Barriers posed by caregivers regarding neonatal pain management in the NICU were categorized into four main themes, which are: lack of holistic views towards neonates, subjective and arbitrary working, work overload, and insufficient professional knowledge.
In standard caregiving, the patient is regarded as a comprehensive human being, and all his human needs in terms of age range, developmental level, and cognition are considered based on his unique characteristics (Eklund et al., 2019). The findings showed that in the context understudy, a holistic view of the neonates is suboptimal and some of the neonates' human needs, such as pain relief, are not well understood. Although this has not been discussed in previous studies as a barrier to neonatal pain management, its sub-themes have been confirmed in some studies, which are discussed below.
The focus on treating the disease has marginalized pain management. According to the some studies, the lack of routine pain relieving care in NICU is a barrier in pain management (Christoffel et al., 2019; Lago et al., 2013).
Pain relief is one of the basic needs of every human being, in which its diagnosis is based on self-reporting due to its subjective nature. However the neonates cannot express and demand this need because of their age range and developmental level. Consistent with the findings of the present study, researchers state that the neonate's inability to express his pain is an influential factor in its inadequate pain management (Akuma & Jordan, 2012; Cong et al., 2013).
Subjective and arbitrary management of neonatal pain was other reported barrier which included individual, interpersonal, and organizational dimensions. From the participants' point of view, lack of suitable interaction between the clinical professions has made it difficult for them to act as a team and in an integrated manner. This issue has brought about inconsistencies in providing services, over-stimulation of the neonates, and losing opportunities in relieving their pain. Christoffel et al. and Razeq et al., pointed out that communication channels between professions need to be improved to perform appropriately against neonate's pain(Christoffel et al., 2019) (Razeq, 2016). Stevens et al. also considers inter-professional collaboration as the basis of effective practice on pain in the NICU and states that free participation of all team members, respect for each other's knowledge, joint decisions, and having a common goal to promote clinical outcomes for neonates are necessary for effective inter-professional collaboration (Stevens et al., 2011).
In addition to the above-mentioned factors, the lack of a clear policy in relieving the neonate's pain has also increased the number of inconsistencies. This phenomenon causes caregivers use analgesic procedures based on their individual opinion and knowledge, which leads to suboptimal neonatal pain management sometimes. This is one of the barriers that has been mentioned in some studies. Among these, we can refer to the study of Stevens et al., and Querido et al. in which the lack of institutional protocols and organizational structure is a reason for inconsistency and variously in pain practices (Querido et al., 2017; Stevens et al., 2011).
The other barrier is the lack of administrative supervision on staff's performance in neonatal pain management. Shirazi et al. maintained that the organizational supervision is effective in staff performance and stated that this issue could increase the caregivers motivation for optimal analgesic performance (Shirazi et al., 2020).
Work overload was one of the most significant barriers to appropriate pain-relieving treatment. Participants discussed the issue from different perspectives. On the other hand, workload and too little time has led caregivers to prioritize more important tasks, so pain management is often overlooked.
On the other hand, work overload caused burnout and physical and mental fatigue for the staff and deprived them of performing well in managing the neonate's pain. Although studies have not explicitly referred to burnout and mental fatigue caused by overwork and its impact on the management of neonate's pain, some of them have pointed to other barriers discussed in this theme. Some studies conducted in Iran have also introduced tremendous workload and physical fatigue of employees as a barrier to proper management of neonate's pain (Mehrnoush & Ashktorab, 2016; Zahedpasha et al., 2017). The other studies also emphasize heavy workload and lack of time as barriers to controlling neonate's pain (Cong et al., 2014; Twycross, 2013). Of course, it is worthwhile to study Yasmeen et al. be mentioned. They concluded that pain management enhancement in NICU can reduce staff’s stress, anxiety, and depression (Yasmeen et al., 2020).
The participants believed that the caregivers have little knowledge of various areas of pain management topics. They stated that caregivers' low ability to use pain assessment tools due to inadequate training is one of the main barriers to proper pain management in NICU. Spence also considers a lack of knowledge in using pain measuring tools (Spence, 2010).
The staff's lack of awareness of environmental stimuli, such as noise and light, makes neonates oversensitive, and this issue prevents optimal pain management. Al-Braiki in his study, considers the noisy and crowded environment as stressful and believes that such an environment can prevent proper relief of neonate's pain (Al-Braiki, 2019). In another study, a noisy and bright environment was mentioned as a hostile environment that can irritate the neonate and aggravate his pain (Christoffel et al., 2019).
Pharmacological interventions are an essential part of the neonatal pain management program. Findings of the study revealed that due to a lack of pharmacological knowledge, the ideal use in the management of neonatal pain is not done. This insufficient knowledge has been addressed in a wide range of information related to the selecting of the appropriate drug in terms of the neonate's condition, the dosage of drugs, and how the drug is administered. Although in previous studies, the issue of drug knowledge deficiency has not been mentioned in detail, Razeq emphasizes inadequate knowledge of caregivers about analgesics as a barrier to better analgesic implementation (Razeq, 2016). Peng et al. also consider inadequate knowledge about providing sufficient opioid analgesics during painful interventions as one of the problems in managing neonate's pain (Peng et al., 2020).
In addition to the above-mentioned factors, participants believed that there was a misunderstanding due to a lack of knowledge among NICU staff that hindered their proper performance in controlling the neonate's pain. They pointed out that pain tolerance is considered normal in neonates undergoing the procedure. This can reduce the motivation of the caregivers to prevent and alleviate the pain. Martinez (Martinez, 2014) concluded that, in the opinion of NICU staff, pain is an unavoidable experience in the NICU, and this reduces their efforts to provide the appropriate analgesic implementation.
Despite the various barriers, significant improvements in neonatal pain management in practice are gained in developed contexts. The evidence-based strategies applied by developed countries can be helpful for improving the pain management in developing nations. Some of the facilitators are recommended as:
- Providing educational resources for care givers in the NICU and continual assessment of their level of knowledge (Hall & Anand, 2014; Spence & Henderson-Smart, 2011)
- Collaboration and support among all health care providers (Balice-Bourgois et al., 2020; Stevens et al., 2011)
- Performing routine assessments to detect neonatal pain (Batton et al., 2006; Sharek et al., 2006).
- control of environmental stimuli (Witt et al., 2016).
- Avoiding prolonged or repetitive pain/stress during NICU care (Batton et al., 2006).
- Protocolized stepwise treatment for the painful conditions encountered in the NICU. (American Academy of Pediatrics, 2016; Spence & Henderson-Smart, 2011).
They are performing continues auditing for appropriate treatment for neonatal pain (Spence & Henderson-Smart, 2011).
Practice Implications:
Some strategies are required to improve neonatal pain management in NICU. There is a lack of knowledge regarding neonatal pain management in the health care team. Practical training of the care providers is essential in areas such as using pain assessment tools, control of environmental stimuli, and pharmacological and non-pharmacological pain-relieving interventions. Development and implementation of an evidence-based pain management protocol that considers the potential of context is one of the steps of achieving optimal pain management. Administrative supervision and frequent audit lead to integrated clinical performance. Also, work overload can disrupt the appropriate management of neonatal pain. To improve the current conditions, paying attention to people directly involved in pain management is necessary. Therefore, similar to educational needs, fulfilling their physical and emotional needs can affect the quality of their performance and create desirable results. Step-by-step change strategies can be used to implement the proposed facilitators successfully.