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PEDIATRIC ANESTHESIA

Videotape Increases Parental Knowledge About Pediatric Pain Management

Robert S. Greenberg, MD^*,, Carol Billett, RN, MS, CPNP^*, Marianna Zahurak, MS, and Myron Yaster, MD^*,

Departments of *Anesthesiology/Critical Care Medicine and Pediatrics, The Johns Hopkins Hospital; and Department of Oncology/Biostatistics, The Johns Hopkins University, Baltimore, Maryland

Address correspondence to Robert S. Greenberg, MD, Blalock 902A, Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21287. Address e-mail to rgreenbe{at}welchlink.welch.jhu.edu

	Abstract

Top Abstract Introduction Methods Results Discussion Appendix 1 References

 
Pediatric pain management often depends on parents recognition and assessment of their child’s pain and their beliefs as to whether the pain should be treated. Parental misconceptions concerning pain assessment and pain management may therefore result in inadequate pain treatment, particularly in patients who are too young or too developmentally handicapped to self-report their pain. We hypothesized that viewing a concise, educational videotape would provide parents with instructive information that could correct misconceptions concerning pain and pain management in children. To do this, we evaluated the impact of an educational videotape on parental responses to a questionnaire about pediatric pain management. Parents of children scheduled for inpatient, postoperative hospital care were studied. After answering 30 questions, parents were randomly assigned to either view (Group 1) or not view (Group 2) a 19-min educational videotape. Immediately after viewing the videotape (Group 1), or 30 min after taking the first test (Group 2), parents were asked to answer the same questionnaire a second time. The effect of seeing the videotape was assessed by comparing post-pre test score differences using paired t-test. One-hundred parents were studied. Randomization was effective in assigning equitable groups. Initial scores of percent answers correct in each group were not different ([mean ± SD] Group 1 [n = 50]: 68.7% ± 18.8% vs Group 2 [n = 50]: 61.5% ± 22.7%; P = 0.09). Viewing the videotape effectively increased test scores: paired t-test within groups demonstrated a significant difference in Group 1 (22.4% ± 16.5%, P < 0.0001), whereas Group 2 scores changed to a much lesser degree (2.7% ± 8.3%, P = 0.0271). All parents who viewed the videotape stated that it was informative regarding their understanding of their child’s pain management. This study demonstrates the effectiveness of an educational videotape in changing parental knowledge concerning postoperative pediatric pain. This effective and efficient teaching medium may be useful in improving pain management in postoperative pediatric surgical patients.

Implications: Pediatric pain management often depends on parents recognition and assessment of their child’s pain and their beliefs as to whether the pain should be treated. This prospective, randomized, controlled study demonstrated the effectiveness of an educational videotape in changing parental knowledge concerning postoperative pediatric pain. This effective and efficient teaching medium may be useful in preventing inadequate pain management in postoperative pediatric surgical patients.

	Introduction

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The common "wisdom" that children neither respond to, nor remember, painful experiences to the same degree that adults do is simply untrue (1–3). Several studies have documented that physicians, nurses, and parents underestimate the amount of pain experienced by children, and that they overestimate the risks inherent in the drugs used in the treatment of pain (4,5). Unrelieved pain interferes with sleep, leads to fatigue and a sense of helplessness, and may result in increased morbidity and/or mortality (6–8).

Pain can be treated effectively, but often depends on an approach that uses validated self-report and objective observational pain measures. A number of valid tools for self-report of pain have been devised (9). For patients incapable of self-report, including newborn or preverbal infants, and those with neurological or developmental conditions that impair cognition or communication, behavioral (e.g., cry, facial grimacing), and physiological reactions (e.g., changes in heart rate, blood pressure, or palmar sweating) can be measured by clinical staff to assess pain (10,11). Parental recognition and assessment of their child’s pain using these techniques and their belief as to whether the pain should be treated is commonly the basis for treatment measures taken (12–15). Since parental misconceptions concerning pain assessment and management may result in inadequate pain treatment, parental education is essential if children are to be adequately treated for pain. Unfortunately, the ability to properly educate parents about this issue is often limited by insufficient resources, time, and personnel.

The use of videotape instruction may overcome some of these obstacles to parental education by providing clear and effective information in a consistent way (16,17). We hypothesized that viewing a concise, educational videotape would provide parents with instructive information that could correct many misconceptions concerning pain, pain assessment, and pain management in children. To do this, we evaluated the impact of an educational videotape on parental responses to a questionnaire about pediatric pain management.

	Methods

Top Abstract Introduction Methods Results Discussion Appendix 1 References

 
The study was a prospective, randomized, masked, study with approval by our Institutional Review Board. Consent was obtained from parents if their child was to undergo an operative procedure with subsequent inpatient postoperative pain management. Parents needed to be able to speak and understand English because the videotape and questionnaire were available only in English. If two parents accompanied the child, one or both could participate as independent subjects. Parents were told that this was a study to see if a video could help them learn more about pain management in children.

Demographic information was collected to describe the parents participating in the study. Parental age, highest level of education (less than high school, high school, college, more than college), and sex were recorded. Also, information about the parent’s child (the patient) was collected, including the child’s age, sex, and previous exposure to pain management.

The videotape presentation, written by the authors and produced by the our Institution, runs for 19 mins and was designed to be an informative and concise representation of modern techniques used to manage pediatric pain in the acute setting. Written at an elementary reading level (6th grade), the script identified several areas of common misconception, including the role or benefit of pain immediately after an operative procedure, the effectiveness and safety of several techniques used in treating pain (e.g., opioid use, patient-controlled analgesia, parent-nurse-controlled analgesia, and epidural [caudal, lumbar] analgesia, and the value of parental contributions to the pain care team. Various methods of pain assessment, including age-appropriate self-report measures and objective pain scores, were demonstrated. Finally, we presented information about the importance of understanding the developmental, cultural, and age-related contributors to pain perception and expression in children. The total cost of producing this videotape was less than $2000, and does not include the volunteered time of physicians, nurses, child-life specialists, parents, and patients.

A 30-question (true/false/don’t know) questionnaire was created, based on the information presented in the videotape, and was designed to assess parental knowledge of these important aspects of pediatric pain management (see Appendix). Knowledge topics included questions about pain assessment and pain management in children, risks and benefits of treating or not treating pain, and the role of the parent in the management of their child’s pain. All parents answered the questionnaire and were then assigned to either view or not view the educational videotape based on a computerized randomization table. Immediately after viewing the videotape (Group 1, n = 50) or 30 min after taking the first test (Group 2, n = 50) both groups were asked to answer the same test a second time. The effect of viewing the videotape was assessed by comparing correct answers of post-pre test score difference using paired t-test. "Don’t know" responses were scored as incorrect. At the conclusion of the study, parents who viewed the videotape were asked whether they thought the videotape was informative regarding their understanding of their child’s pain management.

Study group size was based on prior experience using the study questionnaire and designed to result in an initial score of 60% correct. Accepting the ability to detect a difference of 0.5 standard deviations between scores, assuming a correlation of 0.30, and planning for 85% power, the sample size required was at least 50 subjects in each group. Comparisons were made using paired and unpaired t-tests, and ANOVA where appropriate. A P value of 0.05 was considered statistically significant. Data from the questionnaires were analyzed using JMP (Version 3, SAS Institute, Inc., Cary, NC) and are represented by mean ± SD unless otherwise noted.

	Results

Top Abstract Introduction Methods Results Discussion Appendix 1 References

 
One-hundred parents (50 in each group) were recruited to participate in the study. Randomization was effective in assigning equitable groups with respect to parent age, sex, and highest educational level, and by patient age, sex, and history of previous pain management (Table 1). Initial scores of percent answers correct in each group were not different (unpaired t-test, P = 0.09) (Table 2). Improvements in postviewing scores were identified in Group 1 (22.4% ± 16.5%, P < 0.0001), whereas Group 2 scores (control) changed to a much lesser degree (2.7% ± 8.3%, paired t-test, P = 0.0271) (Table 2). The highest level of parental education and a history of previous pain therapy significantly affected the improvement in postviewing scores (Table 3). In the videotape view group, all participants stated that it was informative and helpful (see Appendix).

	Discussion

Top Abstract Introduction Methods Results Discussion Appendix 1 References

Significant increases in scores, compared with pretest results, were noted in both groups. Although a statistically significant but small increase (2.7%) was noted in those not viewing the videotape (owing to the power of the study), a much larger increase (22%) was demonstrated by those parents in the group that viewed the videotape. Changes in postscore results of parents with higher education (greater than college) were less than those with less education. In fact, this was seen because, in those parents with more education, scores were initially higher and the videotape had less impact on improving such scores. This suggests that those parents with less educational experience (e.g., high school or less) may benefit the most from additional educational exposure, such as viewing a videotape regarding pain management of their children.

Likewise, parents of children who had previously been exposed to pain management had less improvement in scores after viewing the videotape than those with no prior exposure. This indicates that, although some knowledge was gained from previous exposure to pain management (and suggested by the higher prescore values of those with prior pain management), greater improvements were seen in those with no previous exposure. Although increases were larger in this group, increases in scores were also noted by parents already experienced with pediatric pain management.

Effective teaching of major principles of pediatric pain management is crucial to improving the treatment of pain in children. In one study, it was shown that false beliefs about addiction and the proper use of acetaminophen and other analgesics resulted in the failure to provide analgesia to children (22). In another, the belief that pain was useful or that repeated doses of analgesics lead to medication not working well resulted in failure of the parents to provide or ask for prescribed analgesics to treat their children’s pain (15). Furthermore, variations in teaching styles and content introduce inconsistencies in information conveyed to parents by physicians and nurses. There is therefore a need for a simple technique to educate parents about pediatric pain management that is effective, consistent, and acceptable to parents. We hypothesized that viewing a videotape would be an attractive educational alternative because, if effective, it could fulfill these requirements. Indeed, this study demonstrated that viewing this videotape provided parents with concise, useful information concerning pain, pain assessment, and pain management in children in a dependable manner that was different from their routine exposure in the preoperative preparation area.

This study did not compare viewing this videotape with other educational techniques (such as reading an educational pamphlet, personal teaching by a nurse or physician, etc.), nor did we ask which educational technique parents prefer. Furthermore, whereas this study demonstrated improvement in parental knowledge immediately after viewing the videotape, by design, it did not assess the impact of this videotape on long-term parental knowledge or its effect on patient care. Although this study could not address these important issues, we can now use this validated videotape as a tool in future investigations. Nevertheless, despite these limitations, we believe that the addition of this videotape to a comprehensive educational program for parents is valuable.

In conclusion, this study demonstrated that a complex discussion of pediatric pain, pain assessment, and pain management can be effectively communicated to parents of various educational levels via a videotape presentation. This effective and efficient teaching medium may be useful in preventing inadequate pain management in postoperative pediatric surgical patients.

	Appendix 1

Top Abstract Introduction Methods Results Discussion Appendix 1 References

 
Pain Management Questionnaire
(True, False, Don’t Know)

1. Untreated pain after surgery has a useful purpose.

2. Newborn infants can feel pain.

3. Newborn infants cannot get any pain medicines because they are so small.

4. Feelings like being afraid, tired, and feeling out of control can change the way my child shows pain.

5. Children under 2 years of age can tell us where they hurt and explain how much they hurt.

6. Children aged 4 to 6 years can use a Smiley Faces scale to tell how much they hurt.

7. Some children may think that they have pain because of something they did wrong.

8. Some children may not admit that they have pain because they think that pain medicine will be given with a needle.

9. School-age children and teenagers can use a "0 to 10" number scale to describe their pain.

10. Teenagers may not want to admit that they have pain because it might make them look weak in front of their friends.

11. Medicine like morphine is the only way to reduce the pain after an operation.

12. Medicines like morphine should not be given to small children because it is impossible to give a safe dose to a child.

13. It is best to wait until the pain is bad before telling your child to push the button to get more medicine.

14. Parents can help control their child’s pain by pushing a button on a pump called a PCA pump.

15. The PCA button should not be used before a painful event, like the first time your child gets out of bed after the operation.

16. An epidural catheter can be used safely in children to reduce the pain after an operation.

17. The epidural catheter does not hurt the spinal cord.

18. Medicine given through an epidural catheter can help to numb the nerves to the belly and feet.

19. An epidural catheter goes into the spinal cord and can cause a child to be paralyzed.

20. It is best to not tell children the truth when telling them about a painful procedure.

21. It is harder for a child to have a parent in the room when something painful is going to happen.

22. Coping techniques such as deep breathing, counting, or singing with your child during a painful procedure are useless.

23. If a child gets a lot of pain medicine, even for a short time, he will likely become addicted.

24. Children may say that they have more pain to get pain medicine to make them feel high.

25. The side effects of pain medicines like morphine are so serious, it is better for your child to have pain.

26. If your child has side effects, like nausea or vomiting, it is a sign that your child is really allergic to the medicine.

27. Children who get a catheter in their backs for pain medicine, will not be able to move their legs.

28. Children who get a catheter in their backs for pain medicine, must stay in bed.

29. An epidural catheter must be taken out right away after the operation, and cannot stay in overnight.

30. A fast heartbeat, waving their arms, frowning, or crying may mean an infant is hurting.

If you saw the video, was it helpful? YES NO

	Acknowledgments

 
The authors wish to express their gratitude to Lisa Laramee, BA, and the Child Life Television Department for producing the videotape, and to Elizabeth M. Dake, MS, for her help in performing these studies.

	Footnotes

 
This work was performed at the Johns Hopkins Hospital, Baltimore, Maryland.

Reprints of this article will not be available.

	References

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