Health care professionals \200\231 knowledge about pediatric pain Nurses \200\231 knowledge about pediatric pain Over the past 15 years, seven studies have examined nurses \200\231 k nowl- edge about pediatric pain (Table 63.1). Th e results of these studies suggest gaps re main in nurses \200\231 knowledge. Th ese studies have not all used the same questionnaire, thus precluding precise compari- sons. However, the results provide an indication of where gaps in knowledge are; there seem to be particular issues in relation to pain assessment, analgesic drugs, and non-pharmacological methods. Th e one study that took place in the dev eloping world (Ekim et al., in press) suggests there are greater gaps in knowledge than in other countries. Further research is needed to explore this in other devel- oping countries and to identify eff ective ways of providing required education. Strategies for educating parents about pain An essential component of educating children ab out pain is to educate their parents. Just as children require age-appropriate explanations of pain, it is critical to assess parents \200\231 cognitive abil- ity, understanding of p ain, experience with pain, and readiness to learn, in order to provide appropriate educatio n. Th e goals of educating parents about their child \200\231s pain are to improve knowl- e dge and awareness of pain, to decrease misconceptions about pain, to provide pain relief, a nd to facilitate eff ective communi- cation with the health care team (Curtiss, 2010; DiMag gio et al., 2010). Other health care professionals \200\231 knowledge about pediatric pain Little research has been carried out in relation to medical staff s \200\231 knowledge about pediatric pain. O ne study suggests pediatric residents (registrars) have gaps in knowledge similar to those iden- tifi ed with nurses (Saroyan et al., 2008). Th is pilot study tested the hypothesis t hat there are diff erences in residents \200\231 pediatric pain knowledge across diff erent specialities (pediatrics (n = 26), ortho- paedics (n = 19) and anaesthesiology (n = 15)). Pediatric residents had statistically signifi cantly higher knowledge than those working in orthopedics (p = 0.006) and anaesthesiology (p <0.001). Th e pediatric residents on averag e answered 60% or fewer questions correctly. Questions relating to pain assessment for prev erbal and cognitively impaired children were particularly poorly answered. Th ere were also gaps in knowledge about the maximum daily dose of paracetamol (acetaminophen) and equianal gesic doses of diff er- ent opioids. Over the past three decades, a variety of strategies to educate parents about pain have bee n used. Earliest materials consisted of providing information through print materials such as Children \200\231s Cancer Pain can be Relieved (Wisconsin Cancer Pain Initiative, 1989), Making Cancer Less Painful (McGrath et al., 1992) and Pain, Pain, Go Away: Helping Childre n with Pain (McGrath et al., 1994). A randomized trial (Chambers et al., 1997) evaluating t he eff ects of educating parents (n = 82) with the later booklet (a 15-page gen- eral guide to teach parents about assessment and management of pain) revealed that parents in the pai n education group had fewer concerns about the use of paracetamol (acetaminophen) for their child undergoing day surgery and expressed more positive attitudes toward children \200 \231s pain medications. However, there were no group diff erences in medication administrat ion or pain assessment on the fi rst 2 days aft er surgery. As a result of this study, the investigators concluded that simply providing print materials about pain is not enough to c hange parental behavior, more targeted educational strategies are needed to improve parenta l pain assessment and management. Kolarik and colleagues, in one US hospital, explored pediatric residents \200\231 (n = 49) perceptions about their educational needs in palliative care (Kolarik et al., 2006). Reside nts indicated they had little training, experience, or knowledge in most areas of pediatric palliative care and wanted more education regarding pain manage- ment. Similarly, a study amongst pediatric occupational therapists (n = 129) found only a moderate awareness of issu es relating to pain in children (Turnquist and Engel, 1994). Participants thought the educa tion received prior to qualifi cation was limited and their current knowledge was inadequat e. A recent exemplar of this type of targeted parental educational program is the Pediatric PR O-SELF Pain Control Program which includes a comprehensive teaching booklet to increase par - ent \200\231s knowledge, pain management diary to track analgesic dosing, a timer to insu re adherence with analgesic regimen, and interactive nurse coaching (Sutters et al., 2011). Further advances in technol- ogy provide pain education through real time telehealth (vide ocon- ferencing), social media (blogs), Web-based modules, and email or Th ere is a paucity of research in this area but from the studies carried out we can surmis e that knowledge defi cits exist across all professional groups. Recent reviews of curricul ums content in the SECTION 9 special topics 656 Table 63.1 Summary of studies examining nurses \200\231 knowledge Author Sample and questionnaire Gaps in knowledge and mean score Salantera et al. (1999) Pediatric nurses (n=265) in Finland Completed a knowledge and attitudes questionnaire. \227\206 Analgesic drugs \227\206 Non-pharmacological methods Mean score: 63% \227\206 Analgesic drugs \227\206 Non-pharmacological methods \227\206 Physiology of pai n \227\206 Psychology and sociology of pain Mean score: 78% Twycross (2004) Pediatric nurses (n=12) Used a modi \201 ed version of Salantera \200\231s questionnaire \227\206 Pain assessment \227\206 Pharmacology of analgesic drugs \227\206 Use of analge sic drugs \227\206 Non-pharmacological methods Mean score: 66% Manworren (2000) Pediatric nurses (n=274) Pediatric Nurses \200\231 Knowledge and Attitudes Regarding Pain S urvey \227\206 Non-pharmacological methods \227\206 Analgesic drugs \227\206 Incidence of resp iratory depression Mean score: 76% Vincent (2005) Pediatric nurses (n=67) Adapted version of the Nurses \200\231 Knowledge and Attitudes Rega rding Pain Survey \227\206 Pharmacology \227\206 Incidence of respiratory depression Mean score: 74% Rieman and Gordon (2007) Pediatric nurses (n=295) working in Shriner \200\231s Hospitals in the USA Revised version of the Pediatric Nurses \200\231 Knowledge and Attitudes Regarding Pain Survey. \227\206 Pharmacology (particularly opioids) \227\206 Pharmacokinetics \227\206 Non-phar macological methods Mean score: 62% Tierman (2009) Pediatric nurses (n=292) in Ireland Pediatric Nurses \200\231 Knowledge and Attitudes Regar ding Pain Survey \227\206 Pharmacology and the use of opioid analgesia \227\206 Addiction \227\206 Accura cy of child \200\231s self-report of pain Mean score: 38% Ekim et al. 2012 Pediatric nurses (n=224) from \201 ve pediatric hospitals in Turkey Pediatric Nurses \200 \231 Knowledge and Attitudes Regarding Pain Survey UK and Canada suggest limited input about pain within pre-qual- ifi cation curriculums (Bri ggs et al., 2011; Twycross and Roderique, 2011; Watt-Watson et al., 2009). Th is is despite the International Association for the Study of Pain (IASP) (2005) having published a Core Curriculum for Professional Education in Pain. Th e lack of pain content may impact on the quality of care provided to children and indicate a need for post-qualifi cation training. Th ey observed the care of children (n = 132), aged 3 to 17 years, and found nurses with a better knowledge about pain were not more likely to administer pain medications. In the s econd study, the researcher shadowed nurses (n = 12) to collect data about their postoperat ive pain management practices (Twycross, 2007). Participants also completed a modifi ed ver sion of Salantera \200\231s pae- diatric pain knowledge questionnaire (Table 63.1). When qu estion- naire scores were compared to observational data no relationship between individual nurse \200\231s level of knowledge and how well they managed pain was found. Even when nur ses had a good level of knowledge, this was not refl ected in their pain management prac- t ices. Th is study had a small sample size but, along with the results of Vincent and Denyes \200\231 study, suggests nurses may not apply knowl- edge in practice consistently. Resear ch relating to other health care professionals \200\231 use of pain knowledge in practice h as not been car- ried out. Future research should explore whether similar fi ndings occur a cross professional groups. Is knowledge used in practice? For many years it was assumed that educating health care pro fes- sionals about pain management would result in better care and clinical outcomes. More recently it has been acknowledged that while knowledge is necessary, it is not suffi cient for better pain care. An additional consideration must, therefore, be whether health care p rofessionals use their knowledge in practice (see also Yamada and Hutchinson, Chapter 61, t his volume). Limited research has been carried out in this area but two studies have explor ed the rela- tionship between pediatric nurses \200\231 theoretical knowledge and the quali ty of their pain management practices. Why isn \200\231t knowledge used in practice? Th e Promoting Action on Research Implementat ion in Health Services (PARiHS) model was developed as a way of understanding Vincent and Denyes (2004) examined the relationship between knowledge and nurses \200\231 ( n = 67) analgesic administration practices. CHAPTER 63 education for pediatric pain 657 Table 63.2 Elements of PARIHS model prn; this appeared to be the factor that impacted most on prac- tice (Twycross et al., 2013 . Context clearly has a place in ensuring knowledge is used in practice. Indeed, it has bee n postulated that pain management practices remain poor because contextual fac- tors are no t taken into account (Bucknall et al., 2001; Craig, 2009). Future research should explore s trategies that facilitate sustainable changes in unit culture. Element Sub-element Evidence Research Clinical experience Patient experience Local data/information Th e PARiHS model describes facilitators as having a key role in changing practice (Harvey et al., 2002). Indeed, a systematic review concluded that the use of local opinion leaders was an eff ective way of promoting evidence-based practice (Flodgren et al., 2011). As part of an action research project, Williams et al. (2010) evaluated the impact of pain resourc e nurses (PRNs; link nurses) acting as local opinion leaders (n = 30) in two Australian hos pitals. Results demonstrated that 11 months aft er the introduction of PRNs: Context Culture Leadership Evaluation Facilitation Low inappropriate facilitation High appropriate facilitation Source: data from Rycroft-Malone, J, Promoting Action of Research Implementation in Health Services (PARIHS), in Rycroft-Malone, J and Bucknall, T (eds.), Models and Frameworks for I mplementing Evidence-Based Practice: Linking Evidence to Action , Wiley-Blackwell, Oxford, UK, pp. 109 \200\223136, Copyright 2010. \227\206 More patients had a pain score recorded on the daily observa- tional chart ( \207 2 = 6.038, p = 0.014) and in the nursing care plan ( \207 2 = 5.11, p = 0.024). \227\206 An increase in the number of patients with a pain score docu- mented each nursing shift (morning shift : \207 2 = 35.146, p <0.001; aft ernoon shift : \207 2 = 11.717, p <0.001; night shift : \207 2 = 10.700, p <0.001). the complexity of implementing evidence (and knowledge) into practice (Rycroft -Malone, 201 0). Th e model provides a struc- ture to support behavior change and consists of three elem ents (Table 63.2 ), focusing on the interaction of the quality of the evi- dence with the c ontext, and methods of facilitating knowledge translation. All three elements impact on hea lth care professionals \200\231 readiness to change their pain practices thus providing an explana- tion for why education alone is not enough. \227\206 No diff erences were noted in other areas. PRNs may be a useful strategy for improving documentation prac- tices. Further evaluation i s needed to explore the impact on patient outcomes. Gaps in knowledge about the pharmacology of analgesic drugs and the anatomy and physiology of pain may mean the rationale for implementing pain-relieving interventions is not underst ood. If health care professionals lack knowledge about pain assessment they may lack confi dence, or be unable, to assess children \200\231s pain. Similarly if knowledge defi cits ex ist in relation to non-pharmaco- logical methods of pain-relief health care professionals m ay not feel confi dent using these strategies. If the PARiHS model is applied, gaps in know ledge may mean health care professionals do not have access to the evidence to use in pract ice. Some of the reasons knowledge is not used in practice have been explored using the PARiHS m odel. As well as helping us under- stand why knowledge is not always used in practice it al so helps to identify which interventions may help to address this. Strategies for educating health care professionals about pediatric pain Educational strateg ies A literature review carried out in 2002 concluded that not all edu- cational interventi ons designed to improve health care profes- sionals \200\231 knowledge about pain actually did so (Twycross, 2002). Successful programs used a variety of teaching methods (interactiv e and didactic) and encouraged students to refl ect on practice. Francke et al. (1995) had some success using confl uent education methods that emphasize the importance of integratin g left -brain knowledge with right brain creativity. Th is is similar to a stance adopted b y Murinson et al. (2011). Th ese teaching methods help ensure the integration of theory and practice, and acknowledge learner \200\231s feelings and experiences (Francke and Erkens, 1994). Examples of these teaching methods can be seen in Box 63.1 . Beliefs and attitudes are related to individual \200\231s knowledge and clinical experience and thus link to the PARiHS model. Nurses appear to believe some pain is to be expected (a nd accepted) dur- ing hospitalization (Hamers et al., 1994; Woodgate and Kristjanson, 1996) . Further, nurses may see pain management as synonymous with administering analgesic drugs (Twycross, 2004; Twycross et al., 2013). Nurses may not attribute as much priority to pain management as they do to other aspects of their role (Twycross, 1999; Vincent, 2005). Altho ugh it should be noted the importance nurses attribute to pain management tasks does not ne cessar- ily refl ect the likelihood of the task being undertaken in practice (Twycross, 200 8). Context is one of the elements of the PARiHS model. Over the past decade there has been a g rowing awareness that a ward/ unit has a set of informal rules that determine how pain is m an- aged. Th is was demonstrated by the results of Lauzon-Clabo \200\231s (2008) ethnograph ic study on two (adult) wards in one hospital in the US. Participants described a clear but diff erent pattern of pain assessment on each ward. Th e social context of the ward appear ed to infl uence practices. Further, in one Canadian study, pediatric nurses described the unit \200\231s pain management culture as giving pain medications regularly even if they ar e prescribed Using a variety of teaching strategies to enhance learning is sup- ported by the results of a systematic review, exploring the eff ec- tiveness of continuing medical education in cha nging practice and health outcomes (Foresetlund et al., 2009). Educational meetings alone a re unlikely to change complex behaviors. Two factors were found to increase the likelihood of behavior change and improved patient outcomes: using a mixture of interactive and didact ic teach- ing methods, and focusing on outcomes perceived as serious. However, the eff ect is likely to be small SECTION 9 special topics 658 on pediatric pain management practices has been explored in a clustered randomized trial in six Canadian pediatric hospitals (Johnston et al., 2007). Coaching with individual audit f eedback from a chart review was provided every 2 weeks, for 6 months, by an opinion leader. Some changes were found between the experi- mental and control groups although there were inconsistencies across sites. For example: Box 63.1 Examples of con \202 uent education methods \227\206 Using students \200\231 clinical experiences within group discussions \227\206 Role play \227\206 Clinical simulations \227\206 Gaming \227\206 Documented pain assessments increased in the coaching group (from 15% to 58%, \207 2 = 138.34, p <0.0001) and decreased in the control group (from 24% to 9%, \207 2 = 3 4.86, p <0.001). \227\206 Case studies \227\206 Refl ection on what individuals have learned from the sessions \227\206 Refl ection on how this learning will be applied in practice \227\206 Th e use of non-pharmacological interventions increased in the coaching group (fr om 5% to 16%, \207 2 = 28.48, p <0.0001) and decreased in the control group (from 1.5% to 0.3%, \207 2 = 2.23, p = not signifi cant). \227\206 Students sharing how will apply learning in practice (with the group). \227\206 Nurses \200\231 knowledge increased in the coaching group but decreased Educational outreach visits Educational outreach visits (EOVs) involve people visiting clin i- cians where they practice and providing them with information to change how they practic e (Soumerai and Avorn, 1990). EOVs can take many forms. Some examples of the strategies use d are pro- vided in Box 63. 2. A systematic review of 69 studies examined the eff ectivenes s of EOVs on changing practices and health care out- comes (O \200\231Brien et al., 2008). EOVs alone, or combined with other interventions, have a relatively consistent but small im pact on pre- scribing practice. Th eir eff ect in other areas varied from small to modest i mprovements. in the control group (F(1, 791) = 106.3, p< 0.0001). Coaching has also been used successfully with nurses caring for (adult) patients undergoing an arthroscopy (Duncan and Pozehl, 2001). However, providing individual feedback is resour ce inten- sive; an economic evaluation needs undertaking before implement- ing this strateg y more widely. Web-based interventions Web-based educational courses are becoming more common partly becau se in today \200\231s health service there is a need to ensure health care professionals re ceive education in as cost-eff ective way as possible. Th e English Department of Health ad vocate the use of e-learning as one way of addressing this issue (Department of Health, 200 8). One pediatric pain e-learning product was launched in February 2012 and is made up of s ix units that can be purchased together or individually covering: Th e impact of EOVs on pain management practices in pri- mary care has been explored in one study (Schechter et al., 2010). A 1 h teaching session on pain reduction strategies during child- hood immunizations was provided to staff in 13 practices in one state in the US. At 1 month parents were: more likely to report receiving information (p = 0.04); using strate gies to reduce pain (p <0.01); learning something new (p <0.01); using a Shotblocker (p < 0.01); and higher levels of satisfaction (p = 0.015). Rates all remained higher at 6 months (p <0.01) except for satisfaction. Clinician surveys at 6 months revealed signifi cant inc reases in the use of longer needles (infants: p = 0.34; toddlers: p <0.001; adoles- cents: p = 0.002), sucrose (p = 0.003), pinwheels (p <0.001), focused breathing (p = 0.021), and S hotblockers (p <0.001). Th ere was no statistical diff erence in the use of topical anest hetics. EOVs may be a useful strategy for changing pain management practices but further re search is needed. \227\206 Pharmacology of analgesic drugs \227\206 Anatomy and physiology of pain \227\206 Pain assessment \227\206 Non-pharmacological methods of pain-relief \227\206 Managing acute pain \227\206 Managing procedure-related pain. Th e course is aimed at registered health care professionals. Further information can be fo und at: <http://www.healthcare.ac.uk/ cppd/short-courses-postgraduate/managing-pain-in-chil dren- (elearning)/>. Individual feedback Audit and feedback can be a useful method for changing prac- tices with in clinical areas but the eff ects are variable and are par- ticularly eff ective where the re is low compliance with a given standard (Jamtvedt et al., 2006). Th e eff ect of individ ual feedback Web-based courses need evaluating to ascertain their eff ective- ness in increasing knowled ge and changing practice, as well as exploring how their impact compares to courses taught face-to- face. One randomized controlled trial has compared the eff ective- ness of Web-bas ed training about the use of opioid therapy for chronic pain to being given a copy of curre nt clinical guidelines for internal medicine residents (Sullivan et al., 2010). Th e Web-ba sed group had a greater increase in knowledge (p <0.00001) and higher self-ratings of their competence in overall management (Wald \207 2 = 5.17, df = 1, p = 0.02) and in prescribin g opioids (Wald \207 2 = 5.17, df = 1, p = 0.02). However, the Web-based training also cov ered shared decision-making (patient and doctor) and communication skills; it may have been this diff erence rather than the content relating to the use of opioids that was eff ectiv e. Another study evaluated the eff ect Box 63.2 Examples of EOV activities \227\206 Feedback about performance \227\206 Feedback on previously identifi ed obstacles to change \227\206 Mini-education sessions \227\206 Roving education rounds \227\206 Teaching moments. CHAPTER 63 education for pediatric pain 659 of a Web-based palliative care module for medical residents in one US hospital (Dy et al., 2008). Knowledge about palliative care did not increase simply by completing the 4-year res idency program but undertaking the Web-based course resulted in a larger increase in knowle dge. Department of Health. (2008). Modern healthcare training: e-learning in healthcare services . London : Th e Stationery Offi ce . DiMaggio, T., Clark, L., and Czarnecki, M. (2010). Pediatric pain management. In B. St. Mar ie (ed.) Core curriculum for pain management nursing , pp. 481 \200\223542 . Dubuque, IA : Kendall Hunt Professional . Duncan, K. and Pozehl, B. (2001). Eff ects of individual performance feedback on nurses \200\231 adherence to pain management clinical guidelines. Outcome Manage Nurs Pract , 5 , 57 \200\22362 . Conclusion Children and parents require education about pain and pain man- agement. To date there is little research exploring the best ways to provide this education other than in r elation to preparing children for surgery or painful procedures. When developing educationa l materials for children cognitive and psychosocial factors need taking into account. Th er e is a need to create and test educational resources for children. Resources are needed for parents that increase knowledge as well as supporting them to advocate for their child. Te chnology provides new opportunities in this context. Dy, S. M., Hughes, M., Weiss, C., and Sisson, S. (2008). Evaluation of a web- based palliat ive care pain management program for housestaff . J Pain Symptom Manage , 36 (6), 596 \200 \223603 . Ekim, A. and Ocakci, A. F. (2012). Knowledge and attitudes regarding pain management of ped iatric nurses in Turkey. Pain Manag Nurs, 6 April. [Epub ahead of print.] Finley, G. A., McGrath, P. J., Forward, S., McNeill, G., and Fitzgerald, P. (1996). Parents \200\231 management of children \200\231s pain following minor surgery. Pain , 64 , 83 \200\22387 . Flodgren, G., Parmelli, E., Doumit, G., Gattellari, M., O \200\231Brien, M. A., Grimshaw, J ., et al. (2011). Local opinion leaders: Eff ects on professional practice and health care outcomes. Cochrane Database Syst Rev , 8 , CD000125 . Gaps remain in health care professionals \200\231 knowledge about pain that are greater in the developing world. Further research is needed to explore this across all professional gr oups. For practices to change education needs to be provided alongside other strategies pro mot- ing the use of knowledge in practice; education alone is not enough. Th e PARiHS model has been used to provide an explanation for why knowledge is not used in practice. Th is n eeds testing further; organizational culture and the role of facilitation need particular a ttention. Educational interventions should include a mixture of interactive and didactic te aching. Strategies that help link educa- tion with practice should also be encouraged such as refl ection, clinical simulations, and the use of case studies. Web-based materi- als ar e available but their eff ectiveness needs evaluating. Fortier, M. A., MacLaren, J. E., Martin, S., Perret-Karimi, D., and Kain, Z. N. (2009). Ped iatric pain aft er ambulatory surgery: where \200\231s the medication? Pediatrics , 134 (4) , e588 \200\223e595 . Franck, L., Allen, A., Cox, S., and Winter, I. (2005). Parents \200\231 views about infant pain in neonatal intensive care. Clin J Pain , 21 (2), 133 \200\223139 . Francke, A. L. and Erkens, T. (1994). Confl uent education: an integrative method for nursing (continuing education). J Adv Nurs , 19 , 356 \200\223361 . Francke, A. L., Garssen, B., and Abu-Saad, H. H. (1995). Determinants of changes in nurses \200\231 behavior aft er continuing education: a literature review. J Adv Nurs , 21 , 371 \200\223377 . Gaes, J. (1987). My book for kids with cansur . Aberdeen, SD : Melius & Peterson Publishing . Greenberg, R. S., Billett, C, Zahurak, M., and Yaster, M. (1999). Videotape increases paren tal knowledge about pediatric pain management. Pediatr Anesth , 89 , 899 \200\223903 . References American Nurses Association. (2001). Code of ethics for nurses with interpretive Harbeck, C. and Peterson, L. (1992). Elephants dancing in my head: a developmental approach to children \200\231s concepts of specifi c pains. Child Dev , 63 , 138 \200\223149 . statements . Silver Spring, MD : American Nurses Association . American Nurses Association. (2005). Pain management nursing: scope and Harvey, G., Loft us-Hills, A., Rycroft -Malone, J., Titchen, A., Kitson, A., McCormack, B., et al. (2002). Getting evidence into practice: the role and function of facilitation. J Ad v Nurs , 37 (6), 577 \200\223588 . standards of practice . Silver Spring, MD : Nurses Books . American Nurses Association. (2008). Pediatric nursing: scope and standards of practice . Silver Spring, MD : Nurses Books . Huth, M., Broome, M., Mussatto, K., and Morgan, S. W. (2003). A study of the eff ectiveness of a pain management education booklet for parents of children having cardiac surgery. Pai n Manag Nurs , 4 (1), 31 \200\22339 . Association of Pediatric Hematology/Oncology Nurses. (2007). Pediatric oncology nursing: sc ope and standards of practice . Glenview, IL : Association of Pediatric Hematology/Oncology Nurses . Idvall, E., Holm, C., and Runeson, I. (2005). Pain experiences and non- pharmacological str ategies for pain management aft er tonsillectomy: a qualitative interview study of children and parents. J Child Health Care , 9 , 196 \200\223207 . Berenstain, S. (1981). Th e Berenstain bears go to the doctor . New York : Random House . Briggs, E., Carr E. C. J., and Whittaker, M. (2011). Survey of undergraduate pain curriculu ms for healthcare professionals in the United Kingdom. Eur J Pain , 15 , 789 \200\223795 . International Association of the Study of Pain. (2005). Core curriculum for professional education in pain (3rd edn). Seattle, WA : IASP Press . Brillhart, B. (2007). Internet education for spinal cord injury patients: focus Jamtvedt, G., Young J. M., Kristoff ersen, D. T., O \200\231Brien, M. A., and Oxman, A. D. (2006). Audit and feedback: eff ects on professional practice and healthcare outcomes. Coch rane Database Syst Rev , 2 , CD000259 . on urinary management. Rehabil Nurs , 32 (5), 214 \200\223219 . Bucknall, T., Manias, E., and Botti, M. (2001). Acute pain management: implications of scie ntifi c evidence for nursing practice in the postoperative context. Int J Nurs Pract , 7 (4 ), 266 \200\223273 . Jones, M, Qazi, M., and Young, K. (2005). Ethnic diff erences in parent preference to be pr esent for painful medical procedures. Pediatrics , 116 (2), e191 \200\223e197 . Chambers, C., Reid, G., McGrath, P. J., and Finley, G. A. (1997). A randomized trial of a p ain education booklet: eff ects on parents \200\231 attitudes and postoperative pain manage ment , Child Health Care , 26 (1), 1 \200\22313 . Kolarik, R. C., Walker, G., and Arnold, R. M. (2006). Pediatric residents in palliative care: a needs assessment. Pediatrics , 117 (6), 1949 \200\2231954 . Child Life Council. (2007). Child Life Council evidence-based practice statement: preparing children and adolescents for medical procedures . Rockville , MD . Kotzer, A., Coy, J., and LeClaire, A. (1998). Th e eff ectiveness of a standardized educati onal program for children using patient-controlled analgesia. J Soc Pediatr Nurs , 3 , 117 \200\223126 . Craig, K. D. (2009). Th e social communication module of pain. Can Psychol , Kuttner, L. (2010). A child in pain: what health professionals can do to help. 20 , 22 \200\22332 . Bethel, CT : Crown House Publishing . Curtiss, C. (2010). Th e pain management nurse as an educator. In B. St. Marie (ed.) Core c urriculum for pain management nursing , pp. 659 \200\223672 . Dubuque, IA : Kendall Hunt Pr ofessional . LeMay, S., Johnston, C., Choiniere, M., Fortin, C., Hubert, I., Fr chette, G., et al. (2 010). Pain management interventions with parents in the emergency department: a randomized trial. J Adv Nurs , 66 (11), 2442 \200\2232449 . SECTION 9 special topics 660 Sullivan, M. D., Gaster, B., Russo, J., Bowlby, L., Rocco, N., Sinex, N., et al. (2010). Ra ndomized trial of web-based training about opioid therapy for chronic pain. Clin J Pain , 2 6 (6), 512 \200\223517 . Li, H., Lopez, V., and Lee, T. (2006). Psychoeducational preparation of children for surger y: the importance of parental involvement. Patient Educ Couns , 65 , 34 \200\22341 . Sutters, K., Savedra, M., and Miaskowski, C. (2011). Th e pediatric PRO- SELF Pain control program: an eff ective educational program for parents caring for children at home followin g tonsillectomy. J Specialist Pediatr Nurs , 16 , 280 \200\223294 . Manworren, R. C. B. (2000). Pediatric nurses \200\231 knowledge and attitudes survey regarding pain. Pediatr Nurs , 26 (6), 610 \200\223614 . McGrath, P. A. (1990). Pain in children: nature, assessment and treatment . New York : Guilford . Tait, A., Voepel-Lewis, T., Snyder, R., and Malviya, S. (2008). Parents \200\231 understand ing of information regarding their child \200\231s postoperative pain management. Clin J Pa in , 24 (7), 572 \200\223577 . McGrath, P. J., Finley, G. A., and Turner, C. (1992). Making cancer less painful: a handbook for parents . Halifax, NS : Dalhousie University . McGrath, P. J., Finley, G. A., and Ritchie, J. (1994). Pain, pain, go away: helping childre n with pain . Bethesda, MD : Association for the Care of Children \200\231s Health . Tiernan, E. P. (2009). A survey of registered nurses \200\231 knowledge and attitudes regar ding pediatric pain assessment and management: an Irish perspective. Arch Dis Child , 93 (1 002), n18 . McGrath, P. J., Watters, C., and Moon, E. (2010). Technology in pediatric pain management. In G. A. Finley, P. J. McGrath, and C. Chambers (eds.), Bringing pain relief to children: t reatment approaches , pp. 159 \200\223176 . Totowa, NJ : Humana . Turnquist, K. M. and Engel, J. M. (1994). Occupational therapists \200\231 experiences and knowledge of pain in children , Phys Occup Th er Pediatr , 14 (1), 35 \200\22352 . Twycross , A. (2002). Educating nurses about pain management: the way forward. J Clin Nurs , 11 , 705 \200\223714 . Murinson, B., Mezel, L., and Nenortes, E. (2011). Integrating cognitive and aff ective dime nsions of pain experience into health professions education. Pain Res Manag , 16 (6), 421 \200\223426 . Twycross, A. (2004). Children \200\231s nurses \200\231 pain management practices: theoreti cal knowledge, perceived importance and decision-making . Unpublished PhD Th esis, Universi ty of Central Lancashire. Oakes, L. (2011). Infant and child pain management . New York : Springer Twycross, A. (2007). What is the impact of theoretical knowledge on children \200\231s nurs es \200\231 postoperative pain management practices? An exploratory study. Nurse Educ Today , 27 (7), 697 \200\223707 . Publishing Company . O \200\231Brien, M. A., Rogers, S., Jamtvedt, G., Oxman, A. D., Odgaard-Jensen, J., Kristof f ersen, D. T., et al. (2008). Educational outreach visits: eff ects on professional practi ce and health care outcomes. Cochrane Database Syst Rev , 4 , CD000409 . Twycross, A. (2008). Does the perceived importance of a pain management task affect the qua lity of children \200\231s nurses \200\231 post-operative pain management practices? J Clin Nurs , 17 (23), 3205 \200\2233216 . O \200\231Conner-Von, S. (2000). Preparing children for surgery: an integrative Twycross, A. and Collis, S. (2012). How well is acute pain in children managed? A snapshot in one English hospital. Pain Manag Nurs . 29 March. [Epub ahead of print.] research review. AORN J , 71 (2), 334 \200\223343 . O \200\231Conner-Von, S. (2008). Preparation of adolescents for outpatient surgery: using an Internet program. AORN J , 87 (2), 374 \200\223398 . Twycross, A. and Finley, G. A. (in press). Parents \200\231 and children \200\231s views ab out O \200\231Conner-Von, S. (2009). Coping with cancer: a web-based educational program for ea rly and middle adolescents. J Pediatr Oncol Nurs , 26 (4), 230 \200\223241 . pain management. J Clin Nurs . Twycross, A., Finley, G. A. and Latimer, M. (2013). An in-depth study of pediatric post-ope rative pain management practices. J Specialist Pediatr Nurs . 24 March. [Epub ahead of prin t.] Palermo, T. and Valenzuela, D. (2003). Use of pain diaries to assess recurrent and chronic pain in children. Suff ering Child , 3 , 1 \200\22314 . Twycross, A. and Roderique, L. (2011). Review of pain content in three-year preregistration pediatric nursing courses in the United Kingdom. Pain Manag Nurs . 11 July. [Epub ahead of print.] Rieman, M. T., Gordon, M., and Marvin, J. M. (2007). Pediatric nurses \200\231 knowledge an d attitudes survey regrading pain: a competency tool modifi cation. Pediatr Nurs , 33 (4), 303 \200\223313 . Uman, L., Chambers, C., McGrath, P. J., and Kisely, S. (2010). Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Datab ase Syst Rev , 11, CD005179. Available at <http://www.thecochranelibrary.com>. Rycroft -Malone, J. (2010). Promoting Action of Research Implementation in Health Services (PARIHS). In J. Rycroft -Malone and T. Bucknall (eds.) Models and frameworks for implementi ng evidence-based practice: linking evidence to action , pp. 109 \200\223136 . Oxford : Wil ey-Blackwell . US Department of Health and Human Services (1992). Acute pain management in infants, childr en, and adolescents: operative and medical procedure. Quick reference guide for clinicians . AHCPR Pub. No. 92 \200\2230020. Rockville, MD : Agency for Health Care Policy and Researc h . Salantera, S., Lauri, S., Salmi, T. T., and Helenius, H. (1999). Nurses \200\231 knowledge about pharmacological and non-pharmacological pain management in children. J Pain Symptom M anage , 18 (4), 289 \200\223299 . Sato, A., Cliff ord, L., Silverman, A., and Davies, W. H. (2009). Cognitive- behavioral int erventions via telehealth; application to pediatric functional abdominal pain , Child Healt h Care , 38 , 1 \200\22322 . Vincent, C. V. H. (2005). Nurses \200\231 knowledge, attitudes, and practices regarding children \200\231s pain. MCN , 30 (3), 177 \200\223183 . Vincent, C. V. H. and Denyes, M. J. (2004). Relieving children \200\231s pain: nurses \200 \231 abilities and analgesic administration practices. J Pediatr Nurs , 19 (1), 40 \200\223 50 . Watt-Watson, J, McGillon, M., Hunter, J., Choiniere, M., Clark, A. J., Dewar, A., et a l. (2009). A survey of prelicensure pain curriculums in health science faculties in Canadia n universities. Pain Res Manag , 14 (4), 439 \200\223444 . Wisconsin Cancer Pain Initiative . (1989). Children \200\231s cancer pain can be Finley, G. A. and Schechter, N. L. (2003). Sedation. In N. Schechter, C. Berde, and M. Yast er (eds) Pain in infants, children, and adolescents , pp. 563 \200\223577 . New York : Lipp incott Williams & Wilkins , Schechter, N. L., Bernstein, B. A., Zempsky, W., Bright, N. S., and Willard, A. K. (2010). Educational outreach to reduce immunization pain in offi ce settings , Pediatrics , 126 (6) , e1514 \200\223e1521 . relieved . Madison, WI : University of Wisconsin . Simons, J., Franck, L., and Roberson, E (2001). Parent involvement in children \200\231s Wood, D. (1993). How children think and learn . Cambridge, MA : Blackwell pain care: views of parents and nurses. J Adv Nurs , 36 (4), 591 \200\223599 . Publishers . Simons, J. and Roberson, E. (2002). Poor communication and knowledge defi cits: obstacles t o eff ective management of children \200\231s postoperative pain. J Adv Nurs , 40 (1), 78 \200\22386 . Zisk, R, Gray, M., Medoff -Cooper, B., and Kain, Z. N. (2007). Accuracy of parental-globe-i mpression of children \200\231s acute pain. Pain Manag Nurs , 8 (2), 72 \200\22376 . Stinson, J., McGrath, P. J., Hodnet, E., Feldman, B. M., Duff y, C. M., Huber, A. M., et al . (2012). An internet-based self-management program with telephone support for adolescents with arthritis: a pilot randomized controlled trial. J Rheumatol , 37 (9), 1944 \200\223195 2 . Zisk-Rony, R., Fortier, M., Chorney, J., Perret, D., and Kain, Z. N. (2010). Parental posto perative pain management: attitudes, assessment, and management. Pediatrics , 125 (8), 1372 \200\2231378 . Soumerai, S. B. and Avorn, J. (1990). Principles of education outreach ( \200\230academic d etailing \200\231) to improve clinical decision making. JAMA , 263 (4), 549 \200\223556 . Online supplementary materials Figure 63.1 Additional resources CHAPTER 64 Th e ethics of pain control in infants and children Gary A. Walco and Maureen C. Kelley Introduction A common theme throughout writings in pediatric medicine is that \200\230chil dren are not little adults \200\231, oft en referring to physiological and psychological di ff erences related to maturation and develop- ment that must be taken into account in provi ding care. Similarly, in considering ethical challenges related to pain, it is important no t to simply extrapolate from our ethical approach to pain man- agement for adults who typic ally can describe their experience of pain, are fully responsible for themselves, and can r