Running head: pain assessment IN YOUNG CHILDREN The Wisconsin Children?s Hospital Pain Scale for Preverbal Children: A Descriptive Study Experiences of Nurses Using the University of Wisconsin Children?s Hospital Pain Scale for Preverbal Children: A Descriptive Study Most patients in the hospital setting experience pain. Pain is a subjective phenomenon that varies from person to person. The most relied upon indicator of pain is a patient?s verbal report of the pain, but what happens when the patient cannot verbalize his pain? This is the case with infants and other nonverbal patients. They experience pain but are unable to tell a nurse where it hurts, how it hurts, and the intensity to which it hurts. O?Conner-Von (2000) stated “if self-report is not available, physiologic or behavioral measures must be used” (p. 1), and “nurses are the key health care personnel responsible for continuous assessment in children in the health care setting” (p. 1).
Nurses need a reliable and continuous means of pain assessment for the preverbal population. A study of the pediatric pain practices of national health professionals showed that only twenty percent of the sample used a behavioral assessment scale (Broome, Richtsmeier, Maikler, & Alexander, 1996, p. 314).
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Investigation of the tools used to assess pain in the nonverbal population of the pediatric floors in hospitals located in a small Midwestern city revealed that no one method was being used in any of the hospitals. According to several pediatric nurses from various hospitals in the area, nurses were assessing the pain of the nonverbal population based on their own opinions as to whether or not the patient was in pain, how consolable the patient was, and the parent?s report as to whether or not the patient was in pain. While this method of pain assessment can be accurate, it can also vary widely between nurses as no two nurses have the same perception or assessment of any one patient?s pain. In order to ensure that pain of a nonverbal child is being assessed every time by every nurse in a consistent manner, a pain assessment scale is necessary. The University of Wisconsin Children?s Hospital (UWCH) Pain Scale for Preverbal and Nonverbal Children is a scale used to assess pain based on five categories: “facial, vocal/cry, behaviorial/consolability, body movements/posture, and sleep” (Soetenga, Frank, & Pellino, 1999, p. 3).
This scale is in a column format due to previous reports that this form is easier to use in the clinical setting than scales that require the user to add up scores in each category to get an end result (p. 3).
The purpose of this study is to describe the experiences of pediatric nurses at a regional medical center as they implement The University of Wisconsin Children?s Hospital Pain Scale for Preverbal and Nonverbal Children on children between the ages of six and twelve months in the acute clinical setting. Infant pain has for the most part been inadequately assessed and poorly managed. This is largely due to myths that children cannot feel pain or if they do feel pain, are unable to remember the occurrence(McCaffery & Pasero, 1999, pp. 629-630; Soud & Rogers, 1998, p. 689; Brown, 1997, p. 349).
Recent studies have moved more toward the fetus having the “anatomic and neurochemical abilities to experience discomfort” as early as the second trimester (Soud & Rogers, 1998, p. 689.) The central nervous system is as mature as an adult?s by 36 weeks gestation (Brown, 1997,p. 349), and at birth, an infant has comparable, if not more, numbers of nociceptive nerve endings on their skin surface as an adult (McCaffery & Pasero, 1999, p. 629).
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The instant comfort from their mother or fathers smell or sounds they are aware of who is who already. Babies know how to communicate right from the time of birth through crying. Crying is often due to hunger, tired, dirty soiled nappy or illness. Skin to skin when born is known to help the bond between a mother and baby. Also close contact with parents and baby during caring times Eg Feeding, ...
This suggests that infants are as capable as adults of experiences painful impulses. Studies have also shown that infants can in fact remember painful stimuli. Continual behavioral changes in infants after painful procedures indicate that the infants have some ability to remember the painful event (Soud & Rogers, 1998, p. 689).
Infants also can develop behaviors, such as stiffening and withdrawal, in response to the anticipation of repeated painful stimuli such as a heel lance (McCaffery & Pasero, 1999, p. 630).
As these myths have been discredited, more importance has been placed on assessing the pain of the nonverbal child. The assessment, in itself, is challenging. How does a nurse assess the pain when verbal self-report is non-existent? Researchers Jacob and Puntillo (1999) surveyed the practice of childhood pain assessment and management and found that “nurses indicated that physiological changes, facial expression, and body language are determinants of pain” (p. 283).
Because similar physiological changes can occur due to either the actual illness or the pain the infant is experiencing (Jorgensen, 1999, p. 351) and due to the fact that the body adjusts itself in times of stress, returning to normal parameters when the pain still exists (Baylor International, 2000, p. 3), other indicators of pain must be used when assessing the preverbal child. Hudson (1997) reported in response to a question regarding the current recommendations for providing comfort for infants hospitalized in the acute care setting that “behavioral observation has been recommended as the primary pain assessment method for the nonverbal child” (p. 1).
Behavioral indicators of pain include grimacing (facial expression), crying, holding the breath (Brown, 1997, p. 354), “gross motor movement, and changes in behavioral state and functions (e.g., sleeping and eating patterns” (McCaffery & Pasero, 1999, p. 633).
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Facial expression is the most typical behavioral indicator of pain and is characterized by the “brows and forehead bulging, eyes squeezed tightly closed, cheeks raised to form a nasolabial furrow, and the mouth opened and stretched both horizontally and vertically” (McCaffery & Pasero, 1999, p. 633).
These facial expressions are usually accompanied by a cry and are even present during the “silent cry” of an intubated infant (Jorgensen, 1999, 351; McCaffery & Pasero, 1999, p. 634).
Researchers have found that infant?s have a distinct pain cry that may be perceptible by the infant?s mother and other trained individuals (Jacob & Puntillo, 1999, p. 282).
Other studies show the cry of an infant in pain has an increased pitch, “intensity of higher frequency components, and mean cry energy of a vocalization” (Fuller & Conner, 1995, p. 255), and is “tense, harsh, nonmelodious, short, sharp, and loud (McCaffery & Pasero, 1999, p. 633).
Body movement is another behavioral indicator of pain. An infant in pain can have increased body movements such as “kicking, thrashing, and limb/trunk rigidity” (as cited by Hudson, 1997, p. 1) and increased muscle tension as the infant “moves vigorously, extends and flexes arms and legs, and squirms on the bed (Jorgensen, 1999, p. 351).
While some infants in pain exhibit increased activity, the opposite may occur as a child, who has learned that moving or being picked up increases his pain, lies very still in bed (Baylor International, 2000, pp. 2-3).
Sleep and wake patterns can also be affected by pain. A child who is in pain “is typically fussy”, but a sleeping child or one who is seemingly unaffected can still be experiencing pain as they may have decreased resources to expend the energy needed to move or even cry (Jorgensen, 1999, p. 351).
Because of this, no one behavioral indicator can be relied upon to assess the pain level in a nonverbal child. In order for a pain assessment scale to be accurate, multiple behavioral categories need to be integrated (Soetenga et al., 1999, p. 3).
The University of Wisconsin Children?s Hospital Pain Scale for the Nonverbal and Preverbal infant is a pain scale that assesses multiple behavioral categories: “facial, vocal/cry, behavior/consolability, body movements/posture, and sleep” (Soetenga et al., 1999, p. 3).
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This scale, in column format, gives a description of behaviors that a nurse can compare to the behaviors of the patient and obtain a pain rating on a scale of 0-5 (pp. 3-6).
The validity and reliability of this scale was tested and the scale was found to be both valid and reliable (Soetenga et al., 1999).
The construct validity, inter-rater correlation, and internal consistency were all found to be acceptable (p. 9).
“The criterion validity may be low due to comparison of nurse ratings with parents? ratings and the use of a more subjective scale, rather than another behavioral scale” (p. 10).
What are the experiences of pediatric nurses at a regional medical center as they implement The UWCH Pain Scale for Preverbal and Nonverbal Children between the ages of six and twelve months in the acute clinical setting? The variable in this study is the experiences of nurses implementing The UWCH Pain Scale for Preverbal and Nonverbal Children. The operational definition of this variable is the results gathered by the researcher from interviews (see Appendix A) with pediatric nurses who have implemented the scale in the acute clinical setting at a regional medical center. The target population of this study is pediatric registered nurses in the acute clinical setting. The accessible population is pediatric nurses at a regional medical center. This study will be conducted on the pediatric unit of a regional medical center. A descriptive study design will be utilized. In a descriptive study, “phenomena are described or the relationship between variables is examined” (Nieswiadomy, 1998, p. 127) The experiences of nurses implementing the University of Wisconsin Children?s Hospital Pain Scale for Preverbal and Nonverbal Children are the phenomena being described in this study.
The nurses involved in the study will attend an inservice describing and explaining how to use the UWCH Pain Scale for Preverbal and Nonverbal Children. The scale will be implemented for one month. At the end of the month, the nurses implementing the scale will be interviewed and data will be collected. The sample will be a convenience sample of all thirty registered nurses working on the pediatric unit at a regional medical center. Data for this study will be the self-report experiences of nurses participating in the study and will be collected through a semi-structured interview. Set questions will be asked, but the researcher also will be able to ask probe questions to further clarify the responses. Both closed and open-ended questions will be used. The data will be collected by the researcher one month after the implementation of the scale into practice in a controlled environment, such as a conference room, obtained by the researcher. The researcher will make appointments with each nurse involved in the study to allow for adequate time for the interview and to ensure that all nurses are interviewed. The interview schedule is located in Appendix A. Data collected will be compared across all participants of the study. Experiences will be analyzed for major themes, similarities, for opinions as to whether or not this scale is feasible to use in the clinical setting, and suggestions for improvement to the scale or means of implementation. This proposal will be submitted to the Institutional Review Board of the medical center for approval. Informed consent will be obtained from all participants by having the participants sign a statement of informed consent (Appendix B).
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The nurses as employees of the hospital are vulnerable subjects. They will be guaranteed that their participation will in no way negatively affect their job. Participants will be guaranteed anonymity and confidentiality. The researcher will be the only person who can connect any data collected to the person it was collected from. All results will be generalized and in no way linked to any one nurse. All subjects will participate of their own free will without the use of coercion. The benefits of this study appear to outweigh the risks. The benefits will be the reflection of nurses on their means of pain assessment of the preverbal population. There are no known significant risks in this study. All participants will be able to ask questions about the study and were given a means of contacting the researcher if any questions arose at any time before, during, and after the study is completed. Also, all participants will be informed as to how to obtain the results of the study once completed. The results of the completed study will be submitted to The Journal of Pediatric Nursing for publication. Results will also be presented to the Pain Management Panel at the regional medical center. Baylor International Pediatric AIDS Initiative. (2000, June 8).
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Assessment and diagnosis of pain in children. Houston. Retrieved July 11, 2000 from the World Wide Web: http://bayloraids.org/resources/childpain/assess.shtml Broome, M. E., Richtsmeier, A., Maikler, V., and Alexander, M. A. (1996, May).
Pediatric pain practices: A national survey of health professionals. Journal of Pain and Symptom Management, 11, 312-320. Brown, R. E., Jr. (1997).
Care of children with pain. In M. Cahill (ed.), Expert pain management (pp. 348-357).
Springhouse, PA: Springhouse Corporation. Fuller, B. F. and Conner, D. A. (1995, August).
The effect of pain on infant behaviors. Clinical Nursing Research, 4, 253-273. Hudson, D. C. (1997).
Pain management in the hospitalized infant. Journal of the Society of Pediatric Nurses, 2, 93+. Retrieved July 11, 2000 from Firstsearch database on the World Wide Web: http://firstsearch.oclc.org Jacob, E. and Puntillo, K. A. (1999, May-June).
A survey of nursing practice in the assessment and management of pain in children. Pediatric Nursing, 25, 278-286. Jorgensen, K. M. (1999, December).
Pain assessment and management in the newborn infant. Journal of PeriAnesthesia Nursing, 14, 349-256. McCaffery, M., and Pasero, C. (1999).
Pain: Clinical manual. St. Louis: Mosby. Nieswiadomy, R. E. (1998).
Foundations of nursing research. Stamford, CT: Appleton & Lange. O? Conner-Von, S. (2000, July 11).
Pediatric pain assessment. Iowa City: University of Iowa. Retrieved July 11, 2000 from the World Wide Web: http://coninfo.nursing.uiowa.edu/sites/PedsPain/Assess?chiast.html Soetenga, D., Frank, J., and Pellino, T.E. (1999).
Assessment of the validity and reliability of the University of Wisconsin Children?s Hospital pain scale for preverbal and nonverbal children. Pediatric Nursing, 25, pp. 670+. Retrieved July 11, 2000 from Firstsearch database on the World Wide Web: http://www.firstsearch.oclc.org Soud, T. E. and Rogers, J. S. (1998).
Manual of pediatric emergency nursing. St. Louis: Mosby. Educational background (diploma, associate?s degree, B.S.N, advanced degree)? Number of years in nursing? Does unit have written standards for pain assessment? How did you assess the pain of the nonverbal child prior to implementation of the UWCH pain scale? Did you ever take into consideration the behavioral actions of the child to be indications of pain? If so, what behavioral characteristics? Do you feel that adequate explanation and/or instruction were given in regards of using the UWCH pain scale? Was the scale easy to use? Explain, how. What were your experiences in using the UWCH pain scale for preverbal and nonverbal children? What were the advantages/disadvantages of using the scale? Are there any areas where you feel the scale could be modified to ease use or improve the assessment of pain in this population? How would you compare the level of pain assessed using the UWCH pain scale to how you would have previously assessed the pain? Would you have assessed a higher or lower level of pain than what was assessed using the scale? Committee on the Use of Human Subjects in Research I, _______________________________, am being asked to participate in a research project entitled “Experiences of Nurses Using the University of Wisconsin Children?s Hospital Pain Scale for Preverbal and Nonverbal Children: A Descriptive Study.
This project is being conducted under the supervision of Brandee Witbracht and was approved by Bradley University?s Committee on the Use of Human Subjects in Research on ________________. From this project the investigators hope to learn the experiences of nursing implementing the UWCH pain scale. An interview will be conducted after the scale is implemented and responses will be analyzed for themes, similarities, and opinions as to whether or not the scale is feasible for practice. As a participant in this project I shall be asked to attend an inservice explaining the scale and describing how to implement the scale. After the inservice, I will be asked to use the scale in my everyday assessment of pain in the nonverbal population for a period of one month. At the end of the month I will be interviewed by the researcher in a controlled setting obtained by the researcher. The nature of this study has been explained to me by Brandee Witbracht. I understand that the anticipated benefits of my participation in this study are my reflections on my own practice and the protocols of my unit on the assessment of pain in the nonverbal population. There are no known significant risks in this study.
The investigators will make every effort to safeguard the confidentiality of the information I provide. Any information obtained from this study that can be identified with me will remain confidential and will not be given to anyone without my permission. If at any time I would like additional information about this project, I can contact Brandee Witbracht at Bradley University?s Nursing Department. I understand that I have the right to refuse to participate in this study. I also understand that if I do agree to participate I have the right to change my mind at any time and stop my participation. I understand that grades and services I receive from Bradley University or my employment at__________________ will not be negatively affected by my refusal to participate or by my withdrawal from this project. My signature below indicates that I have given my informed consent to participate in the above-described project. My signature also indicates that: I have been given the opportunity to ask any and all questions about the described project and my participation and that all of my questions have been answered to my satisfaction. I have been permitted to read this document and I have been given a signed copy of it. I am legally able to provide consent. To the best of my knowledge and belief I have no physical or mental illness or weakness that would be adversely affected by my participation in the described project. _______________________________________ __________ _______________________________________ __________
