Procedural pain in neonates: Do nurses follow national guidelines? A survey to Swedish neonatal units
Introduction
Invasive procedures are the most common reasons for pain in hospitalized infants. Carbajal et al. (2008) demonstrated that newborns on average were subjected to 12 painful procedures per day during the first two weeks of their Neonatal Intensive Care Unit (NICU) stay, mainly without analgesia. The pain caused by these procedures adds to the burden of stress in the neonate, causing a risk for short- and long term consequences (Abdulkader et al., 2008; Bouza, 2009).
The increasing insight that pain alleviation is a necessity in newborn care has lead to the creation of national and international guidelines for the management of newborn pain. Following the international document (Anand, 2001), early examples of national guidelines can be found in USA and Canada (American Academy of Pediatrics, 2006), Sweden (Larsson et al., 2002) and Australia (Royal Australasian College of Physicians, 2006). Typically, these guidelines have sections on pain assessment and non-pharmacological and pharmacological interventions. The non-pharmacological interventions aim at minimizing stress- and painful events, offering support like non-nutritive sucking and skin-to-skin contact and giving sweet solutions orally prior to minor painful procedures.
National guidelines should be transformed into local written guidelines at every unit providing care for newborn infants. Gharavi et al. (2007) showed that units with local guidelines will provide a higher frequency of pain treatment and documentation of pain. In Sweden 88% of the neonatal units had written pain guidelines 2008 (Eriksson and Gradin, 2008) compared to for example 15% in Australia (Harrison et al., 2006) and 44% in Austria, Switzerland and Germany (Gharavi et al., 2007).
A previous survey to the chief neonatologist at all Swedish NICUs revealed that behavioural (non-pharmacological) interventions were given before some skin breaking procedures at 53–95% of the units. Only one (3%) of the units reported using pharmacological interventions (EMLA cream), before subcutaneous injection. Oral glucose solution for the same procedures were given at 66–91% of the units (Eriksson and Gradin, 2008).
The purpose of this study was to investigate if nurses on neonatal units in Sweden followed the national guidelines for some painful procedures (peripheral venous catheter placement, capillary heel stick, venepuncture and s.c/i.m. injections), and secondly to investigate documentation of pharmacological and non-pharmacological pain-alleviating interventions. The results were compared with those of a preceding chief neonatologist survey (Eriksson and Gradin, 2008).
Section snippets
Design and setting
The study design was a semi-structured survey sent to a sample of nurses at every NICU in Sweden. The units were divided into four categories, from level A: university hospital with full neonatal intensive care services, to level B: county hospital with a neonatal intensive care unit, level C: county and general hospital with partial and short-time neonatal intensive care, to level D: hospital without neonatal intensive care, following the official Swedish ranking (National Board of Health and
Results
One-hundred and twenty surveys (response-rate 67%) were returned from a total of 36 units One of the 45 units that had received the survey reported that they did not provide care for newborn infants, so the response rate for units was 82%. Four of the returned surveys from one unit reported policies and practices concerning older children and were thus excluded, leaving 116 surveys for analysis, from 34 units. Twenty of the reporting units returned all four surveys, ten returned three surveys
Discussion
This study supports the idea that most nurses in Swedish neonatal units provide support, according to the national guidelines, for the infants during commonly performed painful procedures, and is coherent with a recent study showing that Sweden, Denmark and France are most likely to employ evidence based pain-alleviation recommendations (Losacco et al., 2011). This indicates an awareness among the nurses, that providing treatment, behavioural support or both to minimize the infant's pain is
Conclusion
A vast majority of responding NICU nurses provided behavioural and/or pharmacological support at skin breaking procedures, thereby following the Swedish national neonatal pain guidelines. Pharmacological interventions were documented to a higher extent than behavioural support. All units had written guidelines about neonatal pain management. Chief neonatologists reported higher use of glucose, which is recommended in the Swedish national guidelines, than did nurses and specialist trained nurses.
Acknowledgements
This project was supported by the European Community's Seventh Framework Programme under grant agreement no. 223767. We also wish to thank the staff at all units that replied to the survey.
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