Designing and Implementation of Pain Management Program in Neonatal Intensive Care Unit: An Action Research
Abstract
Abstract
Introduction: Despite the scientific progress, the recognition and management of pain in the neonatal intensive care unit faces major challenges. Interprofessional collaboration and service providers' participation show strong evidence for improving performance and creating positive changes in pain management quality. This study was conducted with the aim of designing and implementing a pain management program in the neonatal intensive care unit which was done with the participatory action-research approach.
Method: This action research study was conducted from January 2018 to January 2018 during an action-research cycle with the participation of 61 nurses and doctors in the Neonatal Intensive Care Unit of Tabriz Children's Hospital. The cycle was carried out based on the Ivankova's model (Diagnosing, Reconnaissance, Planning, Acting, Evaluation and monitoring). In the diagnosing phase, the research team identified neonatal pain management in the study setting as a problem that needed improvement. In the reconnaissance phase the dimensions of the problem, challenges and barriers to optimal performance were explained. For this purpose, a variety of quantitative data (assessment of the type and frequency of painful interventions, structured observation of staff performance in neonatal pain management, assessment of nurses' perception of neonatal pain management, and parents' assessment of infant nociception) and qualitative data (examination of field documents and individual interviews) were collected. After integration by the research team, the findings were informed during the planning phase by holding three focus groups. During these meetings, solutions were presented by the participants and the priority of acting phase was determined. Then an operational plan was formulated with participant cooperation. The acting phase was carried out in two stages: "introducing and implementing the neonatal pain assessment tool" and "developing and implementing the neonatal pain management protocol". each stages having two steps. In general, 12 collaborative and interprofessional activities were carried out under the steps of the acting phase. This activities included evidence review and protocol formulation, educational program, performance quality monitoring. The educational program included providing educational content (booklet, protocol and poster) and holding 27 theoretical and practical interprofessional training sessions (face-to-face and virtual classes, and clinical rounds), which were finally evaluated by comparing the pre- and post-test scores. During the evaluation phase, the changes made in the neonatal pain management were examined. For this purpose, a variety of quantitative (structured observation of staff performance in neonatal pain management and assessment of nurses' perception of neonatal pain management) and qualitative data (focus groups) were collected. Then the findings during the focus group meeting of the monitoring phase were informed to the participants and reflection was done. In this meeting, necessary decisions were taken to start the next cycle, which is outside the scope of this study. We used descriptive (frequency/percentage and mean) and analytical statistical methods (paired T-test) of SPSS21 to analyze the quantitative data, and the conventional content analysis of Granheim and Lundman model to analyze the qualitative data.
Findings: The integration of quantitative and qualitative findings from the reconnaissance phase led to the identification of 10 barriers to the optimal neonatal pain management, that included "The high level of exposure of the neonate to non-relieving painful interventions", "Lack of specific approach to neonatal pain assessment", "Stressful environmental stimuli", "Lack of clear policy and integrated action framework", "Insufficient coordination of team members", "Negligent organizational supervision", "Lack of knowledge and clinical skills of staff", "High workload and Lack of time", "Physical and mental fatigue of staff" and "High educational need and low family participation in neonatal pain management". In the planning phase, participants selected "development and application of the neonatal pain management protocol" as the acting phase priority, with an emphasis on interprofessional education. Comparision the average of pre- and post-test scores of the educational program of the acting phase, showed that the post-test scores were significantly higher than pre-test scores (P ≤ 0.001). Also, the findings from the evaluation phase indicate the positive changes in the quality of neonatal pain management. In this regard, three categories were obtained that included "improvement of neonatal pain management", "staff satisfaction" and "necessity of continuing changes". Finally, the reflection of the monitoring phase led to the listing of "Achieved progress", "Items requiring correction" and "Facilitators".
Conclusion: The findings of this action-research study showed that creating a specific action framework with measures such as participatory and interprofessional development of the evidence-based protocol, empowering the staff to use the protocol by holding educational programs as well as consistent organizational supervision on the quality of staff performance can promote the regular assessment of infant pain and use of pharmacological and non-pharmacological methods of neonatal pain management. Neonatal intensive care units can use this change process as a model to develop their own program and improve the quality of neonatal pain management.