Abstracts
BACKGROUND AND OBJECTIVES:
Hospitalized newborns are often submitted to painful and stressing procedures. Adequately measuring and evaluating pain favor its control in this population. For such, education and training strategies are important, emphasizing computer-based technology, which involves software, multimedia packages and network connection. This article aimed at describing the Neonatal Pain Assessment Program II.
CASE REPORT:
The platform used to host the Neonatal Pain Assessment Program II is the Modular Object-Oriented Dynamic Learning Environment (Moodle). The program is made up of eight modules addressing contents regarding pain anatomy and physiology, neonatal pain indicators, use of pain evaluation tools, in addition to detailed explanations of four specific tools to evaluate newborn pain. Resources such as audio presentations, formative evaluation exercises with photos and videos, texts for additional reading and discussion forums are also used.
CONCLUSION:
Computer-based teaching may be considered important knowledge translation facilitator. So, we believe that this initiative, considered novel and innovative, shall favor the use of clinical evidences in different neonatal assistance scenarios, as well as shall enhance knowledge and skills of health students and professionals with regard to neonatal pain evaluation.
Distance education; Educational technology; Newborn; Pain; Pain assessment; Pain prevention and control
JUSTIFICATIVA E OBJETIVOS:
Recém-nascidos internados são frequentemente submetidos a procedimentos dolorosos e estressantes. Mensurar e avaliar a dor adequadamente favorecem seu controle nessa população. Para tanto, estratégias de educação e treinamento são relevantes, destacando-se o ensino mediado por tecnologia, que envolve o uso de softwares, pacotes multimídia e conexão em rede. O presente artigo teve como objetivo descrever o Programa de Avaliação da Dor Neonatal II.
RELATO DO CASO:
A plataforma utilizada para hospedar o Programa de Avaliação da Dor Neonatal II é o Modular Object-Oriented Dynamic Learning Environment(Moodle). O programa é composto por oito módulos, abordando conteúdos referentes à anatomia e fisiologia da dor, indicadores de dor neonatal, utilização de instrumentos de avaliação da dor, além de abordagem detalhada de quatro instrumentos específicos de avaliação da dor no recém-nascido. Recursos como apresentações com áudio, exercícios de avaliação formativa utilizando fotografias e vídeos, disponibilização de textos para leitura complementar, e fóruns de discussão também são utilizados.
CONCLUSÃO:
O ensino mediado por tecnologia pode ser considerado um importante facilitador na transferência do conhecimento. Assim, acredita-se que essa iniciativa, considerada inédita e inovadora, favorecerá a utilização de evidências científicas nos diferentes cenários de assistência neonatal, bem como ampliará o conhecimento e a habilidade de estudantes e profissionais de saúde quanto à avaliação da dor no neonato.
Avaliação da dor; Dor; Educação à distância; Prevenção e controle da dor; Recém-nascido; Tecnologia educacional
INTRODUCTION
Newborn (NB) pain is considered routine for most neonatal assistance units. Recent studies point to the high and concerning number of painful procedures performed during their hospitalization, in addition to the inefficacy of analgesic strategies in neonatal units11. Carbajal R, Rousset A, Danan C, Coquery S, Nolent P, Ducrocq S, et al. Epidemiology and treatment of painful procedures in neonates in intensive care units. JAMA. 2008;300(1):60-70.
2. Harrison D, Loughnan P, Manias E, Johnston L. Analgesics administered during minor painful procedures in a cohort of hospitalized infants: a prospective clinical audit. J Pain. 2009;10(7):715-22.
3. Harrison D, Loughnan P, Manias E, Johnston L. Utilization of analgesics, sedatives, and pain scores in infants with a prolonged hospitalization: a prospective descriptive cohort study. Int J Nus Studies. 2009;46:624-32.-44. Johnston C, Barrington KJ, Taddio A, Carbajal R, Filion F. Pain in Canadian NICUs: have we improved over the past 12 years? Clin J Pain. 2011;27(3):225-32.. Currently, studies indicate that NB pain may activate cortical areas of term and preterm neonates55. Bartocci M, Bergqvist LL, Lagercrantz H, Anand KJ. Pain activates cortical areas in the preterm newborn brain. Pain. 2006;122(1-2):109-17.
6. Slater R, Cantarella A, Gallella S, Worley A, Boyd S, Meek J, et al. Cortical pain responses in human infants. J Neurosci. 2006;26(14):3662-6.-77. Slater R, Cantarella A, Franck L, Meek J, Fitzgerald M. How well do clinical pain assessment tools reflect pain in infants? PLoS Med. 2008;5(6):e129., which reinforces recommendations and protocols being published in the attempt to favor its control88. Anand KJ. International Evidence-Based Group for Neonatal Pain. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med. 2001;155(2):173-80.
9. Batton DG, Barrington KJ, Wallman C. Prevention and management of pain in the neonate: an update. American Academy of Pediatrics Committee on Fetus and Newborn, American Academy of Pediatrics Section on Surgery, Canadian Paediatric Society Fetus and Newborn Committee. Pediatrics. 2006;118(5):2231-41. Erratum in: Pediatrics. 2007;119(2):425.-1010. Lago P, Garetti E, Merazzi D, Pieragostini L, Ancora G, Pirelli A, et al. Guidelines for procedural pain in the newborn. Acta Paediatr. 2009;98(6):932-9.. Pain is a complex, subjective and multidimensional phenomenon, expressed predominantly in verbal terms, which is not the case of NB due to their verbalization inability, being necessary to consider other parameters, especially behavioral and physiological parameters, to confirm its presence1111. Stevens BJ, Pillai Ridell RR, Oberlander TE, Gibbins S. Assessment of pain in neonates and infants. In: Anand KJS, Stevens BJ, McGrath PJ, (editors). Pain in neonates and infants. Philadelphia, 3rd ed. Elsevier; 2007. 67-90p.. The lack of verbal complaint associated to the lack of specific response pattern make NB pain evaluation dependent on indirect methods.
It should be stressed that pain evaluation involves not only its measurement with specific tools, but also clinical reasoning and decision-making as from measurements. So, in addition to providing pain evaluation, tools contribute to the evaluation of analgesic efficacy of interventions, of responses of a same NB to different pain episodes along time and, also, different responses of different newborns to similar painful situations.
Currently, the scientific literature has numerous tools to evaluate NB pain. The high number of published scales shows the difficulty of establishing a valid and reliable scale1111. Stevens BJ, Pillai Ridell RR, Oberlander TE, Gibbins S. Assessment of pain in neonates and infants. In: Anand KJS, Stevens BJ, McGrath PJ, (editors). Pain in neonates and infants. Philadelphia, 3rd ed. Elsevier; 2007. 67-90p. Additionally, no tool available to date is considered ideal1111. Stevens BJ, Pillai Ridell RR, Oberlander TE, Gibbins S. Assessment of pain in neonates and infants. In: Anand KJS, Stevens BJ, McGrath PJ, (editors). Pain in neonates and infants. Philadelphia, 3rd ed. Elsevier; 2007. 67-90p..
It is necessary to use tools with adequate psychometric properties and indicated for the context in which pain occurs, such as clinical condition and gestational age. It is also important a deep evaluator's knowledge about the tool to be applied and its particularities. Finally, it is critical the development of accurate observation skills to simultaneously notice multiple pain indicators and also to establish specific time intervals to evaluate neonatal pain1212. Stevens B, Johnston C, Taddio A, Gibbins S, Yamada J. The premature infant pain profile: evaluation 13 years after development. Clin J Pain. 2010;26(9):813-30.. So, education and training strategies aimed at neonatal pain evaluation may be considered extremely important for the practice of professionals providing direct assistance to this population.
In the traditional teaching model, activities are in general offered in a vertical and mechanical way, with individual and normative approach which makes difficult the sharing of experiences as well as the association between theoretical content and practice1313. Fernandes Md, Barbosa VL, Naganuma M. [Nursing physical examination of the full-term neonate: self-instructional software]. Rev Lat Am Enfermagem. 2006;14(2):243-50. Portuguese.. So, computer-mediated teaching (CMT) is proliferating among health professionals along the last decade1414. Gibbins S, Maddalena P, Yamada J, Stevens B. Testing the satisfaction and feasibility of a computer-based teaching module in the neonatal intensive care unit. Adv Neonat Care. 2007;7(1):43-9.. Currently, online teaching is aimed at qualifying adults in graduation and post-graduation levels, extension, sequential and ongoing education courses1515. Rodrigues RC, Peres HH. Panorama brasileiro de ensino de enfermagem online. Rev Esc Enf USP. 2008;42(2):298-304.. Such models involve computer-mediated strategies, such as software and multimedia packages, and also online teaching strategies, which necessarily involve network connections and may be used as training, enhancing and professional updating tools.
Several advantages may be attributed to CMT, especially temporal flexibility, spatial decentralization, collaboration and communication among users, increased confidence of users with regard to learning, development of IT-related skills, active learning process directed by the user, development of safe learning environments, meeting of different learning needs and decreased teaching time1414. Gibbins S, Maddalena P, Yamada J, Stevens B. Testing the satisfaction and feasibility of a computer-based teaching module in the neonatal intensive care unit. Adv Neonat Care. 2007;7(1):43-9.
15. Rodrigues RC, Peres HH. Panorama brasileiro de ensino de enfermagem online. Rev Esc Enf USP. 2008;42(2):298-304.-1616. Fernández-Alemán JL, Carrillo de Gea JM, Rodríguez Mondéjar JJ. Effects of competitive computer-assisted learning versus conventional teaching methods on the acquisition and retention of knowledge in medical surgical nursing students. Nurs Educ Today. 2009;31(8);866-71.. In a quasi-experimental study, Berger et al.17 17. Berger J, Topp R, Davis L, Jones J, Stewart L. Comparison of web-based and face-to-face training concerning patient education within a hospital system. J Nurses Staff Dev. 2009;25(3):127-32.have compared the effects of online course, online course facilitated by the teacher and instructor-mediated classroom course, offered to 1661 nurses. There has been no significant difference on learning and users' satisfaction with regard to the different teaching strategies; however, the online course has shown better cost-effectiveness: USD 4.05 per student for the online course and USD 59.35 per student for the instructor-mediated classroom course.
With regard to neonatal assistance, the literature shows the development and evaluation of CMT models1313. Fernandes Md, Barbosa VL, Naganuma M. [Nursing physical examination of the full-term neonate: self-instructional software]. Rev Lat Am Enfermagem. 2006;14(2):243-50. Portuguese.,1414. Gibbins S, Maddalena P, Yamada J, Stevens B. Testing the satisfaction and feasibility of a computer-based teaching module in the neonatal intensive care unit. Adv Neonat Care. 2007;7(1):43-9.,1818. Fonseca LM, Góes FS, Ferecini GM, Leite AM, Mello DF, Scochi CG. Inovação tecnológica no ensino da semiotécnica e semiologia em enfermagem neonatal: do desenvolvimento à utilização de um software educacional. Texto e Contexto Enferm. 2009;18(3):549-58.
19. Gonçalves GR, Peres HH, Rodrigues RC, Tronchin DM, Pereira IM. Proposta educacional virtual sobre atendimento da ressuscitação cardiopulmonar no recém-nascido. Rev Esc Enf USP. 2010;44(2):413-20.-2020. Góes Fdos S, Fonseca LM, Furtado MC, Leite AM, Scochi CG. [Evaluation of the virtual learning object "Diagnostic reasoning in nursing applied to preterm newborns]. Rev Lat Am Enfermagem. 2011;19(4):894-901. English, Portuguese, Spanish.. Only the software proposed by Gibbins et al.1414. Gibbins S, Maddalena P, Yamada J, Stevens B. Testing the satisfaction and feasibility of a computer-based teaching module in the neonatal intensive care unit. Adv Neonat Care. 2007;7(1):43-9. refers to neonatal pain evaluation by means of the Premature Infant Pain Profile (PIPP): 68 health professionals have participated in the training and 95% of them were very happy with the software; in addition, users have positively evaluated aspects related to clarity of instructions, easiness to access content and format.
So, CMT strategies may be considered knowledge translation facilitators, especially when used to change practices and improve clinical outocmes2121. Davis D, Davis N. Educational interventions. In: Straus S, Tetroe J, Graham ID, (editors). Knowledge translation in health care: moving from evidence to practice. Hoboken: Wiley-Blackwell; 2009. 113-23p.. Knowledge translation is defined as a dynamic and interactive process involving synthesis, dissemination, exchange and ethical application of knowledge to improve health, health-related products and services quality and to strengthen health assistance system2222. Straus SE, Tetroe J, Graham ID, Zwarenstein M, Bhattacharyya O. Monitoring knowledge use and evaluating outcomes of knowledge use. In: Straus S, Tetroe J, Graham ID, (editors). Knowledge translation in health care: moving from evidence to practice. Hoboken: Wiley-Blackwell; 2009. 151-9p..
There is a major gap between research results and NB pain-related clinical practice2323. Stevens B. Challenges in knowledge translation: integrating evidence on pain in children into practice. CJNR. 2009;41(4):109-14.. Several factors contribute to such gap and, especially in Brazil, research results are predominantly produced in English, professionals do not have the habit of looking for evidences to be used at bedside, there is limited access to complete articles published in arbitrated journals, and it is difficult to critically identify and evaluate evidences of quality.
Considering such obstacles, a computer-mediated education strategy was devised aiming at enhancing knowledge and skills of health students and professionals with regard to evaluating NB pain. This initiative is considered novel and innovative for neonatal assistance and care in Brazil, and contributes to minimize this gap and to make easier the use of scientific evidences in the clinical practice.
Initial experience
The Neonatal Pain Evaluation Program (PAD-Neo) was created in 2010, financed by International Association for the Study of Pain® (IASP®) - Developing Countries Project: Initiative for Improving Pain Education, 2009-2010. In a pioneer fashion, specific tools for neonatal pain evaluation were used, which were validated and consecrated by the international scientific literature.
The program was developed based on the Addie model, acronym for analysis, design, development, implementation and evaluation2424. Molenda M. In search of the elusive ADDIE model. Performance improvement [texto na internet]. Indiana; 2003. [Citado 2011 abr 01]. Disponível em: http://www.comp. dit.ie/dgordon/Courses/ILT/ILT0004/InSearchofElusiveADDIE.pdf
http://www.comp. dit.ie/dgordon/Courses/...
. The analysis stage has involved extensive literature survey and establishment of neonatal pain evaluation tools to be addressed by the course, of virtual learning environment, of hardware and software needs, of image capturing methods (video and pictures), in addition to determining target audience. The following stages (design and development) consisted in planning and developing program objectives, as well as theoretical and practical contents, didactic resources and evaluation tools. The evaluation stage was carried out initially from the perspective of program users, involving 10 health professionals and graduation and post-graduation students.
The "Modular Object-Oriented Dynamic Learning Environment" (Moodle) was the platform used to host PAD-Neo. This is open and free software developed as from a social constructivist approach of education and which allows the development of interactive and collaborative online courses, in addition to learning management of virtual groups and communities2525. Faria NG. Fotografia digital de feridas: desenvolvimento e avaliação de curso online para enfermeiros [dissertação]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2010.. Program content was distributed in modules and the activities of each module were planned to be developed along one week, with approximately two to three weekly hours of activities.
Module 1, in addition to detailed information about the course, had a pre-test made up of 20 multiple-choice questions regarding the subject of the course, with the purpose of evaluating previous users' knowledge.
Modules 2 to 4 had contents on aspects of anatomy and physiology related to NB pain, indicators of neonatal pain and use of neonatal pain evaluation tools. To help the application of tools in the clinical practice, validated and simple scales were selected, as follows: Neonatal Facial Coding System (NFCS2626. Grunau RV, Craig KD. Pain expression in neonates: facial action and cry. Pain. 1987;28(3):395-410.), Neonatal Infant Pain Scale (NIPS2727. Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw. 1993;12(6):59-66.), Premature Infant Pain Profile (PIPP2828. Stevens B, Johnston C, Petryshen P, Taddio A. Premature Infant Pain Profile: development and initial validation. Clin J Pain. 1996;12(1):13-22.) and Crying, Requires Oxygen for saturation above 95%, Increased vital signs, Expression, Sleepless (CRIES2929. Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatr Anaesth. 1995;5(1):53-61.).
It is important to stress that in all modules, discussion forums, additional reading texts and formative evaluation exercises specific for the content of each module were used. At the end of Module 8, a post-test made up of 20 multiple-choice questions and a form with Likert-type questions related to format and content, adequacy of exercises and additional reading, adequacy of activities and workload were applied.
PAD-Neo was evaluated by 10 users, who have integrally completed all activities during the proposed period. In the pre-test, mean number of correct answers was 13±1.88 from a total of 20 questions, and in the post-test, 16±2.41 (p=0.006). One should also stress that users have reported that they were happy or very happy with the following PAD-Neo aspects: workload (43.4 and 56.6%, respectively), organization and content (22.5 and 75%), virtual learning environment (22 and 76%), content applicability (33.3 and 66.7%), and didactic resources (32.5 and 62.5%). Users suggestions included increasing the number of pictures and videos used to apply neonatal pain evaluation scales.
Development of PAD-Neo II
Positive results obtained with the first version, as well as the originality of the initiative, have shown the importance of this education strategy in Brazil. So, we decided to update the program, which started to be called PAD-Neo II and is being developed with the sponsoring of the Research Support Foundation of the State of Minas Gerais (FAPEMIG), Universal Tender, 20132015. For such, not only needs observed by researchers themselves along initial program development and evaluation were considered, but also comments offered by users. We decided to maintain course hosting platform (Moodle), given its ease of use and available resources, as well as basic program structure, that is, modular format, use of four pain evaluation tools, use of resources such as discussion forums, exercises, and additional reading texts, among others.
In the second version of the program, we decided to maintain Module 1 with informative features and presentation with general orientations about the development of the course, by means of user's guide and timetable, among other resources. In addition, we have maintained the pre-test, made up of multiple-choice updated questions related to the subject of the course. Modules 2 to 4 content was updated with regard to anatomy and physiology aspects, neonatal pain indicators and use of NB pain evaluation tools. Available educational and support resources include audio presentations on the subject, formative evaluation exercises, additional reading texts, in addition to discussion and operational forums.
Similar to the initial version, PAD-Neo II Modules 5 to 8 address specific scales for neonatal pain evaluation. However, authors considered necessary to replace two tools, namely PIPP and CRIES. PIPP scale was recently updated and reviewed and was called PIPP-Revised3030. Stevens BJ, Gibbins S, Yamada J, Dionne K, Lee G, Johnston C, et al. The premature infant pain profile-revised (PIPP-R): initial validation and feasibility. Clin J Pain. 2014;30(3):238-43.; although pain indicators have been maintained, instructions and consequently the scoring method of the tool were changed3030. Stevens BJ, Gibbins S, Yamada J, Dionne K, Lee G, Johnston C, et al. The premature infant pain profile-revised (PIPP-R): initial validation and feasibility. Clin J Pain. 2014;30(3):238-43., so, this version was adopted. Additionally the CRIES scale was replaced by the BIIP tool. CRIES was developed to evaluate postoperative pain; however, other included tools (NFCS, NIPS AND PIPP) were also validated for this purpose and, in addition, they have more robust psychometric properties as compared to CRIES. It should be also stressed that such scale considers ideal oxygen saturation as above 95%. However, this index does not confirm current recommendations, especially for preterm neonates, where desirable oxygen saturation levels vary between 85 and 93%3232. Finer N, Leone T. Oxygen saturation monitoring for the preterm infant: the evidence basis for current practice. Pediatr Res. 2009;65(4):375-80.. We, then, decided to replace CRIES by BIIP, developed and validated by Holsti & Grunau3131. Holsti L, Grunau RE. Initial validation of the Behavioral Indicators of Infant Pain (BIIP). Pain. 2007;132(3):264-72. and Holsti et al.3333. Holsti L, Grunau RE, Oberlander TF, Osiovich H. Is it painful or not? Discriminant validity of the Behavioral Indicators of Infant Pain (BIIP) scale. Clin J Pain. 2008;24(1):83-8., which considers NB behavioral status, facial mimic and hands movements as indicators. Both tools, PIPP-R and BIIP, went through transcultural and content validation processes for our proposal and respective manuscripts are being prepared.
So, the last four modules are made up of an audio presentation where information about the tools is detailed (NFCS, NIPS, PIPP-R and BIIP), as well as about indicators and scoring methods; exercises including pictures and videos of NBs in painful and/or potential painful conditions; discussion forum; operational forum; additional reading texts.
Formative evaluation exercises based on videos and pictures are considered of particular importance and differential in the initiative since they simulate daily painful situations in neonatal assistance. The presentation of real scenarios in real time helps evaluators' training and enhances their capacity of simultaneously observing multiple pain indicators; this may also improve the use of neonatal pain evaluation tools in the clinical practice1212. Stevens B, Johnston C, Taddio A, Gibbins S, Yamada J. The premature infant pain profile: evaluation 13 years after development. Clin J Pain. 2010;26(9):813-30.. For this reason, PAD-Neo II has several pictures and four videos per module, which are used as exercises.
At the end of the course we have maintained the form to evaluate workload, content organization, virtual environment, content applicability and didactic resources.
It is noteworthy that, at the moment, PAD-Neo II is in process of completion. Next, program format and content shall be validated. So, eight information technology or related areas professionals, eight neonatal nursing professionals and eight professionals with experience in distant education will be invited to participate in this validation process3434. Associação Brasileira de Normas Técnicas. ISO/IEC 9126-1. Engenharia de software - Qualidade de produto. Parte 1: Modelo de qualidade. 2003.,3535. Associação Brasileira de Normas Técnicas. ISO/IEC 14598-6. Engenharia de software - Avaliação do produto. Parte 6: Documentação de módulos de avaliação. 2004.. PAD-Neo II shall be initially evaluated by IT or related areas professionals and technical corrections shall be made, if needed. Then, neonatal nursing and education professionals will evaluate and, if needed, corrections and adaptations shall also be made.
CONCLUSION
Computer-mediated teaching strategies may be extremely important to change practices, in this case, neonatal pain evaluation in healthcare settings. As from the results of the first version of the program, we believe that PAD-Neo II will allow the translation of specific knowledge and skills and is distinguished by the use of robust and internationally recognized tools for neonatal pain evaluation. We hope that PAD-Neo II as extension strategy for health area graduation students as well as for professionals involved with neonatal assistance, as soon as its validation process is completed, shall contribute to the teaching process of this subject. We also expect to measure the effects of the course in the clinical practice, not only regarding professional practices but also neonatal outcomes.
ACKNOWLEDGMENTS
To the International Association for the Study of Pain (IASP) for financing in the Developing Countries Project: Initiative for Improving Pain Education (2009) modality, for the initial development of the Neonatal Pain Evaluation Program (PAD-Neo). To our colleagues Adriana Moraes Leite, Amélia Fumiko Kimura, Angélica Arantes S. Oliveira, Bonnie Stevens, Carmen Gracinda S. Scochi, Luciana Mara Monti Fonseca, Priscila Costa, Roberta Cardoso, Sharyn Gibbins, who participated in the PAD-Neo working team.
To the Research Support Foundation from the State of Minas Gerais (FAPEMIG) for granting financing in the Universal Demand modality, Tender 02/2012, APQ-00370-12, for PAD-Neo II development and validation.
-
*
Received from the Maternal-Child Nursing and Public Health Department, School of Nursing of Minas Gerais, Belo Horizonte, MG, Brazil.
REFERENCES
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1Carbajal R, Rousset A, Danan C, Coquery S, Nolent P, Ducrocq S, et al. Epidemiology and treatment of painful procedures in neonates in intensive care units. JAMA. 2008;300(1):60-70.
-
2Harrison D, Loughnan P, Manias E, Johnston L. Analgesics administered during minor painful procedures in a cohort of hospitalized infants: a prospective clinical audit. J Pain. 2009;10(7):715-22.
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3Harrison D, Loughnan P, Manias E, Johnston L. Utilization of analgesics, sedatives, and pain scores in infants with a prolonged hospitalization: a prospective descriptive cohort study. Int J Nus Studies. 2009;46:624-32.
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4Johnston C, Barrington KJ, Taddio A, Carbajal R, Filion F. Pain in Canadian NICUs: have we improved over the past 12 years? Clin J Pain. 2011;27(3):225-32.
-
5Bartocci M, Bergqvist LL, Lagercrantz H, Anand KJ. Pain activates cortical areas in the preterm newborn brain. Pain. 2006;122(1-2):109-17.
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6Slater R, Cantarella A, Gallella S, Worley A, Boyd S, Meek J, et al. Cortical pain responses in human infants. J Neurosci. 2006;26(14):3662-6.
-
7Slater R, Cantarella A, Franck L, Meek J, Fitzgerald M. How well do clinical pain assessment tools reflect pain in infants? PLoS Med. 2008;5(6):e129.
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8Anand KJ. International Evidence-Based Group for Neonatal Pain. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med. 2001;155(2):173-80.
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9Batton DG, Barrington KJ, Wallman C. Prevention and management of pain in the neonate: an update. American Academy of Pediatrics Committee on Fetus and Newborn, American Academy of Pediatrics Section on Surgery, Canadian Paediatric Society Fetus and Newborn Committee. Pediatrics. 2006;118(5):2231-41. Erratum in: Pediatrics. 2007;119(2):425.
-
10Lago P, Garetti E, Merazzi D, Pieragostini L, Ancora G, Pirelli A, et al. Guidelines for procedural pain in the newborn. Acta Paediatr. 2009;98(6):932-9.
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11Stevens BJ, Pillai Ridell RR, Oberlander TE, Gibbins S. Assessment of pain in neonates and infants. In: Anand KJS, Stevens BJ, McGrath PJ, (editors). Pain in neonates and infants. Philadelphia, 3rd ed. Elsevier; 2007. 67-90p.
-
12Stevens B, Johnston C, Taddio A, Gibbins S, Yamada J. The premature infant pain profile: evaluation 13 years after development. Clin J Pain. 2010;26(9):813-30.
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13Fernandes Md, Barbosa VL, Naganuma M. [Nursing physical examination of the full-term neonate: self-instructional software]. Rev Lat Am Enfermagem. 2006;14(2):243-50. Portuguese.
-
14Gibbins S, Maddalena P, Yamada J, Stevens B. Testing the satisfaction and feasibility of a computer-based teaching module in the neonatal intensive care unit. Adv Neonat Care. 2007;7(1):43-9.
-
15Rodrigues RC, Peres HH. Panorama brasileiro de ensino de enfermagem online. Rev Esc Enf USP. 2008;42(2):298-304.
-
16Fernández-Alemán JL, Carrillo de Gea JM, Rodríguez Mondéjar JJ. Effects of competitive computer-assisted learning versus conventional teaching methods on the acquisition and retention of knowledge in medical surgical nursing students. Nurs Educ Today. 2009;31(8);866-71.
-
17Berger J, Topp R, Davis L, Jones J, Stewart L. Comparison of web-based and face-to-face training concerning patient education within a hospital system. J Nurses Staff Dev. 2009;25(3):127-32.
-
18Fonseca LM, Góes FS, Ferecini GM, Leite AM, Mello DF, Scochi CG. Inovação tecnológica no ensino da semiotécnica e semiologia em enfermagem neonatal: do desenvolvimento à utilização de um software educacional. Texto e Contexto Enferm. 2009;18(3):549-58.
-
19Gonçalves GR, Peres HH, Rodrigues RC, Tronchin DM, Pereira IM. Proposta educacional virtual sobre atendimento da ressuscitação cardiopulmonar no recém-nascido. Rev Esc Enf USP. 2010;44(2):413-20.
-
20Góes Fdos S, Fonseca LM, Furtado MC, Leite AM, Scochi CG. [Evaluation of the virtual learning object "Diagnostic reasoning in nursing applied to preterm newborns]. Rev Lat Am Enfermagem. 2011;19(4):894-901. English, Portuguese, Spanish.
-
21Davis D, Davis N. Educational interventions. In: Straus S, Tetroe J, Graham ID, (editors). Knowledge translation in health care: moving from evidence to practice. Hoboken: Wiley-Blackwell; 2009. 113-23p.
-
22Straus SE, Tetroe J, Graham ID, Zwarenstein M, Bhattacharyya O. Monitoring knowledge use and evaluating outcomes of knowledge use. In: Straus S, Tetroe J, Graham ID, (editors). Knowledge translation in health care: moving from evidence to practice. Hoboken: Wiley-Blackwell; 2009. 151-9p.
-
23Stevens B. Challenges in knowledge translation: integrating evidence on pain in children into practice. CJNR. 2009;41(4):109-14.
-
24Molenda M. In search of the elusive ADDIE model. Performance improvement [texto na internet]. Indiana; 2003. [Citado 2011 abr 01]. Disponível em: http://www.comp. dit.ie/dgordon/Courses/ILT/ILT0004/InSearchofElusiveADDIE.pdf
» http://www.comp. dit.ie/dgordon/Courses/ILT/ILT0004/InSearchofElusiveADDIE.pdf -
25Faria NG. Fotografia digital de feridas: desenvolvimento e avaliação de curso online para enfermeiros [dissertação]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2010.
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26Grunau RV, Craig KD. Pain expression in neonates: facial action and cry. Pain. 1987;28(3):395-410.
-
27Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw. 1993;12(6):59-66.
-
28Stevens B, Johnston C, Petryshen P, Taddio A. Premature Infant Pain Profile: development and initial validation. Clin J Pain. 1996;12(1):13-22.
-
29Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatr Anaesth. 1995;5(1):53-61.
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Publication Dates
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Publication in this collection
Apr-Jun 2014
History
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Received
19 Dec 2013 -
Accepted
10 May 2014