Impact of an education programme for staff working with children undergoing painful procedures

AIM: Needle phobia is very common in children, particularly in those with chronic illness who may have to endure many painful procedures. A programme developed to educate paediatric healthcare professionals working with children undergoing painful procedures was evaluated to identify: (1) whether the education programme led to an increase in participating clinicians' knowledge and confidence; and (2) the effectiveness of the education programme in changing practice for patient care. METHOD: Five senior house officers undertook the one-hour training provided by the hospital play specialist. Questionnaires were completed by the clinicians at the beginning and end of the programme. Nurses reported on the clinicians' adherence to best practice. Twenty-one children who had undergone painful procedures were interviewed with their parents to assess their levels of pain, distress, satisfaction and coping style. RESULTS: Participants had increased their knowledge of how to work with children undergoing painful procedures. The main changes in knowledge reported by the clinicians were involving the nurse and the play specialist, preparing the equipment out of sight of the child and using distraction techniques. Parents and children reported low levels of distress during painful procedures, high levels of satisfaction with the procedure and listed a number of coping strategies that helped the child, and the parent, to cope during the procedure. Staff reports indicated that the protocol for painful procedures and that techniques such as distraction were being used in the majority of cases to help the child to cope. CONCLUSION: There are useful pain control techniques that can be taught relatively quickly by nursing staff to paediatric healthcare professionals that do make a substantial difference to the care of children.     

Mommy first

Parents of children with special health care needs are often required to assume responsibility for the complex care of their children. It is important for pediatric nurses to remember these parents are, first and foremost, the child's parents and primarily responsible for loving their child, providing a safe and secure home, and fostering their child's development as a person. Pediatric nurses should support the parents in the medical/nursing care of their child in whatever way possible so the parents have more time to parent. This account from a mother of a child with developmental delay helps remind us of our need to help support parents in being "parents first."     

Using Buzzy,Shotblocker, and Bubble Blowing in a Pediatric Emergency Department to Reduce the Pain and Fear Caused by Intramuscular Injection: A Randomized Controlled Trial

IntroductionProcedural pain in general, and intramuscular (IM) injection pain in particular, is one of the most distressing and painful health care experiences for children. Pharmacologic and nonpharmacologic methods are used as forms of pain control for children undergoing acute painful interventions in emergency departments.MethodsThis study was a prospective, randomized controlled trial. The sample consisted of children aged 5 to 10 years old who required IM injections. Children were placed in 4 subgroups through randomization, using a computer program: the Buzzy (MMJ Labs. Atlanta, GA) group (n = 40), the ShotBlocker (Bionix Development Corporation, Toledo, OH) group (n = 40), the bubble-blowing group (n = 40), and the control group (n = 40). Immediately before and after the injection, the children, their parents, and an observer were asked to evaluate the child’s level of fear. The Oucher scale was also employed by the observers, children, and parents immediately after the procedure to assess the level of pain in the children in each group.ResultsNo statistically significant difference was determined between the control and intervention groups in terms gender, age, previous pain experienced with injection, the parent who was with the child, the parent’s age. A significant difference was found between the intervention and control groups in terms of levels of pain and fear during IM injection. Pain and fear were notably less in the group of children receiving the Buzzy intervention.DiscussionThe Buzzy intervention should be used when children are undergoing IM injections to reduce their levels of pain and fear.     

Parent perceptions of child vulnerability are associated with functioning and health care use in children with chronic pain

ContextThe extent to which parent variables are associated with the level of disability experienced by children with persistent pain has been an area of increasing research.ObjectivesTo evaluate the extent to which parent perceptions of their child’s vulnerability are associated with functioning and health care utilization among children with persistent pain. We also evaluated whether perceptions of child vulnerability contribute to an indirect relationship between parent distress and child functioning and/or child health care utilization.MethodsThe study sample comprised 87 patients aged 6–18 years and a parent attending a chronic pain clinic. Children completed questionnaires on functional limitations, and parents completed questionnaires on parent distress, perceptions of child vulnerability, and extent of the child’s pain-related health care utilization. Hierarchical regression and bootstrapping mediation analyses were used to test study hypotheses.ResultsPerceptions of child vulnerability were found to be clinically elevated in nearly half (46%) of parents/caregivers, and average child functional ability for the sample was substantially lower than healthy norms. Parent perceptions of greater child vulnerability were significantly associated with poorer child functioning and more child pain-related health care utilization regardless of child age, sex, and duration of persistent pain. Parent distress was found to be indirectly related to child health care utilization through parent perceptions of child vulnerability but directly related to child functioning.ConclusionParent perceptions of child vulnerability appear important for understanding levels of child functional limitations and health care utilization among children with chronic pain.     

Painful pricks and prickle pains: is there a relation between children's ratings of venipuncture pain and parental assessments of usual reaction to other pains?

OBJECTIVE: The objective of this study was to examine whether parental assessment of a child's usual behavioral reaction to common painful events predicts the child's ratings of needle pain intensity from routine venipuncture. DESIGN: Children aged 3 to 12 years (n = 88) used the Faces Pain Scale to rate how much venipuncture hurt and also indicated whether the pain was more, less, or the same as expected. The child's parent (mother) used the same scale to predict how much the needle would hurt the child as well as to rate the child's pain as observed at the time of venipuncture. Parents also estimated their child's usual reaction to six common painful events. An independent observer used a behavioral checklist to rate the child's pain response at the time of venipuncture as well as to assign a global pain rating on the Faces Pain Scale. OUTCOME MEASURES: The Faces Pain Scale and a behavioral checklist (scoring facial, vocal, motor, and verbal reactions) were used in this study. RESULTS AND CONCLUSIONS: Those children who reported venipuncture as hurting more than expected also gave the highest mean needle pain ratings and tended to have their pain underpredicted by their parents before venipuncture. For these children, parental estimates of reactions to other painful events proved to be a useful predictor of self-reported needle pain. Parent and child ratings of pain agreed more closely for those parents who indicated having relied on what their child "did" rather than "said." Additionally, and consistent with previous studies, independent observation of children's facial responses was the most useful indicator of needle pain severity. Preparation of children for venipuncture may be enhanced by asking a parent beforehand how the child usually responds to everyday pain. Specifically, reaction to other sharp time-limited pains (e.g., finger pinch, stepping on a prickle) may provide a useful guide to identifying which children will report experiencing greater pain than expected from venipuncture.     

Test or trauma? The voiding cystourethrogram experience of young children

Many diagnostic procedures, while necessary and appropriate, may be experienced by a child as a trauma. Health care professionals often perceive invasive procedures such as surgery and needle biopsies as more painful and threatening to the child than "test" such as voiding cystourethrograms (VCUGs). However, clinical experience indicates that the VCUG is often perceived by children as more highly distressing than other procedures. Success and a sense of competence (or shame and doubt) in mastering challenging life experiences, such as medical procedures, contribute to a child's evolving self-concept (Harter, 1983). These memories and successful behaviors can be applied to future similar situations. Health care professionals are challenged to help the child and the parents through the procedure with minimal distress in an effective and efficient manner. A series of vignettes illustrating parents' and children's experiences with a VCUG procedure highlight the impact of the VCUG on children's coping ability and adjustment. Recommendations for developmentally appropriate clinical practice standards of care related to the VCUG procedure in young children also are presented. Preparation as an ongoing partnership process among children, parents, and health care professionals.     

A study of the effectiveness of a pain management education booklet for parents of children having cardiac surgery.

Parents need education about pain so they can support their hospitalized child and manage their child's pain at home. The purpose of this study was to examine the effectiveness of a pain booklet on parental pain support to children experiencing postoperative pain. A randomized, repeated measures, experimental design using a pain education booklet and a standard care comparison group was used to study parents of 51 children (3 to 16 years of age) having cardiac surgery. Measurement techniques used to assess differences in parental pain management included: attitudes about pain medication, child and parent pain ratings (Oucher), opioids used, recovery, satisfaction, and comfort in communication. Results indicate that children do report moderate levels of pain postoperatively. Parents who were exposed to the pain assessment and management for parents education booklet preoperatively significantly increased their knowledge and attitudes toward pain medication scores from pre- to post-test, whereas those in the control group remained stable. Post-test scores were not significantly different between groups. Child and parent pain ratings were significantly and positively correlated. Practice implications include the use of an educational booklet about pain with parents before surgery to increase their knowledge about and attitudes toward pain management. Additionally, a parent may provide an alternative pain report when a child is unable to or unwilling to self-report their pain.     

Techniques to comfort children during stressful procedures

Medical procedures can be unpleasant experiences for children, their parents, and health care providers. We present this model of working with children having invasive procedures with the aim of helping to increase the comfort of infants and children and also parents and medical staff. The model has five parts: (1) Preparing the child and parent for the procedure and for their role during the procedure; (2) inviting the parent/caregiver to be present; (3) utilizing the treatment room for stressful procedures; (4) positioning the child in a comforting manner; and (5) maintaining a calm, positive atmosphere.     

Children visiting parents in inpatient psychiatric facilities: perspectives of parents, carers, and children

A significant number of clients utilizing mental health services will also be parents. Being a child of a parent with mental illness increases health risks for the child, and hospitalization of the parent has been identified as one of the most difficult times for children. However, few proactive measures have been taken to understand or provide for the needs of children visiting psychiatric inpatient facilities. The aim of this exploratory study was to identify the perspectives children, their parents, nominated carers, and clinicians from their experience of children visiting. The study used qualitative data gathered from interviews to develop an understanding of the issues. The purpose of this paper was to present the findings from parents, carers, and children. Children indicated that they wanted to visit and to remain involved with their parent, but that there was little support from staff. Families indicated that children visiting psychiatric inpatient facilities were not well managed, and they received little support about decisions around children visiting. The issue of children visiting psychiatric facilities when they have a parent who is an inpatient appears not to have been addressed in models of inpatient mental health care.     

Parental preparation of children for routine physical examinations.

Preparation of the child and parents/caretakers for health care events is expected to decrease a child's anxiety and uncooperative behaviors. The purpose of this study was to ascertain the methods of preparation (discussion, reading, play, other) and levels of discussion used by parents in readying their preschool and school-age children for six selected events during routine physical examinations. A phone survey was conducted to all parents of children, ages 2 to 12 years, who visited an academic nursing center or public school for a routine physical examination (n = 132). The events are "listen to heart," "look in ears," "take temperature," "feel the stomach," "look at the throat," and "give a shot." The most common method of preparation parents used was discussion that consisted largely of procedural information rather than a reciprocal dialogue with the child. Preschool children were told what the health care provider would do and what they should do during the physical examination more often than school-age children.     

Strategies for feeling secure influence parents' participation in care

This study investigates what makes parents of hospitalized children feel secure and factors influencing their level of participation. It also studies, whether the degree to which parents participate affects their child's pain and sleep during hospitalization. Questionnaires were distributed to a series of parents whose children were discharged from two paediatric surgical wards and one paediatric medical-surgical ward at two university hospitals in Sweden. Parental security is almost equally distributed among three given alternatives: security derived from trusting that professionals know how to take care of the child; security derived from having control over what is happening to the child; and security derived from being the one who knows the child best. Depending upon the strategy chosen, parents want to participate at different levels in their child's care. The results indicate a relationship between parental participation and their estimation of their child's pain. The study confirms a pattern, developed in a previous study, in how parents adopt different strategies affecting their participation during their child's hospitalization. Some parents who wanted to participate in more aspects of their child's care seemed to think that their child had less pain than parents who preferred more limited participation.     

Parent Participation in Care: Bridging the Gap in the Pediatric ICU

Family-centered care is emerging as a driving philosophy in all aspects of health care. Active participation of parents in the care of their child in the hospital setting is becoming one of the central concepts of this philosophy. Studies demonstrate the benefits for children, parents, and families. Although research supports the need for increased parent participation during a child's hospital stay, integrating research findings and changing practices of health care professionals may not be easy. Pediatric nurses, especially those working in critical care environments, may have difficulty integrating this philosophy into their care. Realizing the numerous benefits that exist, health care providers would be prudent to embrace the concept of parent participation in care. This article reviews the emergence of parent participation, what it encompasses, its benefits, and the challenges of implementation. Several strategies are examined as a basis to find ways in which the concept of parent participation can become a daily reality in the pediatric intensive care unit. Only after gathering a full understanding of the nature of parent participation in care can we begin to develop individualized strategies and approaches for incorporating these interventions into our practices and thus provide children with true family-centered care.     

Addressing the support needs of families during the acute hospitalization of a parent with mental illness: A narrative literature review

Hospitalisation of a parent with acute mental health problems impacts the consumer, their extended family/carers and children. Mental health nurses are at the forefront of promoting recovery for consumers in an acute inpatient setting. Recovery‐oriented care can include provision of family‐focused care which supports recovery of the parent‐consumer and their family members and contributes to prevention of intergenerational mental illness. The aim of this narrative literature review was to explore existing knowledge regarding the experiences, care and support needs of parent‐consumers, their family members/carers and children during the parent's acute mental health hospitalisation. It also aims to explore existing knowledge about the practices of mental health nurses providing care to this consumer group, to inform future healthcare practice and strengthen parent, child and family outcomes. Nineteen published studies addressed the review questions. In the context of hospitalisation, the majority of research regarding parenting with a mental illness is focused on mothers. Parents reported experiencing stigma during their hospitalisation. Separation from children was a concern for parents and their extended family, but admission provided an opportunity for the parent to receive treatment and for the family to receive support. Mental health nurses did not always identify parental status on admission. When parental status was identified, nurses reported issues regarding logistics and practicalities of using family rooms, children visiting the unit, and their own professional knowledge and organisational support regarding familyfocused care. Implications for practice are identified, highlighting how mental health nurses can develop their practice to support the recovery of parent‐consumers.     

State Versus Trait: Validating State Assessment of Child and Parental Catastrophic Thinking About Children's Acute Pain

Pain catastrophizing has emerged as one of the most robust predictors of child pain outcomes. Although assessments of state (ie, situation-specific) pain catastrophizing in children and parents are often used, their psychometric properties are unknown. This study aimed to assess factor structure, reliability, and predictive validity of state versions of Pain Catastrophizing Scales for children and parents relative to corresponding trait versions for child and parental pain-related outcomes. Data were pooled from 8 experimental pain studies in which child and/or parent state catastrophizing (measured immediately before application of a pain stimulus) and trait catastrophizing were assessed in community-based samples of children aged 8 to 18 years (N = 689) and their parents (N = 888) in Dutch or English. Exploratory factor analyses were conducted to examine the underlying factor structure of the state versions of the Pain Catastrophizing Scale for parents/children, revealing a single factor solution that explained 55.53% of the variance for children and 49.72% for parents. Hierarchical linear regression analyses were used to examine relative influence of state versus trait catastrophizing on child and parent pain-related outcomes. Child and parent state catastrophizing were significantly associated with child pain intensity, child state anxiety and parental distress. State catastrophizing scores showed stronger associations than trait scores for most outcomes.

Seizures in infants and young children: an exploratory study of family experiences and needs for information and support.

An exploratory study of the experiences of parents caring for young children with seizure disorders and their perceived needs for information and support was conducted. A questionnaire and interview protocol was designed to elicit information about the child's seizure history, child and parent health history, medical and support services, child and family demographic information, parent experiences in caring for a young child with seizures, and perceptions about needs for information and support. Interviews were conducted with 31 parents who were recruited from a pediatric neurology clinic at a university hospital. Interviews were audiotaped, transcribed, and analyzed for major themes. The study revealed a broad range of experiences in caring for young children with seizures, and the early onset and severity of seizures often influenced these experiences. Obtaining information that was easily accessible and helped them to better understand their child's diagnosis and treatment was a challenge reported by many parents. In addition, interviews revealed that parents felt a need for support and information from individuals who were knowledgeable about the medical, developmental, emotional, and family issues related to coping with seizures in infants and young children. Recommendations for a comprehensive approach to the management of seizures for infants and young children are proposed, with particular focus on the role of nurses and early intervention professionals in providing information and support to families.     

Parents' support and satisfaction with their child's postoperative care

It is recognized that parents' presence during their child's hospitalization is of benefit to the parents and the child. However, the level of parental involvement in their child's care may be influenced by many factors, such as the amount of support nurses provide for parents. This article reports on two themes from the findings of a larger study on parental involvement in children's postoperative pain management - parental support and parents' satisfaction with their child's postoperative pain management. The aim of the larger study was to explore both nurses' and parents' perceptions of parental involvement in their child's postoperative pain management. The methods used were both qualitative and quantitative. The qualitative method of phenomenology was used to guide 20 nurse and 20 parent interviews. Quantitative methods involved surveying the nurses and parents on their perceptions of how supportive the nurses were towards the parents. The charts of 20 children were reviewed for pain-related data. This article reports on the issues of parent support from the results of the survey, and on satisfaction relating to their child's postoperative pain management from the parent interviews. The findings demonstrated that nurses perceived that parents were receiving more support from them than that which parents felt they were receiving. Parents were more satisfied with their child's pain management and children received more analgesia when they were cared for by a lower grade nurse.     

Unravelling the Relationship Between Parent and Child PTSD and Pediatric Chronic Pain: the Mediating Role of Pain Catastrophizing

Clinically elevated rates of post-traumatic stress disorder (PTSD) symptoms are found among many youth with chronic pain and their parents and are linked to worse child pain outcomes. Conceptual models of mutual maintenance in pediatric PTSD and chronic pain posit that child and parent pain catastrophizing are key mechanisms underlying this co-occurrence. To our knowledge, the current study is the first to examine child and parent pain catastrophizing as potential mediators in the child PTSD-child pain and parent PTSD-child pain relationships among a cohort of youth with chronic pain. One hundred two children (72.5% female, mean age=13.5 years), recruited from a tertiary level chronic pain program, and 1 of their parents participated. At intake, parents completed psychometrically sound self-report measures of PTSD symptoms and catastrophizing about child pain. Children completed self-report measures of PTSD symptoms, pain catastrophizing, pain interference, and pain intensity. Findings revealed that relationships between child PTSD and child pain as well as parent PTSD and child pain were mediated by child (but not parent) pain catastrophizing. This suggests that children's catastrophic thinking about pain may explain how child and parent PTSD symptoms influence children's experience of chronic pain and is a potential target in family-based interventions to improve pain and mental health outcomes.