An Educational Intervention to Improve Nurses’ Understanding of Pain in Children in Western India

Original Article An Educational Intervention to Improve Nurses’ Understanding of Pain in Children in Western India Ashish R. Dongara, MD,*,† Somashekhar M. Nimbalkar, MD,†,‡ Ajay G. Phatak, MPH,‡ Dipen V. Patel, MD,† and Archana S. Nimbalkar, DCh§ ---

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From the *Department of Pediatrics, Narayana Multispeciality Hospital, Rakhial, Ahmedabad, Gujarat, India; † Department of Pediatrics, Pramukhswami Medical College, Karamsad, India; ‡Central Research Services, Charutar Arogya Mandal, Karamsad, India; § Department of Physiology, Pramukhswami Medical College, Karamsad, India. Address correspondence to Somashekhar M. Nimbalkar, MD, Pramukhswami Medical College, Karamsad, Anand, Gujarat, India 388325. E-mail: somu_somu@ yahoo.com Received February 21, 2016; Revised September 16, 2016; Accepted October 4, 2016. No external funding was sought for the study. 1524-9042/$36.00 Ó 2016 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2016.10.003

ABSTRACT:

Accurate assessment of pain and its management is a challenging aspect of pediatric care. Nurses, usually the primary caregivers, showed inadequate knowledge and restrictive attitudes toward pain assessment. We evaluated an educational intervention to improve nurses’ assessment of pain in a teaching hospital in India. A convenient sample of nurses working in the neonatal intensive care unit, pediatric ward, pediatric intensive care unit, and pediatric cardiac intensive care unit were included in the study. Workshops to improve understanding of pain, its assessment, and management strategies were conducted. A modified and consensually validated Knowledge and Attitudes Survey Regarding Pain questionnaire-2008 consisting of 25 true/false questions, eight multiple choice questions, and two case scenarios was administered before, immediately after, and 3 months after the workshops to evaluate impact of the intervention. Eightyseven nurses participated. Mean (standard deviation) experience was 4.04 (5.9) years. Thirty-seven percent felt that they could assess pain without pain scales. About half (49.4%) of the nurses had not previously heard of pain scales, while 47.1% reported using a pain scale in their routine practice. Significant improvement was observed between pretest and post-test total scores (15.69 [2.94] vs. 17.51 [3.47], p < .001) as well as the pretest and retention score (15.69 [2.94] vs. 19.40 [4.6], p < .001). Albeit the study site and sampling frame may limit the reliability of the findings, the educational intervention was successful, and better retention test scores suggest a cascading effect. Pain assessment and management education of children should be incorporated in the nursing curriculum and should be reinforced in all pediatric units. Ó 2016 by the American Society for Pain Management Nursing

Pain Management Nursing, Vol -, No - (--), 2016: pp 1-9

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Pain is the most common side effect of hospitalization. There have been reports that almost 80% of perioperated hospitalized children experience moderate to severe pain (Polkki, Pietila, & Vehvilainen-Julkunen, 2003). Untreated or mismanaged pain is found to adversely affect the cardiovascular, respiratory, and gastrointestinal system as well as immunological function, and hence indirectly delays recovery, prolongs hospitalization, or worsens illness (Al-Atiyyat, 2008; Schechter, Berde, & Yaster, 2003). Despite such serious implications, suboptimal pain management is common (Breivik et al., 2009). Multiple reports testify to a lack of sufficient knowledge in tackling pain among health care providers—both nursing staff and doctors (Al Qadire & Al Khalaileh, 2014; Latchman, 2014; Lui, So, & Fong, 2008; Schultz, Loughran-Fowlds, & Spence, 2010). Pain in children is even more a complex issue. There are multiple misconceptions and beliefs that impair a health care provider’s ability to identify and treat pain, especially in children (Dongara, Shah, Nimbalkar, Phatak, & Nimbalkar, 2015; Helgadottir & Wilson, 2004; Manworren, 2000; Nimbalkar, Dongara, Ganjiwale, & Nimbalkar, 2013; Nimbalkar, Dongara, Phatak, & Nimbalkar, 2014). Previous studies conducted at our medical center have demonstrated a deficit in knowledge and improper attitudes pertaining to pain in pediatric patients (Dongara et al., 2015; Nimbalkar et al., 2013; Nimbalkar et al., 2014). Education and training has showed an improvement in the knowledge and attitudes regarding pain and also improved pain management practices among the nursing staff (Huth, Gregg, & Lin, 2010; Pederson, 1996; Treadwell, Franck, & Vichinsky, 2002). As a starting point, a workshop-based module was designed and tested for educating the nursing staff about identification and management of pain in pediatric patients.

this study showed a delay in administration of first dose of analgesic and increased interval between subsequent doses. De Rond et al. (2000) conducted a study wherein a pain monitoring program consisting of two components, education and implementation of daily pain assessment, showed an increase in pain knowledge questionnaire scores from 69.1% to 75.8%. Johnston et al. (2007) conducted a study wherein one-on-one coaching of the nursing staff across six pediatric hospitals was performed. Though a significant site-to-site variation was noted, an overall improvement in nurses’ knowledge, frequency of assessing pain, and usage of nonpharmacological interventions was observed. Huth et al. (2010) reported positive influence of a dedicated educational intervention focusing on pediatric pain on knowledge and attitudes of Mexican nurses. A study by Vael & Whitted (2014) deduced that education altered nursing practices about pain assessment and increased frequency of pain assessment. Evans & Mixon (2015) tried high-fidelity simulation, including case study and roleplay, incorporated in undergraduate nursing students’ curriculum. Albeit a concurrent control group was not included, comparison with historical control groups suggested better performance of nurses in the simulation group with respect to the Knowledge and Attitudes of Survey Regarding Pain. Shen & El-Chaar (2015) conducted a three-phase study in a neonatal intensive care unit. A preintervention pain analysis of heel lancing in 25 neonates was assessed in the first phase using the Neonatal Pain Agitation and Sedation Scale. In the second phase, the nursing staff and physicians were educated about oral sucrose. A repeat analysis of severity of pain during heel lancing of 25 neonates was performed, which showed a decrease in pain following the education intervention.

METHODS LITERATURE REVIEW Various educational methods to improve identification and management of pain by nurses have been tried. Unfortunately, the literature from developing economies is scarce. Pederson (1996) conducted a study in which a cohort of 35 nurses underwent a 2-hour training program and showed improved knowledge about pain and nonpharmacological interventions as well as increased application in day-to-day usage. In the study conducted by Knoblauch & Wilson (1999), nurses were monitored before and after training as they administered analgesics using chart audits of a convenience sampling of children who had undergone tonsillectomies during the study period. Surprisingly,

Setting The study was conducted at a tertiary-level teaching hospital located in the rural part of western India from December 2013 through March 2014. The study was approved by the institutional ethics committee. Sample All the nurses working in the neonatal intensive care unit, pediatric ward, pediatric intensive care unit, and pediatric cardiac unit of the hospital were eligible to be included in the study. All the nurses were exposed to pediatric patients on a daily basis. All eligible nurses were invited for the training program and explained about the study. The nurses were

Intervention Improving Nurses’ Understanding of Pain

included in the study after obtaining written informed consent. Instrument The investigators had used a Knowledge and Attitudes Survey Regarding Pain questionnaire (Ferrell & McCaffery, 2008) that was modified, validated, and utilized by the authors in previous studies (Nimbalkar et al., 2013; Nimbalkar et al., 2014). This questionnaire was developed in 1987 by Ferrell and McCaffery. An updated version was released in April 2008 (Ferrell & McCaffery, 2008). The questionnaire has 25 true/false questions, eight multiple-choice questions (MCQs), and two case-based scenarios. The questionnaire was modified to suit our setup. This modified questionnaire was consensually validated, pretested on 10 randomly selected nurses outside the study sample. The questionnaire had a Cronbach a > 0.70 for attitude and knowledge. Higher scores reflected better knowledge (Ferrell & McCaffery, 2008). Training and Assessment A 3-hour workshop session was designed consensually by the investigators to educate the nursing staff regarding the physiology of pain, its assessment, and management strategies. Three separate sessions were conducted to cover all of the 104 nurses. A modified and consensually validated Knowledge and Attitudes Survey Regarding Pain questionnaire-2008 was administered before, immediately after, and 3 months after the workshops to evaluate the impact of the intervention. No time limit was imposed on them. Statistical Analysis Descriptive statistics (mean [standard deviation, (SD)], and frequency [%]) were used to portray the profile of the study population. Analysis of variance/Chi-square test/correlation coefficient were used to determine associations depending on variable type. The analysis was performed using STATA 14.

RESULTS Out of 104 eligible nurses, 94 (90.38%) completed the first assessment and training, 90 (86.54%) completed post-training assessment, and 87 (83.7%) completed the 3-month retention assessment. All of the nurses were women. Most of them were cardiac ward nurses who were unmarried, young, without any children, and less experienced, as shown in Table 1. The mean (SD) age of the nurses was 27.36 (6.25; range: 23-50) years. Forty-three (49.4%) nurses had not heard of pain assessment tools and 46 (52.9%) perceived that these tools may not be useful. Most of them were

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TABLE 1. Baseline Sociodemographic Characteristics and Perceptions about Pain of the Study Participants Sociodemographic Characteristics and Perceptions of Pain

Frequency (%) (N ¼ 87)

Sociodemographic characteristics Ward Neonatal 27 (31.0) Cardiac 38 (43.7) Pediatric 22 (25.3) Marital status Married 37 (42.5) Unmarried 50 (57.5) Experience <1 year 34 (39.1) 5 years 34 (39.1) >5 years 19 (21.8) Children 0 65 (74.7) 1 21 (24.1) 2 1 (1.2) Age 20-25 years 47 (54.0) 26-30 years 22 (25.3) 31-40 years 13 (14.9) >40 years 5 (5.8) Mean (SD): 27.36 (6.254) Perceptions about pain assessment tools Have you previously heard of pain assessment tools Yes 44 (50.6) No 43 (49.4) Are they useful Yes 41 (47.1) No 46 (52.9) Will you like to use these scales in ward Yes 33 (37.9) No 54 (62.1) Are you currently using any sort of assessment tool Yes 46 (52.9) No 41 (47.1)

reluctant to use such scales in the wards (54 [62.1%]), although most (57 [65.5%]) agreed on the importance of these tools in reliably assessing pain and more than half (46 [52.9%]) reported using some pain assessment tool in the ward, as mentioned in Table 1. A statistically significant improvement was observed in mean (SD) total post-test score pertaining to true/false questions as compared to the pretest score (12.47 [2.30] vs. 13.64 [3.00], p ¼ .005). The mean (SD) total post-test score improved significantly over the next 3 months (13.64 [3.00] vs. 14.98 [3.61], p ¼ .003). A statistically significant improvement was observed in the mean (SD) total post-test score pertaining to MCQs as compared to the pretest score (3.22 [1.48] vs. 3.86

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TABLE 2. Performance in True/False Questions and Multiple-Choice Questions Questions (Frequency [%] of Correct Answers)

Post-test Frequency (%) (N ¼ 87)

Retention Test Frequency (%) (N ¼ 87)

10 (11.5) 45 (51.7)

10 (11.5) 59 (67.8)

38 (43.7) 63 (72.4)

31 (35.6) 12 (13.8) 46 (52.9)

27 (31.0) 31 (35.6) 60 (69.0)

23 (26.4) 49 (56.3) 67 (77.0)

43 (49.4) 26 (29.9) 35 (40.2)

39 (44.8) 26 (29.9) 53 (60.9)

37 (42.5) 27 (31.0) 44 (50.6)

23 (26.4)

38 (43.7)

50 (57.5)

46 (52.9)

57 (65.5)

64 (73.6)

62 (71.3)

57 (65.5)

75 (86.2)

47 (54.0) 53 (60.9) 44 (50.6)

58 (66.7) 50 (57.5) 46 (52.9)

76 (87.4) 59 (67.8) 41 (47.1)

45 (51.7)

48 (55.2)

44 (50.6)

41 (47.1)

38 (43.7)

28 (32.2)

47 (54.0)

61 (70.1)

56 (64.4)

77 (88.5) 71 (81.6)

73 (83.9) 70 (80.5)

72 (82.8) 73 (83.9)

53 (60.9)

61 (70.1)

69 (79.3)

39 (44.8)

35 (40.2)

45 (51.7)

42 (48.3)

43 (49.4)

55 (63.2)

Dongara et al.

True/false questions 1 Vital signs are always reliable indicators of the intensity of a patient’s pain. 2 Because their nervous system is underdeveloped, children under two years of age have decreased pain sensitivity and limited memory of painful experiences. 3 Patients who can be distracted from pain usually do not have severe pain. 4 Patients may sleep in spite of severe pain. 5 Combining analgesics that work by different mechanisms may result in better pain control with fewer side effects than using a single analgesics agent. 6 The usual duration of analgesia of 1-2 mg fentanyl IV is 4-5 hr. 7 Opioids should not be used in patients with history of substance abuse. 8 Patients should be encouraged to endure as much pain as possible before using an opioid. 9 Children younger than 11 years cannot reliably report pain, so clinicians should rely solely on the parents’ assessment of the child’s pain intensity. 10 Patients’ spiritual beliefs may lead them to think pain and suffering are necessary. 11 After an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with an individual patient’s response. 12 Lack of pain expression does not necessarily mean absence of pain. 13 Patients should be maintained in a pain-free state. 14 If a patient reports pain relief and euphoria, he or she should be given a lower dose of the analgesic. 15 Patients can tolerate high doses of opioids without sedation or respiratory depression. 16 Estimated pain by an MD or RN is a more valid measure of pain than the patient self-report. 17 Patients may be hesitant to ask for pain medications due to their fears about use of opioids. 18 Patients have the right to expect total pain relief as the goal of treatment. 19 Continuous assessment of pain and medication effectiveness is necessary for good pain management. 20 Giving opioids on a regular basis is preferred over a PRN schedule for continuous pain. 21 A patient should experience discomfort before giving the next dose of pain medication. 22 Comparable stimuli in different people produce the same intensity of pain.

Pretest Frequency (%) (N ¼ 87)

23 24 25

Nondrug interventions (heat, music, imagery, etc.) are very effective for mild to moderate pain control but rarely helpful for more severe pain. Beyond a certain dosage of morphine, increases in dose will not increase pain relief. In order to be effective, heat and cold should only be applied to the painful areas.

26 (29.9)

23 (26.4)

19 (21.8)

48 (55.2)

58 (66.7)

47 (54.0)

73 (83.9)

66 (75.9)

82 (94.3)

Total score (True/false questions)

2 3 4 5 6

7 8

Recommended route of administration of opioid analgesics to patient with post of pain Which of the following analgesics medications is considered as a drug of choice for the treatment of prolonged moderate to severe pain for post op Analgesics for post op pain should initially be given Most likely explanation for why patient with pain would request increased doses of pain medication is The most accurate judge of the intensity of the patients pain is Narcotic/opioid addiction is defined as psychological dependence accompanied by overwhelming concern with obtaining and using narcotics for psychic effect, not for medical reasons. It may occur with or without psychological changes of tolerance to analgesia and physical dependence (withdrawal). Using this definition, how likely is that opioid addiction will occur as a result of treating pain with opioid analgesics The time to peak effect for fentanyl is The time to peak effect of PCM given orally is

12.47 (2.3)

13.64 (3.00)

14.97 (3.61)

64 (73.6)

74 (85.1)

80 (92.0)

32 (36.8)

44 (50.6)

53 (60.9)

74 (85.1) 36 (41.4)

69 (79.3) 59 (67.8)

66 (75.9) 35 (40.2)

28 (32.2) 0

26 (29.9) 12 (13.8)

60 (69.0) 44 (50.6)

24 (27.6) 22 (25.3)

21 (24.1) 31 (35.6)

24 (27.6) 23 (26.4)

Total score (MCQs)

Total score (True/false questions þMCQs) Case scenarios

1A

Rahul is 16 years old and this is his first day following cardiac surgery. As you enter his room, he smiles at you and continues talking and joking with

Mean (SD) 3.21 (1.4)

3.86 (1.45)

4.42 (1.74)

15.69 (2.94)

17.51 (3.47)

19.40 (4.61)

Pretest frequency underestimating/ undertreating pain (%) (N ¼ 87)

Post-test Frequency underestimating/ undertreating pain (%) (N ¼ 87)

Retention test Frequency underestimating/ undertreating pain (%) (N ¼ 87)

81 (93.1)

81 (93.1)

80 (92.0)

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(Continued )

Intervention Improving Nurses’ Understanding of Pain

MCQs 1

Mean (SD)

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TABLE 2. Continued Questions (Frequency [%] of Correct Answers)

1B

2A

2B

MCQ ¼ multiple-choice questions; PCM ¼ paracetamol; BP ¼ blood pressure; HR ¼ heart rate; RR ¼ respiratory rate.

Post-test Frequency (%) (N ¼ 87)

Retention Test Frequency (%) (N ¼ 87)

68 (78.2)

66 (75.9)

74 (85.1)

56 (64.4)

68 (78.2)

61 (70.1)

70 (80.5)

50 (57.5)

45 (51.7) Dongara et al.

his visitor. Your assessment reveals the following information—BP: 120/80, HR: 80, RR: 18. On a scale of 1-10, he rates his pain 8. On the patients chart you must mark his pain as ___? He has received PCM 2 hours before the assessment. Serial pain assessments reveal a score range of 6-8. He has identified 2 as an acceptable level of pain relief. Fentanyl is to be given as required. What will be your next step? Niraj is 16 years old and this is his first day following cardiac surgery. As you enter his room, he is lying quietly and grimaces as he turns in bed. Your assessment reveals the following information—BP: 120/80, HR: 80, RR: 18. On a scale of 1-10, he rates his pain 8. On the patients chart you must mark his pain as ___? He has received PCM 2 hours before the assessment. Serial pain assessments reveal a score range of 6-8. He has identified 2 as an acceptable level of pain relief. Fentanyl is to be given as required. What will be your next step?

Pretest Frequency (%) (N ¼ 87)

Intervention Improving Nurses’ Understanding of Pain

FIGURE 1. - Box plots depicting comparison of pre, post, and retain scores.

[1.45], p ¼ .001). The mean (SD) total post-test score of MCQs improved significantly over the next 3 months (3.86 [1.45] vs. 4.42 [1.74], p ¼ .006), as shown in Table 2 and Figure 1. The mean (SD) improvement (post/pre) in total score (true/false þ MCQs) was not associated with being married (2.08 [3.93] vs. 1.62 [4.08], p ¼ .60) or having children (2.27 [4.31] vs. 1.66 [3.91], p ¼ .54). The improvement was neither associated with age (correlation coefficient [r] ¼ 0.12, p ¼ .28) nor with experience (correlation coefficient [r] ¼ 0.12, p ¼ .25). However, the improvement was significantly higher in pediatric units as compared to neonatal units (p ¼ .007) and cardiac units (p ¼ .006). Despite some improvement in knowledge, the nurses not only underestimated the pain but also were hesitant to administer proper drugs for the management of pain. In case scenario 1, 81 (93.1%), 81 (93.1%), and 80 (92.0%) of the nurses underestimated the pain during pre, post, and retain evaluation. Furthermore, only 19 (21.8%), 21 (24.1%), and 13 (14.9%) correctly identified line of treatment during pre, post, and retain evaluation pertaining to pain level in case scenario 1. In case scenario 2, 56 (64.4%), 68 (78.2%), and 61 (70.1%) nurses underestimated pain during pre, post, and retain evaluation. Surprisingly, significantly more nurses correctly identified line of treatment in post (17 [19.5%] vs. 37 [42.5%], p ¼ .002) and retain (17 [19.5%] vs. 42 [48.3%], p < .001) evaluation as compared to baseline (pre) evaluation.

DISCUSSION The nurses were relatively young with a mean age of 27.36 years. Most of the nurses had experience of

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<5 years, were unmarried, and did not have children. Their initial perceptions about pain assessment tools were a reason to worry. More than half of them had heard of pain scales and were using them in practice, but most of them felt that these pain assessment tools were not useful and they would not like to use the scales to assess pain in children in the wards. There was a statistically significant improvement in the score of true/false questions and MCQs of the nursing staff in the pretest, post-test, and 3-month retention test. This signifies an improvement in knowledge about pain in children after training. Similar improvement in knowledge was also observed by Johnston et al. (2007) and Huth et al. (2010). We do not know whether this improvement in scores would reflect as better pain management in patients. The improved knowledge could be a reflection of increasing frequency of pain assessment and attention to patients’ complaints as noted by Johnston et al. (2007) and de Rond et al. (2000), increase in interventions as noted by Pederson (1996), or as improvement in both patient and staff satisfaction as noted by Treadwell et al. (2002). A study by Knoblauch and Wilson (1999) noted a paradoxical deterioration after training. However, this deterioration was gauged as time to administration of first analgesic and interval between two doses of analgesics, so it cannot be considered a reflection of pain management as a whole entity. The improvement was not associated with age, experience, marital status, or whether the nurses had children. These findings are not surprising considering the composition of this study group. The ward where they are working has a significant impact on the improvement with nurses from the cardiac ward having very limited improvement. With the training programs and nurses’ backgrounds being similar, this probably indicates an area to focus and conduct reinforcement sessions. The nurses scored lower and showed less improvement in questions that were related to pharmacology and dosages of analgesic medications, especially opioids. This finding was observed despite the fact that the original questionnaire was edited to remove difficult questions regarding pharmacodynamics of drugs and dosages, keeping only questions related to routinely used medications. This highlights another area to focus on in training programs. A very important finding of this study is the significant improvement that is noted not only between the pretest and post-test but also between the post-test and 3-month retention test. This finding suggests that the training triggered some sort of snowball effect, encouraging the nursing staff to educate themselves and

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Dongara et al.

improve their knowledge, as depicted by higher retention test scores. Limitations One of the shortcomings of this study is that the investigators have not yet conducted a repeat survey to ascertain long-term retention of knowledge. Further, the translation of knowledge into practice was not evaluated. Although a convenient sample was drawn, 87 (83.7%) of all eligible nurses participated; hence, the findings are quite reliable in this aspect. However, this study was conducted at an academic hospital, and generalizability of the results in nonacademic settings may be limited. Implications for Nurses’ Education, Practice, and Research The nurses’ training module in the United Kingdom is reported to lack basic training about pain, its assessment, and management strategies (Twycross, 2000). Pediatric pain is still a neglected area. Nursing education in India propagates a generalist approach, and most nurses working in India possess some kind of diploma. Most of the nurses learn specific aspects of care by experience, as there is no subspecialty in nursing education. The authors feel that it is time to increase the availability of subspecialty certificate courses, such as primary care, emergency care, and intensive care unit care, in nursing education. With respect to pediatric specialties, there is a need to introduce certificate courses, such as pediatric intensive care nursing, neonatal intensive care nursing, emergency pediatric care, and pediatric cardiac critical care, which would include modules on standardized pain management. The curriculum relating to pain management would need to have standardized infant and pediatric pain instruments training, pharmacological, and nonpharmacological approaches as well as quality improvement training to improve care.

Developing a module related to identification and management of pain for nurses is challenging. Although the contents of such a module may vary depending on the needs, a generalized framework of the broad domains of such a module can be developed before minor contextual modifications. It is not possible to have bedside training for obvious reasons. Simulation using a standardized patient is not feasible in the pediatric population, and other low-fidelity simulations should be tested. Case scenario is a simple, feasible, and effective toll to start with, but other methods like videos with physiological readings may be tried. Emotional sensitization before the training module was successfully tried at our center for empowering interns about infection control protocols. Thus, the training module can be supplemented with pretraining sensitization to enhance the effectiveness of the module. The translation of knowledge into practice to achieve optimal pain management is the ultimate long-term goal of such intervention. An adequate support system, blame-free environment, and regular audits followed by reinforcement if required should be performed until optimal pain management becomes a culture.

CONCLUSIONS The educational intervention was successful, and better retention test scores suggest a cascading effect. Pain assessment and management in children should be incorporated in the nursing curriculum and should be reinforced in all pediatric units.

Acknowledgment The authors thank Dr. Nisha Fahey, MD, for providing the English language check for the manuscript.

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Intervention Improving Nurses’ Understanding of Pain

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