massage, positioning, touch and assurance, providing company, heat and cold and distraction were the common methods employed in the order of decreasing frequency. On logistic regression analysis, training was found to significantly contribute to the knowledge of nurses regarding infant pain perception (P=0.03) whereas experience had no effect on the knowledge or practice of pain assessment and alleviation.
The current study is the first to examine the knowledge, attitude and practice of nurses looking after children in the intensive care unit. It also gives an informative and detailed picture of the practice of pain alleviation in children in the setting of a developing country. A similar deficiency in the knowledge, perception and practice of pain management of neonates was reported from Jamaica among physicians and nurses.  The use of a questionnaire as a data collection method allowed for anonymity and helped to avoid interviewer bias.  On the other hand, a major limitation might be related to the validity and reliability of these questions, especially whether the respondent practiced what was claimed. A study conducted using personal interviews or observations may give more in-depth and detailed information.  However, our resources were limited to carry out such an extensive study.
The fact that only one-third of the staff had formal training in pediatric or pediatric critical care nursing is important. This lack of training implies that the majority rely on their individual experience as well as on observing their peers to obtain the nursing skills required in their practice. Against this backdrop, the survey could identify areas of lacunae in knowledge, viz. lack of awareness regarding pain perception in preterm infants and ignorance about the magnitude as well as the memory of pain perceived by infants. We were also able to demonstrate training as an important factor contributing to knowledge among nursing personnel as against experience. This is important in the context of our country where the majority of specialized training to nursing personnel is imparted informally during their job assignments. At the same time, it is known that nursing education, professional activity, and years of clinical experience contribute to the knowledge necessary for competency in pain management. , Since nursing education and professional activity can be augmented by in-house educational activities, stress may be given on improving the knowledge through such educational programs.
From the survey, we have been able to formulate a list of interventions and conditions that are perceived to be painful by the attending nurses. These observations/opinions require validation by objective data from observing the children during these procedures and assessing their pain behavior using an accepted pain scoring system. Since this was out of the scope of the current survey, we did not attempt this corroboration.
We observed heterogeneity in the response of nurses regarding assessment of pain from various critical care areas. Asking the child about pain is impractical in neonates. Therefore, this was hardly practiced in the neonatal medical ICU. The use of physiological measurements to indicate pain was poorly utilized in the PICU though it was reasonably practiced in the NICU and SICU. This indicates an inclination of nurses in the NICU and SICU to use objective measures to support assessment of pain. However, we also found the absence of any objective scoring systems in use to assess pain in children. This may possibly be due to the lack of awareness of such scoring systems or the dearth of time for implementation of such scoring systems. Such a situation reflects the lack of sensitivity to the need of assessing pain in an objective manner in children. This is possibly an area that has to be brought to the notice of policy-makers in this field.
Another finding was the difference in the practice of measures adopted to facilitate painful interventions. The practice of restraint as the most common modality in the NICU and SICU may reflect the age of the children managed in these ICUs. The NICU admits only neonates and the SICU has a mixed population of neonates and older children. The PICU manages only infants and older children, and distracting the child appeared popular here. This difference in practice reflects the natural response of caretakers in handling children of different age groups. The use of EMLA, infiltration of local anesthetics and judicious use of narcotics or sedatives during painful procedures are interventions that may be considered to improve quality of pain management in our setting.
To conclude, this survey has identified areas of lacunae in the knowledge and practice of nurses regarding pain management in children. These deficiencies need to be improved by better training for better practice of pain relief of sick children in the setting of a developing country.
The authors would like to acknowledge Dr. Praveen Kumar, Additional Professor, Department of Pediatrics and Dr. JK Mahajan, Department of Pediatric Surgery for permission to conduct the survey in the Neonatal Medical ICU (NICU) and Neonatal Surgical ICU (NSICU) respectively.
[Table 1], [Table 2], [Table 3]