Exploring How NICU Nurses in Oman Experience and Understand Neonatal Pain and Its Management 2019
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` Exploring How NICU Nurses in Oman Experience and Understand Neonatal Pain and Its Management 2019 Thesis submitted for the degree Doctor of Philosophy Nasiha Marhoon Al-Braiki C1253293 School of Healthcare Sciences Cardiff University i i Dedication My thesis is dedicated to my children Saam and Asir. Saam has been always by my side and has helped to look after his brother when I am away. To Asir, who has had lots of struggle throughout the PhD period. His sickness has not been only a great lesson for me to be resilient, patient and motivated, but has also shaped me to be a different person who should never give up. To my best mum in the world who has been always there with her prayers and encouragement, love and belief in me. Acknowledgements My sincerest thanks go to all the parents for their support and trust, and to all the healthcare professionals (ward nurses, and consultants) who gave their continuous support and time to follow-up the progress of my study. Without their generosity this study would not have been possible and I will never forget the kindness and warmth of all the participants. My special thanks go to Ms. Nima Al-Amri for being always their whenever I needed her support. I am very grateful to my supervisors Prof. Billie Hunter and Dr Dikaios Sakellariou for their guidance, encouragement, compassion, support and belief in me is what kept me going and have given me much needed strength to keep me going. My deepest thanks to you both. I am forever thankful to Dr Katie Featherstone who stood by my side while I experienced the highs and lows of the PhD process in the first three years, and for her empathy, compassion, and persistent support. Thank you for being always there. Warm thanks are also extended to Dr Aled Jones for his outstanding insight throughout all the panel reviews. My thanks to my brilliant colleague Dr Ada Bonina who has offered her constant advice, support towards the end. All my thanks for Prof. Peter Godwith for his continuous support in sharing his valuable thoughts and being always there to answer my questions. Finally, a sincere and grateful thank you to my lovely family for their prayers, constant love, support and keeping me grounded, especially my mum, and husband. Last, but not least, I would like to acknowledge my PhD colleagues in Cardiff University for their help and support, especially Ahmed Al-Ghamdi, Dawood, Laura Goodwins for sharing her work to guide me to the right way. i i i Abstract Minimising infant pain has become a significant concern worldwide. However, in Oman neonatal pain management strategies and protocols vary considerably among neonatal healthcare professionals and between neonatal intensive care units (NICUs), and they are not evidence based (EB). Moreover, there are no neonatal pain assessment tools to help staff detect and learn how to manage pain. The guidelines of care in Oman are frequently outdated, and not standardised. Moreover, they tend to be irrelevant to neonates, particularly for neonatal pain management because they are focused on the needs of adult patients. This study used an ethnographic approach to explore how nurses ’ approach and interact with babies being cared for in a NICU in Oman, with a particular focus on pain. There have been very few qualitative studies of NICU nursing that have focused on neonatal pain. An ethnographic approach enabled me to explore how organisational culture informs the management of neonatal pain; for example, how pain was perceived, assessed, and managed by nurses, the barriers or challenges the nursing staff face from implementing appropriate strategies, and the impact of NICU environment on how nurses interact with babies. The study’s primary aim was to explore the experiences and understanding of neonatal pain and its management among the nurses caring for babies who have been admitted to the NICU in ‘Hope’ Hospital in Oman. Data collection took place over four months. A range of qualitative data collection (observation and interviews) methods was used to answer the research questions. Following a period of 6 weeks general observation of nurses’ work in NICU, semi structured interviews were conducted with a purposive sample of 16 Omani and non-Omani neonatal nurses until data saturation was reached. The sample included nurses with different levels of training to explore whether, how and why nurses differ in their behaviours, approaches and beliefs regarding pain and pain management. Four themes emerged from the data analysis, ‘the inconsistency of pain practice’, ‘the NICU environment’, ‘the nursing culture’ and ‘complexity of organisational culture’. In the first theme ‘the inconsistency of pain practice’, the nurses described neonatal pain management in the unit as varied and inconsistent. The lack of resources, non-acceptance of EB practice, and lack of involving nurses in decision m aking of patients’ care were major concerns to nurses and hindered their care for the babies. The babies’ centrality was not visible and was not a priority in the unit’s daily routines, which indicates that patient -centred care (PCC) was not applied. The participants reported hierarchical issues, doctors who dominated the nurses, nurses having i v no clinical autonomy, care based on the healthcare provider’s clinical judg ement, no evidence- based practice, and no consistency of care due to limited neonatal pain guidelines. The second theme showed that the NICU environment has particular environmental stressors (crowded, busy, noisy, and excessive handling) that create major challenges for the nursing staff in their practice and interaction with the babies. Most nurses reported that these stressors affect the babies’ development and cause the nurses stress. The third and fourth themes show how the nurses reacted to the unit’s policy, nurse– doctor relationship, and the impact on nursing confidence and autonomy. The lack of training, years of exper ience and the doctors’ dominance contributed to the nurses’ lack of professional autonomy, lack of confidence, and lack of ownership. Although the nurses in the interviews were knowledgeable about pain and its management, the nurses showed that their actions were not consistent with their knowledge. The organisational culture had an impact on the nurses’ performance and it was unhealthy, blaming and unsupportive. The participants were overwhelmed, depressed and unsatisfied. The lack of training was a major concern. The findings suggest some areas of improvement to implement PCC. The work environment in the NICU should create a friendly and supportive climate for the nurses to ensure safety and achieve optimal outcomes for babies and their families. The patient care culture has to change from task orientation to PCC and a trusting relationship should be built between the nurses and the baby’s families. The hospital organisation has to make PCC a priority by putting the babies and their families first, involve the families in the decision- making process of their own baby’s care and help the nurses provide individualised care to patients and improve their own quality of life. Emotional support services should meet the nurses ’ and families ’ emotional well-being. To create a culture of PCC, the hospital should reject any behaviours that do not put the patients first. Neonatal pain training and education was found to be of great importance for the implementation of PCC. EB pain policies and guidelines, and job descriptions should be developed and evaluated periodically to ensure consistency of practice and maintain patient- centredness. This thesis emphases the importance of a person-centred approach in neonatal pain management. v Glossary Expatriate or non-nationals : An expatriate is defined as any person living in Oman who is not a citizen of Sultanate of Oman. Omanisation : is a process launched in 1988 by the government of Oman that aims to provide various opportunities to increase participation of Omani labour in Oman’s economy and to reduce dependence on expatriate labour for self-reliance (Oman Information Centre 2018). Willayat : are the administrative districts in Oman. There are 60 willayats in the Sultanate (Department of Health information and Statistics 2017, p.3). Health centre : "A health centre provides primary healthcare to the people in the surrounding catchment area" (Department of Health information and Statistics 2017, p.3). Extended Health Centre : "A health centre that provides primary healthcare services and in addition there are some specialised outpatient clinics in different specialties. They serve the people in the catchment area. They do not have inpatient services" (Department of Health information and Statistics 2017, p.3). Regional Hospital : "A hospital that provides secondary and tertiary care to inhabitants of the health region in which it is located. It is usually built in the centre of a health region and is considered as a referral hospital for critical cases from other hospitals and health centres of the health region. Regional hospitals of the Muscat Governorate act as national referral hospitals for critical cases from other regional hospitals" (MOH 2014, p.2). v i Abbreviations ARI Acute Respiratory Infection BFHI Baby Friendly Hospital Initiative CCP Child Care Plan. CDD Control of Diarrhoeal Disease. CSGs Community Support Groups DGHS Directorate General Health Services. DGs Director Generals DNMA Directorate of Nursing and Midwifery Affair EMRO East Mediterranean Regional EPI Expanded Program of Immunisation HRD Human Resource Development