Evidence-Based Practice – Task 2

A1. Healthcare Problems

Pain is defined as an unpleasant sensory and emotional experience often associated with potential or actual damage to the human body tissue. Pain is a major problem within the delivery of healthcare, and especially for sick newborn infants or babies. In pediatric pain management, healthcare providers often prefer pharmacological pain relief. However, research indicates that this method may be ineffective and pose short-term and long-term side effects such as neurodevelopmental sequelae. Consistently, the effectiveness of analgesic methods has been termed ambiguous.

A2. The significance of the Problem

As compared to adult patient or older children, pediatric patient experience pain that is difficult to assess and treat. Pain management in children is often undertreated because of the belief that they do not suffer pain or remember the pain. However, evidence indicates that uncontrolled pain affects the patient’s quality of life, their emotional, cognitive, and behavioral elements (Kahsay, 2017). Pain management in the pediatric unit is important and beneficial in improving behavioral, physiologic, and hormonal outcomes (Mangat, Oei, Chen, Quah-Smith, & Schmölzer, 2018). Additionally, pain management prevents adverse consequences, especially on long-term neurological development. For instance, studies on animal models indicate that pain can affect future stress response. Consistently, while pharmacological methods are the most preferred mode of pain management, some are associated with adverse effects. For example, opioids are associated with adverse effects such as respiratory depression and somnolence. Understanding the adverse effects associated with pharmacological pain management, healthcare providers are now adopting non-pharmacological pain management. In light of this, the study sought to examine the effectiveness of non-pharmacological pain management in pediatric settings as compared to pharmacological intervention.

A3. Current Practice

Acute and chronic pains are common problems that are often debilitating to pediatric populations. Within the current practice, healthcare providers often use pharmacological relief to manage pain in children. Unfortunately, as Kahsay (2017) expounds, the current pharmacological procedures are extrapolated from adult pain management and do not have any evidence of value in children. Besides, the current pharmacological treatment options have various adverse effects on children. For instance, Wren et al. (2019) note that opioid therapy is one of the pharmacological interventions used and is often referred to as the cornerstone of acute, postoperative, and chronic pain management in pediatric. Unfortunately, despite the benefits associated with opioids, they also have several side effects such as constipation, psychiatric comorbidities, cognitive function, and respiratory depression. Increased use of opioid use is also linked to physical tolerance, drug dependence, heightened pain sensitization, and addiction, which can have adverse effects in the future. D’Souza, Wren, Almgren, Ross, Marshall, and Golianu (2018) also note that the long-term use of opioids risks outweighs the benefits, especially with chronic pain patients. Consistently, and recognizing the negative effects associated with the use of opioids, there have been efforts to adopt analgesia treatment. Within the clinical practice, healthcare providers are now combining pharmacological and non-pharmacological treatment options to reduce the adverse impacts of opioids. The combination of two methods is intended to enhance patient comfort, reduce reliance on opioid therapy, and improve functionality.

A4. Impact on Background

Acute and chronic pain affects millions of pediatric patients every year. However, despite the increased focus on the importance of controlling pain, pain management remains suboptimal. Uncontrolled pain in children is associated with various adverse effects on the emotional, physical, cognitive, and the psychological well-being of the patients. Uncontrolled pediatric pain is also likely to affect patient outcomes, which will be reflected in organizational outcomes.

B. Evidence Sources

Research Articles

The article by Bergomi, Scudeller, Pintaldi, and Dal (2018) highlighted that there is increased evidence supporting the use of non-pharmacological methods for pain relief in children. Various non-pharmacological methods such as distraction and cryotherapeutic topical analgesia have been identified as beneficial in pain management among children. However, Bergomi et al. note that evidence about distraction methods as a pain relief technique have been conflicting. Recognizing this, the article sought to examine the effectiveness of non-pharmacological pain management techniques. The randomized controlled study enrolled 150 children aged 5 to 12 years. The results of the study indicated that non-pharmacological techniques were effective in the management of pain in pediatric unit. In particular, use of animated cartoons and Buzzy ® were significantly effective in pain intervention among children.

The second research article by Oliveira and Linhares (2015) is a systematic review to assess the impact of non-pharmacological pain relief in children. Firstly, the article starts by recognizing pain as a global health concern, which is stress with various effects on child development and quality of life. Oliveira and Linhares highlight that use of pharmacological or non-pharmacological interventions depends on the type of pain, the context, and the dimensions of pain. Consistently, the aim the study was to systematically evaluate the effectiveness of non-pharmacological pain acute pain relief method for preschool and school age children. Supported by 12 empirical studies, the study found that distraction from parents, objects, or an MMD device as a pain management intervention is an effective strategy in acute pain relief. The goal of using distraction is to shift the child’s attention from pain towards more enjoyable stimuli. The method was also found to be the least time-consuming and cost-effective to administer. However, two studies that were reviewed examined the use of pharmacological and non-pharmacological techniques to relieve pain in children. Accordingly, the authors assert that caution should be exercised when drawing conclusions because it was not clear whether non-pharmacological method worked on itself or in association with pharmacological technique. 

Non-Research Articles

According to the article, the American Academy of Pain Medicine in collaboration with the American Academy of Pediatrics understands that pain is associated with injuries and diseases (Pennsylvania Department of State, 2017). Children and adolescents are more likely to experience acute pain. The guidelines provided for safe prescription of opioids for Pennsylvania recognize the effects associated with the use of opioids and provide a detailed outline of when opioids can be used. Further, the article recommends the use of non-pharmacological pain management interventions citing the adverse effects associated with opioids. In support, an article posted on the American Society of Anesthesiologists (2019) has also cited the adverse effects of opioids. In particle, the article acknowledges the fear of opioid abuse in parents but still notes that some parents believe that opioids are still more effective in managing pain in children. The article highlights the conflicted relationship between opioids, adverse effects, and risks. In addition, the article highlighted that parents are not asking about alternatives to opioids used. Nonetheless, in the end, the article acknowledges that there are better and effective alternatives to opioids, which can be used in pain management among children.

C. PICOT Question

In pediatric care settings, how effective is non-pharmacological pain management as compared to pharmacological pain management in controlling pain in children during hospitalization.

D. Evidence Matrix

Authors	Journal Name	Year of Publication	Research Design	Sample Size	Outcome Variables Measured	Quality (A, B, C)	Results/Author’s Suggested Conclusions
Birnie et at.	Canadian Journal of Pain	2018	Qualitative study	20 children aged 4 to 7 years	To examine the effectiveness of technology-based intervention in managing acute pain in young children and the usability of the Achy Penguin app in helping children with acute postoperative pain.		The authors’ conclusion indicated the promise of the Achy Penguin app in improving pain assessment  and management in children. However, Birnie et al. highlighted that it is important to carry further research to determine the effectiveness of the application before implementation.
Efe, Özcan, Dikmen, & Altaş	The Open Pain Journal,	2017	Descriptive study	92 pediatric nurses in 17 university hospitals in Turkey	To determine the use of non-pharmacological methods by nurses to relieve post-operative pain in children aged 6 to 12 years.		The authors found new non-pharmacological methods used by nurses in pediatric unit to manage pain. Some of the methods used by nurses included distraction, positive reinforcement, comforting, thermal regulation, relaxation, and massage among others.
Oliveira& Linhares	Psychology and Neuroscience	2015	Systematic review	12 articles	Systematically review the recent literature on the effectiveness of non-pharmacological pain management intervention for children during medical procedures.		The authors noted that the review demonstrated the effectiveness of non-pharmacological pain management intervention in children undergoing medical procedures. Distraction was cited as one method to relieve acute pain in the pediatric setting. Nonetheless, the authors also noted that there lack enough randomized controlled trials in this particular area and recommend the need to design this design.
Chotolli & Luize	Revista Dor	2015	Descriptive, exploratory study	35 nursing professionals	Identify pain measurement scales and non-pharmacological interventions used in pediatric settings by nurses.		The authors observed major difficulties among participants in measuring pain in children between 0 and 2 years. Pharmacological pain relief methods were found to be the first choice of participants. There is insufficient knowledge of non-pharmacological pain relief methods among participants. Recommendations included training on pain measurement scale and non-pharmacological pain management interventions.
Bergomi, Scudeller, Pintaldi, & Dal.	Journal of Pediatric Nursing	2018	Randomized controlled study	150 children were enrolled in the study	Evaluate the effectiveness of two non-pharmacological interventions – Buzzy® device and animated cartoons during venipuncture in pediatrics.		The authors found that the use of non-pharmacological interventions during venipuncture were effective. In particular, distractions such as cartoons and Buzzy® were especially effective.

E. Recommended Practice Change

Evidence indicates that pharmacological pain management has various adverse effects as Wren et al. (2019) highlight that opioid is the most popular pharmacological intervention in the pediatric setting and although it is often referred to as the cornerstone of pain management, it is associated with several negative effects. Considering the negative outcomes associated with pharmacological interventions, healthcare providers are shifting to non-pharmacological interventions. The reviewed studies indicate the effectiveness of non-pharmacological interventions in pain management within pediatric healthcare settings. In particular, Oliveira and Linhares (2015) found that the integration of pharmacological and non-pharmacological pain management interventions was efficient in the management of acute and chronic pain in the pediatric setting.. Consistently, Bergomi et al. (2018) found that the use of non-pharmacological intervention in pediatric pain management was effective. In particular, the study found that distractions such as cartoons and Buzzy ® were considerably effective. Efe et al. (2017) found several non-pharmacological interventions used by Turkish nurses in the pediatric unit. The article found strong evidence indicating the effectiveness distraction, positive reinforcement, thermal regulation, touch, presence, and helping with daily activities as strongly effective in pediatric pain management. Additionally, the article by Birnie et al (2018) introduced a new pain intervention method. The use of technological interventions in healthcare has taken center place and the introduction of a mobile-based intervention in pain-management is inevitable. Results indicated that the mobile-based app has potential to improve pain assessment and management, but future research is necessary to explore the effectiveness of the application. Contrary to the other articles,  Chotolli and Luize (2015) results indicated that knowledge of non-pharmacological pain management interventions remain scarce, which implied the need for educational interventions to inform nurses and other healthcare providers of non-pharmacological pain management methods. Accordingly and drawing upon the reviewed articles, the recommended practice change is the adoption of integrated non-opioid pharmacological and non-pharmacological pain management in the clinical practice.

F1. Key Stakeholders

The key stakeholders involved in the change process include healthcare organization implementing the clinical practice. The second stakeholder includes administrative personnel, pediatricians, and pediatric nurses working in the healthcare organization and who will be the drivers of change. The administrative personnel will be responsible for initiating the change in the organization, provide the necessary resources, and oversee the implementation of the proposed intervention. Pediatricians and pediatric nurses will be the change drivers, who will implement the change within the organization. The two groups of stakeholders interact with patients and are responsible for the delivery of care. The other key stakeholders include children who will receive evidence-based intervention.

F2. Barriers

Considering that the proposed clinical practice is a new practice, the change is likely to face some barriers. Some of the project barriers that are likely to face the implementation of integrated non-opioid pharmacological and non-pharmacological interventions are lack of knowledge and skills and resistance to change. In one of the reviewed articles, results indicated that lack of knowledge about non-pharmacological interventions prevented the implementation of these changes and hindered the effectiveness of the intervention. Lack of knowledge and skills is a major barrier in the implementation of evidence-based interventions. The other barrier is resistance to change. This barrier can especially be caused due to lack of knowledge about the changes or negative attitudes from nurses about the change process leading to resistance. Physicians who feel they were left out in the change process may be opposed to the change.

F3. Strategies for Barriers

The success of the proposed change depends on the ability to overcome barriers. The first strategy to overcome these barriers includes providing education and necessary training programs to increase knowledge and awareness of non-pharmacological interventions and the way they can be used in pain management in the pediatric unit. The other strategy is including the key stakeholders from the beginning of the change process to reduce resistance.

F4. Indicator to Measure Outcome

The objective of the proposed change in clinical practice is to eliminate the adverse effects associated with pharmacological pain management interventions, especially opioids. The aim is to integrate nonopioid pharmacological and non-pharmacological pain relief methods to improve patient outcomes. The indicator to measure outcome will be the adoption of integrated non-opioid pharmacological and non-pharmacological methods in the pediatric setting. Specific goals to measure the outcome include improved patient outcomes in relation to pain management and reduced adverse effects of pain management interventions. 

Pain management in the pediatric setting is a major healthcare concern. Use of pharmacological pain management has been associated with several adverse effects. With this knowledge, the proposed change within the clinical practice is the use of non-pharmacological interventions. Evidence indicates that integrated nonopioid pharmacological and non-pharmacological pain management interventions are effective in the management of pain in pediatric settings. Notably, the proposed intervention is likely to face various barriers during the implementation process such as lack of knowledge and resistance from pediatricians and pediatric nurses.  Nonetheless, these barriers can be overcome to ensure the change process is successful.

References

American Society of Anesthesiologists. (2019). Parents worried about risks, but still think opioids are best for kids’ pain relief, nationwide survey shows. Retrieved from https://www.asahq.org/about-asa/newsroom/news-releases/2019/01/physaneswk19-news-release

Bergomi, P., Scudeller, L., Pintaldi, S., & Dal, M. A. (2018). Efficacy of Non-pharmacological Methods of Pain Management in Children Undergoing Venipuncture in a Pediatric Outpatient Clinic: A Randomized Controlled Trial of Audiovisual Distraction and External Cold and Vibration. Journal of Pediatric Nursing, 42, e66-e72.

Birnie, K. A., Nguyen, C., Do, A. T., Baker, L., Campbell, F., Lloyd, S., Ouellette, C., … Stinson, J. (2018). A parent-science partnership to improve postsurgical pain management in young children: Co-development and usability testing of the Achy Penguin smartphone-based app. Canadian Journal of Pain, 2(1), 280-291.

Chotolli, M. R., & Luize, P. B. (2015). Non-pharmacological approaches to control pediatric cancer pain: nursing team view. Revista Dor, 16(2), 109-113.

D’Souza, G., Wren, A. A., Almgren, C., Ross, A. C., Marshall, A., & Golianu, B. (2018). Pharmacological Strategies for Decreasing Opioid Therapy and Management of Side Effects from Chronic Use. Children, 5(12), 163.

Efe, E., Özcan, D., Dikmen, S., & Altaş, N. (2017). Turkish Pediatric Nurses’ Use of Non-Pharmacological Methods for Postoperative Pain Relief in 6 to 12 Year Old Children. The Open Pain Journal, 10(1), 56-64.

Kahsay, H. (2017). Assessment and treatment of pain in pediatric patients. Current Pediatric Research, 21(1), 148-157.

Mangat, A., Oei, J.-L., Chen, K., Quah-Smith, I., & Schmölzer, G. (2018). A Review of Non-Pharmacological Treatments for Pain Management in Newborn Infants. Children, 5(130), 1-12.

Oliveira, N. C. A. C., & Linhares, M. B. M. (2015). Nonpharmacological interventions for pain relief in children: A systematic review. Psychology and Neuroscience, 8(1), 28-38.

Pennsylvania Department of State. (2017). Safe prescribing of opioids in pediatric and adolescent populations. Retrieved from https://www.dos.pa.gov/ProfessionalLicensing/BoardsCommissions/Documents/PA%20Guidelines%20-Pediatric%20and%20Adolescent%20Populations.pdf

Wren, A. A., Ross, A. C., D’Souza, G., Almgren, C., Feinstein, A., Marshall, A., & Golianu, B. (2019). Multidisciplinary Pain Management for Pediatric Patients with Acute and Chronic Pain: A Foundational Treatment Approach When Prescribing Opioids. Children (basel, Switzerland), 6(2). doi:10.3390/children6020033.