LITE STIKK KAN VELTE STORT LASS : Om bruken av ikke-medikamentell smertelindring til barn på sykehus

Formål: Utforske og beskrive erfaringene til sykepleiere som bruker ikke-medikamentell smertelindring til barn på sykehus i Norge. Teoretisk forankring: Rådende litteratur i forhold til bruk av ikke-medikamentelle smertelindringsstrategier til barn gjøres rede for. I tillegg belyses problemstillingen ved hjelp av teoretiske perspektiver rundt: Smerteforståelse – historisk utvikling, definisjoner, smertesyn og barns opplevelse av smerte. Metode: Studien er utforskende og benytter fokusgruppeintervju som metode for innsamling av data. Tre fokusgrupper ble gjennomført med til sammen 14 deltakere. En kombinasjon av ”snøballutvalg” og maksimum variasjonsutvalg ble benyttet for å rekruttere sykepleiere. Intervju og analyse av data ble utført ved å benytte prinsipper fra Kvales perspektiver på intervjuforskning. Resultater: Sykepleiere bruker et stort antall ulike ikke-medikamentelle smertelindringsstrategier, hovedsaklig i forbindelse med smertefulle prosedyrer. Dette bidrar til et bedre samarbeid med barnet og mindre behov for å holde barnet fast. Vellykket bruk av ikke-medikamentell smertelindring avhenger av at strategien velges ut fra barnets behov for kontroll, grad av tillit til sykepleieren samt positiv innstilling til ikke-medikamentell smertelindring på avdelingen. Sykepleiekulturen på avdelingen har stor betydning for bruken og for å hevde eget smertesyn. Konklusjon: Tillit er grunnleggende for bruken av ikke-medikamentell smertelindring til barn som gjennomgår prosedyresmerter. Det er av avgjørende betydning at barnet tilbys ikke-medikamentell smertelindring som er individuelt tilpasset i forhold til behovet for kontroll over situasjonen. Forskningen om ikke-medikamentell smertelindring bør dreies mer mot hvilke strategier som har effekt på hvilke barn, heller enn om en strategi har generell effekt eller ikke. Nøkkelord: barn, ikke-medikamentell smertelindring, smerte, sykepleiekultur, smertesyn

Restraint during medical procedures in hospitalized preschool children. An exploratory study.

Background: This study examined the use of physical restraint during medical procedures on newly admitted preschool children in a pediatric hospital unit. The use of physical restraint during medical procedures can be a distressing experience for children, parents and health care providers. Peripheral vein cannulation (PVC) is a commonly performed medical procedure in hospitals and was used as an example to study restraint. While some guidelines exist regarding how to care for children during medical procedures, physical restraint is seldom discussed in clinical practice and research and is not specifically regulated in legislation. Perspectives from symbolic interactionism (SI) were used in this study to develop a more thorough understanding of the multiple meanings of the interactions that occurred in the observed situations involving the use of physical restraint. Symbolic interactionism considers how we construct meaning and how people interact based on those meanings in addition to establish “a definition of the situation” one operates in as well as how this structures human interaction. Results: Children’s expressions when they faced a PVC were explored. Based on analysis of the video recorded observations and field notes, we suggest a typology of the participating children’s expressions during the PVC procedure; protest, escape and endurance. When expressing protest, the children showed an insistent attitude, disagreed with adults and maintained their own views. When expressing escape the children “panicked” and avoided the hands of adults when being approached. When expressing endurance, the children were stiff, motionless and introverted. The observations showed that the children appeared to resist participation, and minimal or no physical restraint was required when they expressed endurance. Interactions between parents and health care providers during the PVC were explored. The analysis of video recorded observations and field notes revealed three patterns of interactions between parents and health care providers during the PVC. In the first pattern, parents and health care providers pacified the children’s strong protests by keeping an ongoing, distractive conversation about everyday matters and parents acted as co-helpers to perform firm restraint. The second pattern showed that the parents either stopped or distanced themselves in interaction with the health care providers. The parents’ restraint grip became looser which allowed the children to uphold resistance. This was observed after failed attempts to insert the PVC. The third pattern followed as a consequence of parental distancing in the second pattern. When the parents did not support the health care providers anymore, they either helped each other to continue distracting the children, or they ceased distraction attempts and just concentrated on finishing the procedure. Nurses’ and physicians’ perspectives on their performance of the PVC, and the use of restraint were explored. Health care providers had different perspectives on restraint during the observed PVC procedures which resulted in three main themes. “Disparate views on the concept of restraint and restraint use”, exhibited as tension in their naming of and deliberations about restraint. “Ways to limit the use of physical restraint and its negative consequences”, concerned meanings about why the medical procedure was necessary and the importance in helping parents and children to remain rational and calm to prevent the need for restraint. “Experiences with the role of parents and their influence on restraint”, concerned how reluctant and unconfident parents were associated with an escalation of emotions and an increase in forceful restraint. Parents/close relative were interviewed about their participation in the observed PVCs and the use of restraint. The analysis revealed two major themes. The first theme that emerged, “Negotiating what quality of PVC performance to expect”, was based on how: parents expected child-friendly encounters, the performance of PVC caused unexpected and unnecessary suffering for the child, and parents explained and excused the negative experience with the performance of PVC. The second theme: “Negotiating own role and participation in child suffering during the PVC”, was based on parents’ ceaseless strive to be acknowledged for suggestions regarding ways to ease the procedure, uncertain consequences of the procedure and the use of restraint for the children, and the parental protective role and self-criticism. Discussion: The results demonstrate different interactions, expressions, and challenges for children, parents and health care providers during the PVC procedure. Reduction of restraint is difficult to accomplish unless the existence of restraint is acknowledged and made a part of the professional debate among health care providers. Some children’s expressions were ignored, and despite strong resistance to the PVC, restraint was applied. By acknowledging the relevance of “experienced restraint” in research and clinical practice, it may help secure the children’s and parent’s experience, and allow health care providers to better customize their practices. Health care providers need to prepare themselves and the parents better in the planning and management of medical procedures where restraint may occur. Reported differences in perspectives among health care providers such as whether the use of restraint in a practice is sound, necessary, justifiable and legal, highlights the need for discussion around professionalization and formalization of the use of restraint in medical procedures on children. Conclusion: The results may contribute to better acknowledge children’s opinions and emotions, and to increase awareness of the unclear roles parents are given or expected to assume during medical procedures. The multiple perspectives, insecurity, disagreement, negative views and lack of discussions about restraint, call for reflection and critical assessment of appropriateness and alternative strategies. This may lead to more careful and judicious consideration of restraint in pediatric units, and opportunities to critically discuss ongoing practices of restraint management. Research and open discussions are more difficult if restraint is illegal or if it is unclear what is legal. More research on restraint in the pediatric setting and learning from other fields of health care where coercion is common, may contribute to harm-reduction, reduced use of physical restraint, and better quality of care

Resistive expressions in preschool children during peripheral vein cannulation in hospitals: a qualitative explorative observational study

Background Children may resist common medical procedures, and this may lead to the use of restraint. This can be challenging to all of the involved parties, but empirical research is scarce on children’s expressions during these procedures. Methods To explore preschool children’s resistive expressions during peripheral vein cannulation we video recorded and performed an in-depth analysis of naturally occurring situations with six newly hospitalized preschool children. Results Fourteen attempts of peripheral vein cannulation were recorded. A typology of resistive expressions was developed consisting of: protest, escape, and endurance. During the expression of protest, the children showed an insistent attitude where they were maintaining their view. The expression of escape was when children were panicked, avoiding hands of adults when being approached. When expressing endurance the children were stiff, motionless and introverted. Less physical restraint is required during endurance, but children still appear to refuse participation. Conclusions We identified three types of resistive expressions that can be used to better understand the individual child and inform clinical judgment in challenging procedural situations. This knowledge can help to sensitize health care providers in their attempt to arrange for children’s participation

Restraint in paediatric dentistry: a qualitative study to explore perspectives among public, non-specialist dentists in Norway

Objective The aim of this study was to explore the perspectives of non-specialist dentists on the use of restraint in paediatric dentistry in the Public Dental Service in Norway. Materials and Method Two focus group interviews involving four and five dentists, respectively, were conducted in one of the most populated counties in Norway in September 2019. The thematic analysis by Braun and Clarke informed the qualitative analysis. Results According to the dentists, physical restraint in paediatric dentistry is usually used when dental treatment is absolutely necessary. The qualitative analysis revealed the following three main themes: (1) some dentists justify the use of restraint in paediatric dentistry; (2) physical restraint is often legitimised by the fact that the child is sedated; (3) the use of restraint evokes difficult ethical evaluations. Additionally, the dentists had an overarching perspective of acting in the child’s best interest, but they sometimes struggled to find a justifiable path in situations involving restraint. Conclusions Dentists seem to consider the use of restraint combined with sedation as legitimate for absolute necessary dental treatment. Furthermore, the use of restraint involves difficult ethical evaluations

Exploring perspectives on restraint during medical procedures in paediatric care: a qualitative interview study with nurses and physicians

The aim of this study was to explore nurses’ and physicians’ perspectives on and reasoning about the use of restraint during medical procedures on newly admitted preschoolers in somatic hospital care. We analysed qualitative data from individual interviews with a video recall session at the end with seven physicians and eight nurses. They had earlier participated in video recorded peripheral vein cannulations on preschool children. The data were collected between May 2012 and May 2013 at a paediatric hospital unit in Norway. The analysis resulted in three main themes: (1) disparate views on the concept of restraint and restraint use (2), ways to limit the use of physical restraint and its negative consequences, and (3) experience with the role of parents and their influence on restraint. Perspectives from both healthcare professions were represented in all the main themes and had many similarities. The results of this study may facilitate more informed and reflective discussions of restraint and contribute to higher awareness of restraint in clinical practice. Lack of guidance and scientific attention to restraint combined with conflicting interests and values among healthcare providers may result in insecurity, individual dogmatism, and a lack of shared discussions, language, and terminology

Children’s, parents’, and teachers’ experiences of the feasibility of a telerehabilitation intervention for children with acquired brain injury in the chronic phase – a qualitative study of acceptability and participation in the Child In Context Intervention (CICI)

Abstract Background This is a qualitative feasibility study of the Child in Context Intervention (CICI). The CICI is an individualized, goal-oriented and home-based tele-rehabilitation intervention which targets everyday functioning of children (6–16 years) with acquired brain injury in the chronic stage, and their families, one year or more after insult, who have ongoing challenges (physical, cognitive, behavioral, social and/or psychological). The aim of this study is to better understand how children, parents and teachers experienced participation and acceptability; to develop knowledge about the mechanisms of change, and to explore how the CICI was tailored to the context. Methods Six families and schools participated in the intervention, which comprised seven tele-rehabilitation sessions in which the child and parent participated, one in-person parent seminar and four digital school meetings. A multidisciplinary team delivered the intervention to 23 participants over a 4- to 5-month period. The intervention involved psychoeducation about targeted acquired brain injury-related problems, such as fatigue, pain, or social challenges. All but one consented to participate in the current digital interview study. The data were analyzed using content analysis. Results The experience of participation and acceptability varied among the children. Attendance was consistently high; the child participants felt mostly listened to and could influence goal setting and strategies. However, engaging and motivating the child participants proved somewhat challenging. The parents found the CICI rewarding, useful and relevant. However, they had different experiences regarding which intervention component they perceived as most helpful. Some argued in favor of the ‘whole intervention’, while others highlighted new knowledge, SMART goals or the school collaboration. The teachers found the intervention acceptable and useful but wanted a better meeting plan. They had difficulties in finding time for meetings, emphasized the involvement of school leaders, and appreciated the digital format. Conclusions Overall, the intervention was perceived as acceptable, and the participants felt that the various intervention components contributed to improvements. The CICI’s flexibility facilitated tailoring to different contexts based on the children’s functional level. The digital format saved time and provided flexibility regarding the amount of attendance but limited full participation from children with more severe cognitive impairments. Trial registration ClinicalTrials.gov Identifier: NCT04186182

Rehabilitation for children with chronic acquired brain injury in the Child in Context Intervention (CICI) study: study protocol for a randomized controlled trial

Background: Pediatric acquired brain injury (pABI) is associated with long-term cognitive, behavioral, social, and emotional problems, which may affect the quality of life, school, and family functioning. Yet, there is a lack of evidence-based community-centered rehabilitation programs for chronic pABI and these children do not systematically receive comprehensive rehabilitation. The Child In Context Intervention (CICI) study is a pragmatic randomized controlled trial (RCT) for children with chronic pABI, which aims to evaluate the effectiveness of an individualized and goal-oriented intervention targeting everyday functioning of the child and family. Methods: Children aged 6–16 years with MRI/CT-verified intracranial abnormalities will be included in the CICI study if they have persistent self- or parent-reported cognitive, emotional, and/or behavioral challenges 1 year or more after insult and attend school regularly. A total of 70 families will be randomized 1:1 to an intervention or a control group. The intervention consists of seven family sessions, one parent seminar, and four school sessions delivered over approximately 6 months. The parent seminar will be held in person, and the other sessions will mainly be video based. The children’s and families’ self-reported major challenges in everyday life will be targeted using SMART goals. Evidence-based strategies, when available, will be applied to achieve the goals, combined with psychoeducation. Goal attainment scaling (GAS) will be used to evaluate goal attainment. Data is collected at baseline and after approximately 6 and 9 months. External assessors are blinded to group allocation. Primary outcomes are parent-reported brain injury symptoms in children and parenting self-efficacy at 9 months of follow-up. Secondary outcomes include child-reported brain injury symptoms, quality of life, executive functioning in daily life, parent emotional symptoms, family functioning, and unmet family health care needs. A process evaluation will be conducted. Discussion: The current study provides an innovative approach to rehabilitation for children in the chronic phase of ABI and their families. This complex intervention may contribute to the development of evidence-based, high-quality rehabilitation for a large patient group, which is underrepresented in clinical research. It may also improve collaboration between specialized rehabilitation facilities, schools, and local health care services. Inclusion for the trial started in April 2021