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Article Excerpt
Pediatric nurses play a pivotal role in the management of children's pain. Effective treatments for alleviating pain and several valid and reliable pain measures for assessing pain in infants and children have been developed. Yet, concerns remain that nurses do not always make appropriate pain management decisions (Rush & Harr, 2001).
Some evidence exists that nurses do not use pain assessment tools consistently. In one survey of 260 pediatric nurses, only one-third used the pain assessment scale that their hospital had recommended (Jacob & Puntillo, 1999). Similar findings have been reported by other researchers (Reyes, 2003; Simons & MacDonald, 2004). Nurses' perceptions of children's pain levels do not always match children's self-reports, which are considered the most reliable indicators of pain (Broome & Huth, 2003). Vincent and Denyes (2004), for example, found that 55% of the pediatric nurses surveyed thought children over-reported their pain.
Several investigators have also suggested that nurses underutilize prescribed treatments (Boughton et al., 1998; Ellis et al., 2002). Vincent and Denyes (2004) found that nurses did not administer analgesics to 26% of the children who reported having pain, and gave only 23% of available total analgesics to others. The wide array of non-pharmacologic strategies available for relieving pain, such as distraction and relaxation techniques, has not been used consistently by pediatric nurses (Jacob & Puntillo, 1999; Pederson & Harbaugh, 1995, Twycross, 2007).
Previous research indicates that nurses do not effectively treat children's pain, and therefore, organizations have established proactive standards to better assure that children's pain is treated effectively. In 1992, guidelines for the treatment of acute pain management in children were issued in the U.S. by the Agency for Health Care and Policy Research in 1992 (Acute Pain Management Guideline Panel, 1992). In 1999, the Joint Commission issued new performance standards related to pain assessment and treatment (Joint Commission on Accreditation of Health Care Organizations, 1999). Subsequently, the American Academy of Pediatrics (2001) issued a policy statement on the relief of pain in children. Because of the recent focus on pain management, it seems appropriate to revisit the question of how nurses perceive children's pain and what treatment strategies they consider. Previous studies have been based on small, local samples, so it would be especially useful to gather information from a larger and more geographically dispersed sample of nurses.
Although research (Boughton et al., 1998; Ellis et al., 2002) has suggested that nurses' treatment of children's pain is sometimes inadequate, studies (Vincent & Denyes, 2004) also have found considerable variability among nurses. If this variation is systematically related to the characteristics of nurses, it would be possible to identify where deficiencies are most concentrated so efforts to improve nurses' knowledge and performance could be appropriately targeted.
Only a few nurse characteristics have been studied with any regularity. Several studies conducted in different countries suggest that nurses who have more clinical experience (Polkki, Vehvilainen-Julkunen, & Pietila 2001; Salantera, Lauri, Salmi, & Helenius, 1999; Vincent & Denyes, 2004), are better educated (He, Polkki, Vehvilainen-Julkunen, & Pietila, 2005; Polkki et al. 2001; Salantera et al., 1999), or have had personal experience with pain (Burokas, 1985; Holm, Cohen, Dudas, Medema, & Allen, 1989) are especially skilled at managing children's pain. However, findings are not consistent across studies, and several researchers have reported that clinical experience (Caty, Tourigny, & Koren, 1995; Dudley & Holm, 1984; Holm et al., 1989), education (Burokas, 1985; Vincent & Denyes, 2004), and personal experience with pain (Vincent & Denyes, 2004) are unrelated to nurses' pain management decisions. The lack of agreement might reflect methodological weaknesses, particularly small sizes, and convenience samples. These inconsistencies suggest the need for further exploration of the factors that affect nurses' pain perceptions and treatment decisions with a large and more representative sample of nurses.
Purpose
The purpose of this study was to describe pediatric nurses' projected responses to children's pain as described in vignettes of hospitalized children and to explore nurse characteristics that might influence those responses. The specific research questions were:
* What are nurses' perceptions of hospitalized children's pain levels, and what decisions do they say they would make regarding the treatment of children's pain?
* Are nurses' characteristics related to variations in pain perceptions and proposed pain treatments?
It was hypothesized that nurses with higher levels of education, more clinical experience, and personal experience with intense pain would be more likely than other nurses to ascribe high levels of pain in hospitalized children and to propose giving them more pain treatments.
Method
Study Design. Data for this study were collected in a cross-sectional mailed survey that was carefully developed by researchers with expertise in survey design. The survey incorporated three case reports (vignettes), each describing a hospitalized school-aged child who was experiencing pain. School-aged children were selected because of evidence that the ability to correctly use pain scales improves with age and becomes especially reliable after age 6 (Stanford, Chambers, & Craig, 2006). For each vignette, respondents were asked to complete several questions relating to their perceptions of the child's pain and their pain management recommendations for the child. The cover letter assured prospective respondents that participation was completely voluntary. They were also told that, in appreciation of their cooperation, they would be entered into a raffle drawing for a $200 gift certificate. They were instructed to return a postcard with identifying information separately from their questionnaire, so that the survey could be returned anonymously. The study proposal was approved by the medical center's Institutional Review Board.
Sample. Questionnaires were mailed to a sample of registered nurses residing throughout the United States. Researchers attempted to secure the names and contact information of a nationally representative sample of pediatric nurses through the American Nurses Association (ANA), but ANA was unable to provide a national list of RNs with a pediatric specialty. Thus, an alternative source of recruiting a geographically diverse sample was used. The population for this study was composed of RNs who subscribed to pediatric journals or who purchased pediatric books. The accessible population was 9,000 pediatric nurses whose names and addresses were available through the Marketing Services of Boston Company. The researchers were aware that they were recruiting a sample that was likely to be experienced, well-educated, and well-read.
Based on earlier research (Calderone, 1990; McDonald, 1994), researchers assumed a small-to-moderate effect size for key relationships in this study. With an effect size of 0.35, power of 0.80, and alpha of 0.05, it was estimated that a sample of 272 nurses was needed. Response rates to mailed surveys tend to be low, even when efforts are made to enhance them; researchers therefore anticipated a response rate in the vicinity of 40%. Questionnaires were mailed to a random sample of 700 RNs from the list of 9,000 pediatric nurses in January 2005.
A modified Dillman approach (Dillman, 2000) was used to enhance response rates. This primarily involved the use of repeated mailings of the instrument and an incentive. The final sample, corrected for known ineligibles and address changes, was 663 nurses presumed to be eligible, of whom 334 responded (50% response rate).
Survey instrument. The questionnaires included three vignettes and questions about pain management for each depicted child. The survey also included questions about the respondents' demographic characteristics and professional background.
Vignettes. Each vignette included a description...
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