Exploring how NICU nurses in Oman experience and understand neonatal pain and its management

Minimizing infant pain has become a significant concern worldwide. However, in Oman there are no standardized, evidence-based (EB) guidelines of care for achieving this goal. Pain management strategies and protocols vary considerably among neonatal health care professionals and between neonatal intensive care units (NICU) and are not evidence based. Moreover, there are no neonatal pain assessment tools to help staff detect and learn how to manage pain. This study used an ethnographic approach to explore how nurses approach and interact with babies being cared for in a neonatal intensive care unit in Oman, with a particular focus on pain. There have been very few qualitative studies of NICU nursing, and no studies have been found that focused on neonatal pain. An ethnographic approach enabled me to explore how organizational 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, 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 NICU Nurses caring for babies who have been admitted to NICU in ‘Hope’ Hospital in Oman. Data collection took place over four months. A range of qualitative data collection methods were used to answer the research questions (observational field work and interviews). Following a period of 6 weeks general observation of nurses’ work in NICU, semi-structured interviews were conducted with a purposive sample of 20 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. The immediate outcomes of the study were to achieve a better understanding of how neonatal pain was assessed and managed by nurses in NICU, how this was influenced by organizational culture, and to gain insight into nurses’ understandings of baby’s pain and how it was managed. Four themes emerged from the research data collection, the NICU environment, complexity of organisational culture, lack of professional autonomy and inconsistency of pain practice. In the first theme, the NICU environment has particular environmental stressors (crowded, busy, noisy, and handling). It appeared that the environment is one of the major challenges for nursing staff in their practice and interaction with the babies. The majority of nurses reported that these stressors affect babies' development and cause the NICU nurses to experience stress. In the second theme, the organisational culture appear to have an impact on nurses' performance, as the culture was experienced as unhealthy, blaming and unsupportive to the nursing staff. Due to that, all the nursing staff revealed that they were overwhelmed, depressed and unsatisfied. Lack of training was a major concern to the nurses. The third and fourth themes, showed that lack of neonatal policies and guidelines, lack of resources, non-acceptance of evidence based practice, and lack of involving nurses in decision making of patients' care were of major concern to nurses that hindered their care for the babies in NICU. Also, lack of training, the year of experience and doctors’ dominance contributed to the nurses’ feeling of powerlessness, lack of confidence, and lack of ownership. Although the participants showed themselves to be knowledgeable about pain and its management this varied from one nurse to another, and the majority of the nurses during the observation showed their actions were not consistent with their knowledge. Most importantly, babies' centrality was not visible and was not a priority in the unit's daily routines, which indicates that the concept of patient centred care (PCC) was not applied. The research findings suggest some areas of improvement to implement PCC, in which the health of work environment in NICU needs attention to ensure safety and optimal outcomes for babies and their families. A cultural shift is needed for healthy relationships to support health care providers (nurses) and the baby's families. The culture of patient's care has to shift from task orientation to patient centred care. The hospital organisation has to make PCC a priority and this can be achieved through involvement of family to meet baby's needs, by developing a trusting relationship between nurses and baby's families and by introducing emotional support services. To create a culture of PCC, hospital culture has to be sensitive to reject any behaviours that do not put patients first. Also, neonatal pain education is of great importance to support in PCC implementation, to bridge the gap of knowledge and empower the nurses. Evidence based pain policies and guidelines, and job description at all the levels should be developed and implemented across the country and evaluated periodically to ensure consistency of practice and maintain patient centeredness