Vivências de enfermeiros intensivistas na avaliação e intervenção para alívio da dor na criança

Descriptive survey of daily practical experiences of pediatric nurses in the assessment and intervention to pain relief in children, during nursing care provided in pediatric and neonatal intensive care units, and the influence of the infrastructure of care and system organization. The sample was made up of 109 nurses. The principal results indicated that the majority of the nurses considered the academic training obtained as insufficient to support this aspect of nursing care; that they had not received local training in evaluating pain or in relief interventions; that the staff ratio is inadequate and as well as the availability of institutional guidelines to improve the quality of analgesia. It was concluded that nurses value the assessment and intervention to pain relief in children, but describe aspects which compromise practice: lack of collaborative practice, lack of processes definition, lack of formal and continuing education and lack of infrastructure. These aspects compromise the implementation of scientific evidences capable of improving practical aspects of analgesia in children under intensive care.


ABSTRACT
Descrip ve survey of daily prac cal experiences of pediatric nurses in the assessment and interven on to pain relief in children, during nursing care provided in pediatric and neonatal intensive care units, and the infl uence of the infrastructure of care and system organiza on. The sample was made up of 109 nurses. The principal results indicated that the majority of the nurses considered the academic training obtained as insuffi cient to support this aspect of nursing care; that they had not received local training in evalua ng pain or in relief interven ons; that the staff ra o is inadequate and as well as the availability of ins tu onal guidelines to improve the quality of analgesia. It was concluded that nurses value the assessment and intervenon to pain relief in children, but describe aspects which compromise prac ce: lack of collabora ve prac ce, lack of processes defi ni on, lack of formal and con nuing educa on and lack of infrastructure. These aspects compromide the implementa on of scien fi c evidences capable of improving prac cal aspects of analgesia in children under intensive care.

Pain Child
Intensive care Nursing care Analgesia RESUMEN Survey descrip vo sobre experiencias prác cas diarias de enfermeras pediátricas en evaluación e intervención del alivio del dolor en niños, durante cuidados de enfermería brindados en unidades de cuidados intensivos pediátrica y neonatal, e infl uencia de la infraestructura de cuidado y organización del sistema. La muestra consis ó en 109 enfermeras. La mayoría de las enfermeras consideraron que la capacitación académica obtenida era insufi ciente para enfrentarse a tal aspecto del cuidado de enfermería; relataron no recibir capacitación ins tucional en evaluación del dolor e intervenciones palia vas; manifestaron insufi ciencia de can dad de personal, así como indisponibilidad de direc vas ins tucionales para mejorar la calidad de la analgesia. Las enfermeras valorizaron la evaluación e intervenciones palia vas, aunque describieron aspectos que comprometen la prác ca: habitualidad colabora va, de defi nición en procesos, de capacitación formal con nuada y defi ciencias estructurales. Esto difi culta la implementación de evidencias cien fi cas capaces de mejorar aspectos prác cos de la analgesia en niños bajo cuidados intensivos. Atención de enfermería  Analgesia  INTRODUCTION   Pain is a complex, subjec ve and mul factorial phenomenon, defi ned by the Interna onal Associa on for  the Study of Pain (IASP) as an unpleasant sensory and  emo onal experience associated with actual or poten al ssue damage (1) . It is characterized by complexity, subjec vity and mul dimensionality, including psychological and social aspects of the individual's life, and may not be regarded as a purely physical phenomenon (2) . The relief of pain and the promo on of comfort are essen al interven ons that involve -in addi on to scien fi c knowledge and technical skills -ethical and humanitarian issues in nursing prac ce. The importance of studying pain is due to the fact that the sensa on creates stress, suff ering and discomfort to the pa ent and their family (3) . This being so, with the goal of improving the treatment of pain, the Joint Commission on Accredita on on Healthcare Organiza ons (JCAHO), established the assessment of pain as a fi h vital sign as an indicator of the quality of care. However, it should be evaluated and recorded at the same me as the other vital signs, so that its assessment may be standardized, along with the ac ons undertaken, their basis and the results obtained (4) .

Dolor Niño Cuidados intensivos
Gaps in knowledge about pain and analgesia result in inadequate treatment and failure to value the child's complaints of pain by many health care professionals, who are unaware of the varying forms of pain assessment, including scales and the diff erent indica ons for the use of analgesics, as well as the actual, desirable and side-eff ects verifi ed (5)(6)(7) . The management of pain in child and neonate is complex and includes the child, family members and health care professionals' individual characteris cs (2) . Another issue of fundamental importance is the par cipa on of the parents in the processes of assessing pain and providing pain relief interven ons, as they know their children and are sensi ve to changes which take place in their behavior (8) .
Studies have shown a quan ta ve lack of nursing professionals, as well as shortcomings in these professionals' training in the na onal health system, which results in excessive workload and compromise the quality of the care given. These issues compromise pa ent safety and make it diffi cult to a ain excellence in nursing care, as the nurse spends a lot of me trying to correct systemic problems, a situa on which can compromise the individualiza on and integrality of pa ent care (9) . Because the iden fi ca on of pain, eff ec ve steps for pain relief and the assessment of their outcomes are dynamic and interdependent processes, this study should further the understanding of nurses' experience in care delivery for seriously ill children and neonates with regard to the assessment of pain relief and related interven ons, so as to iden fy issues referent to the care provision system that might compromise nursing prac ce and pa ent safety.

METHOD
This is a descrip ve survey, developed during the II Interna onal Symposium in Neonatal and Pediatric Intensive Care (11th to 14th November 2008) at the Federal University of São Paulo. Authoriza on was obtained from the event organizers and the nurses gave their consent to par cipate. The sample was made up of nurses who agreed to par cipate in the research under the terms expressed for their free and informed consent and who handed back the fi lled-out ques onnaire. Data collec on was carried out once approval had been given by the ins tu on's Research Ethics Commi ee. To study the research variables, a ques onnaire was elaborated, which consisted of asser ons about painful phenomena, focusing on the assessment, interven on and measurement of pain relief outcomes, as well as care structure and process characteris cs that might interfere in pain management in nursing prac ce. These variables were measured by means of a Likert scale, made up of the categories 'strongly agree (AS)', 'agree' (A), 'disagree' (D), 'strongly disagree' (SD), 'neither agree nor disagree' (NAND), 'never' (N), 'rarely' (R), 'some mes' (S), 'frequently' (F) and 'always' (AL). The instrument was put together based on the background literature and the researchers' academic and professional experience regarding pain, pediatrics, pediatric intensive care, evalua on of quality in health service quality assessment and pa ent safety. A stas cal descrip ve analysis of the data was implemented, with the categorical variables analyzed according to absolute and rela ve frequencies and the numerical variables according to median, average and standard varia on.

RESULTS
The sample was made up of 109 nurses, all of whom were female, with an average age of 31.3(±6.5), mainly from the south-west region of Brazil (64.2%). The majority had post-graduate qualifi ca ons lato sensu (61.5%) or stricto sensu (a) 1 (20.2%), an average of 8.2 (±7.0) years since gradua on, an average 1.4 (±0.8) held more than one job, and the clinical fi eld was the principal area of ac vity (84.3%). According to their post-gradua on ar-(a) The major difference is that of these two post-graduate degrees, the latter is necessary for those intending to progress to Master and PhD courses. Translator's note.
The management of pain in child and neonate is complex and includes the child, family members and health care professionals' individual characteristics. Another issue of fundamental importance is the participation of the parents in the processes of assessing pain and providing pain relief interventions... eas, it was observed that 71.1% were specialized in pediatrics, neonatology, pediatric or neonatal intensive care, while 28.9% were specialized in other areas. Regarding the areas they worked in, it may be iden fi ed that the majority (93.4%) work in pediatrics or neonatology, with intensive care (69.7%) being the main area of work, followed by clinics (15.7%).

Rev Esc Enferm
Most (73.4% ) of the nurses state that they received academic training with content rela ng to pain and analgesia in pediatrics, although 65.2% consider that the training was insuffi cient to underpin their professional prac ce. Also, about a third of the sample had never received formal training on pain relief (26.6%). As to the origins of the training, there was academic training (47.5%), obtained in undergraduate, specializa on or Masters' courses, followed by training received during courses or events (27.5%), and through a combina on of both training forms (25.0%). Table 1 presents the responses of the nurses concerning the process of assessing pain in children and neonates, in which they state that the nurse is the health care professional who most values the assessment of pain; that the scales favor the process of assessing pain; that assessing the facial expression is one of the principal methods for assessing pain in neonates and that physiological parameters are more specifi c for evalua ng pain. They believe that the length of clinical experience in the area and the con nuous infusion of analgesics in cri cally ill children interfere in the assessment carried out. By far the majority agree that many children may suff er pain as a result of inadequate assessment.  Table 2 presents the results of the inves ga on of the par cipa ng nurses' care experiences, according to the responses obtained to the asser ons proposed by the study.
The majority of par cipants described the assessment as not being a rou ne ac vity in their workplace, and stated that it is not considered a fi h vital sign. They report that they do not receive frequent training on the subject and are not sure that there will be enough registered nurses for them to carry out the assessments, or that on-the-job training will allow all health care professionals to assess pain in a systema zed way. They agree that the parents provide key informa on concerning the assessment of their children's pain, although the par cipa on of parents is not a frequent prac ce. Table  3, below, iden fi es aspects of nurses' daily prac ce related to how analgesics are prescribed and administered.
Regarding the administra on of analgesics prescribed at the doctor's discre on most of the nurses disagree that it is always the doctor who carries out the pain assessment, although they know that the methods if necessary and upon medical criteria are diff erent to nursing prac ce in administering analgesics. The majority believe that it is possible for pre-school children to use pa ent-controlled-analgesia and for their parents too, when appropriately trained.
In Table 4, which presents ques ons related to interven ons for pain relief in children and neonates, the interviewees affi rm that analgesia is not carried out based on scien fi c evidence, that dipyrone is the most prescribed medica on for pain, and that non-pharmacological methods for relieving pain are well-accepted in prac ce. They disagree that analgesia is always given before invasive procedures, but agree that the use of supplementary analgesia is necessary for painful procedures. They believe that children are at greater risk of respiratory depression than adults when opioid analgesics are used, and also affi rm that analgesics can cause adverse events and have serious sideeff ects in neonates, and should only be prescribed when the presence of pain has been confi rmed. It is noted that the nurses disagree that in intensive care units, analgesia must always be associated with seda on to achieve the best therapeu c effi ciency, and affi rm that seriously-ill children and neonates with con nuous infusion of seda ves need supplementary analgesia. Regarding the statement that they have the materials and equipment necessary for carrying out appropriate interven ons for relieving pain in children there were diff erences of opinion: 51.8% agreed and 48.2% disagreed. They cannot rely on having enough staff in the team, and do not receive constant training in their ins tu ons such that they can implement scien fi c evidence in the prac ce of analgesia with their pa ents. Moreover, they refer to the inexistence of ins tu onal protocols which would permit them to improve the quality of prac ce in analgesia, and affi rm that the presence of the pain team improves the quality of care.  Pre-school children, adequately trained, can use patient-controlled analgesia.  Table 5, the process of outcomes assessment in nurses' daily prac ce is presented. The nurses report that a er an interven on, they never (9.3%), rarely (22.2%) or some mes (26.0%) carry out an evalua on of the care plan's effi cacy. Most interviewees consider that nursing technicians or auxiliaries some mes, rarely or never evaluate and communicate the expected outcomes, and that healthcare professionals communicate the results of pain assessments and adopted pain relief measures during shi change. More than half (59.4%) of the nurses express that in their ins tu ons it is diffi cult to modify treatment schemes when the health care professional detect that these are not effi cacious. We receive constant training at our institution which permits us to implement evidence in the practice of analgesia with our patients.

Rev Esc Enferm
An evaluation of the care plan´s effi cacy is carried out after an intervention. (n=108) 10 In your place of work the health care professionals communicate the pain assessments and relief measures adopted at handover. that they possess knowledge about the issue, they do not consider their learning suffi cient. There is a lack of connuing educa on courses on issues of clinical relevance, which makes it diffi cult to implement evidence into care prac ce, which could contribute to pa ent safety (6) .
The evalua on and relief of pain are processes that need competency and teamwork for the promo on of effi cacious and personalized care to the pa ents and their families. Through their privileged posi on with the paent, the nurses can evaluate the pa ents' physical and psychological well-being, and especially the response to treatment ins tuted (6,10) . However, among the interviewees, divergence may be observed between the premise and the prac ce, as, in spite of their considering pain assessment important and their affi rming that the nurse is the professional who is most concerned with this, it is not a rou ne ac vity in their workplaces, as they divide their roles with nursing technicians and auxiliaries, even in places where there are enough nurses for providing direct pa ent care.
Based on the work structure characteris cs the nurses described, a nega ve infl uence on nursing prac ce outcomes is supposed. A shortage of health care professionals and lack of team training for pain assessment stand out. The quan ta ve shortage of nursing professionals and the employment of less qualifi ed staff for carrying out ac vi es of medium to high complexity lead to a work overload and increase the physical and mental exhaus on of the workers, which compromises the implementa on of changes in the care given and puts pa ent safety at risk, which in turn compromises the ins tu on legally (11) . Many registered nurses s ll hold two jobs, the result of the low salary and low social value a ributed to nursing in Brazil (2,(12)(13) .
In the face of this work structure, many children may suff er pain due to not being appropriately assessed, which disrespects the ethical and legal du es to alleviate the suffering caused by pain, according to the Brazilian Rights of the Hospitalized Child and Adolescent (14) .
Scales are instruments which favor the process of pain assessment and have been available for use since the end of the 1980's, being constantly recommended in the literature in general (7,15) . However, no validated, safe, objec ve and simple to use instrument exists for applica on in all age ranges, which joins a wide range of informa on and is suitable for children's needs and comprehension. Therefore, it is diffi cult to choose an instrument (16) . Observing neonates' facial expressions was considered one of the main pain assessment methods in this age range, which demonstrates knowledge about the issue. Studies have cited facial mimicry as a sensi ve and useful signal, as facial movements become more expressive when neonates are submi ed to painful procedures (12,17) .
The rarity of the par cipa on of parents in assessing their children's pain is evidence of the diff erence between what is believed and what happens. Communica on between the family and the nurse remains precarious (2) . Pain-scale scores indicated by the parents, when compared to those indicated by the nursing assessments, are closer to the children's self-assessments (17) . It follows that, faced with the benefi ts of involving the family in the process of assessing pain, strategies must be developed which facilitate their involvement in this process.
The fact that doctors do not carry out the pain assessment in the mode of administra on termed 'at doctor's discre on', breaks the law that regulates professional nursing prac ce. Yet again, the discourse diff ers from prac ce, and both the nursing and medical teams must re-think the way analgesics are prescribed so as to demonstrate what really happens in prac ce. The most appropriate way of administering analgesics showed diff erent points of view and indecision, in line with other works (2,6) . One should note the importance of not choosing just one method, as each child must be assessed individually and the method proposed which best meets their needs.
In this context of pain relief eff orts, pa ent-controlledanalgesia has been considered an important method for administering medica on, as it maintains plasma c levels of the drug which are suited to each pa ent, respec ng their individuality (18) . It should be emphasized that that the Brazilian literature on the effi cacy and safety of this method with children is scarce.
Non-opioid analgesics, principally the non-hormonal an -infl ammatories, are the drugs of choice for trea ng pain in children, which corroborates this survey's fi nding which iden fi es dipyrone as the medica on most prescribed for analgesia (19) . The authors observe in the literature that the scien fi c underpinnings for the use of the drug are dissonant from its use in prac ce. It is worth emphasizing that there is no scien fi c evidence which substan ates that a child is at greater risk than adults of developing respiratory depression when administered opioids -many studies have encouraged and valued the use of this class of drugs in the treatment of pediatric and neonatal pain (3,8,20) . Many children con nue to be subjected to painful procedures without suitable analgesia. One study found that 8.0% of the children had received analgesia for the inser on of a central catheter, 100.0% for a thoracic drain, while none received analgesia for arterial, venous, capillary and lumbar puncture or for tracheal intuba on -the authors of the study emphasizing that in adults, these procedures are rarely carried out without analgesia (21) -which is similar to the fi ndings of the present study. Unfortunately, this under-treatment of pain is rou ne in various services and studies confi rm this reality in the treatment of children (6,(14)(15)20) .
Although the literature cites that the con nuous administra on of analgesic and seda ve drugs is, theore cal- ly, the most appropriate way of relieving pain in intensive care units, taking into account that the analgesics treat the pain secondary to the invasive methods or referred to by the child and the seda ve reduces the anxiety and stress resul ng from a hos le environment (22) , a large part of this study disagreed that this associa on should always be undertaken. The authors no ced that there is a lack of reviews and prac cal guides, as well as many recommenda ons which are based on experiences with adults (22) . Many nurses do not receive training in their workplace, are not encouraged to a end scien fi c events, and do not work with protocols which permit the implementa on of evidence into analgesic prac ce, demonstra ng fl aws in the work structure.
There is li le valua on among nurses of recording signs and complaints of pain, apart from the measures adopted for evalua on and control and results of interven ons carried out (15) . According to the reality as depicted in this study, con nuity of treatment is hindered; fi rstly by the fact that nursing technicians and auxiliaries never, rarely or some mes evaluate the results being awaited and communicate them to the team, or that they communicate the pain evalua ons and the measures taken for pain relief at handover; and secondly by the fact that nurses do not carry out the evalua on of care plans' effi cacy frequently.
The authors iden fi ed that it is not always easy for nurses to modify treatment schemes when they detect that the exis ng ones are not effi cacious, which shows that the health service hierarchy can compromise the pa entcentered care. Nurses need constant recycling and scien fic background for group discussions, and also need to pos-sess concrete informa on about the effi cacy or ineffi cacy of the established treatment. It is important for nurses to demonstrate excellence and competency in the work they accomplish, without mechanical prac ce, as knowledge is the base for any team discussion and work that seeks excellent care delivery to children and their families.

CONCLUSION
The nurses in this study demonstrate their concern with and value pain assessment and pain relief intervenons, although they do not carry out such ac ons rounely, which demonstrates a concept which diverges from prac ce. In spite of their awareness about the importance of carrying out such ac ons, they have not transformed prac ce, which a tude one should expect of a nurse, as an ac ve agent in the iden fi ca on of ever more qualifi ed ways of mee ng the holis c and individual needs of the pa ent and family. The health care professionals describe situa ons which demonstrate the lack of structure for incorpora ng good nursing prac ce into pa ent care, eminently due to the lack of qualifi ed team members or to the numerical insuffi ciency of staff , an aspect cited more than lack of material resources or equipment. Another highlight is that healthcare ins tu ons neither undertake educaonal programs on this issue nor implement care protocols or processes which make it possible to improve care. This demonstrates not only permanent educa on teams' lack of prepara on to iden fy relevant issues for care prac ce that need change with a view to achieving be er results, but also the inexistence of ins tu onal philosophies and policies aimed at developing good prac ce in nursing.