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Andrea Castro Bernal
HContents
OS TE D BY lists available at ScienceDirect
 Journal of Nursing Sciences 9 (2022) 533e541
International

Review

Nurses’ experiences of caring for preterm infants in pain: A meta-

ethnography
Tingting Zhao a, Angela R. Starkweather b, Adam Matson c, d, Shabnam Lainwala c, d,

Wanli Xu a, Xiaomei Cong a, e, *

a School of Nursing, University of Connecticut, Storrs, CT, USA
b College of Nursing, University of Florida, Gainesville, FL, USA
c Division of Neonatology, Connecticut Children’s Medical Center, Hartford, CT, USA

d Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA

e School of Nursing, Yale University, Orange, CT, USA

ARTICLE I N FO A B S T R A C T

Article history: Objective: Preterm infants are subjected to numerous painful procedures during their neonatal intensive
Received 21 June 2022 care unit (NICU) hospitalization. Despite advancements in pain alleviation, nurses remain challenged to
Received in revised form provide timely and effective pain management for preterm infants. Greater understanding of the lived
25 August 2022 experience of nurses caring for preterm infants in pain could provide novel insights to improve pain
Accepted 8 September 2022
management for this vulnerable population. The aim of this meta-ethnography was to synthesize and
Available online 16 September 2022
interpret qualitative findings of nurses’ experiences of taking care of preterm infants in pain.
Methods: An extensive literature search in PubMed, CINAHL, PsycINFO, Scopus, BIOSIS and ProQuest
Keywords:
Dissertation and Theses Database was conducted, including studies within the past 10 years. Two nursing
Neonatal intensive care units
researchers conducted data extraction and analysis independently. Inclusion criteria were applied to
Premature infant
Pain measurement search for qualitative studies of nurse participants who worked in the NICU taking care of preterm in-
Parents fants. Studies published in a language other than English, articles that did not include qualitative data
Pain and qualitative data that could not be extracted from the findings or did not discuss nurses’ experiences
Nursing care were excluded. Critical Appraisal Skills Programme was used for literature quality evaluation.
Nurses Results: Eight studies remained after further screening according to inclusion and exclusion criteria.
These eight studies were conducted from 2013 to 2018 and totally enrolled 205 nurses from Iran, Canada,
the United States, Finland, Sweden, Switzerland, and Australia. Five themes emerged on the nurses’
perspectives of taking care of preterm infants in pain: 1) They sense the neonatal pain; 2) Adverse
consequences of unrelieved pain; 3) Barriers of managing pain; 4) Concerns of available approaches for
pain relief; 5) Failure to work with parents.
Conclusions: This meta-ethnography identified nurses’ understanding of pain in preterm infants that can
be assessed, and they acknowledged that unrelieved pain could cause developmental deficits in infants.
The barriers are lack of training and support on pain assessment and intervention in preterm infants.
Optimizing workload and environment, developing age-specified pain assessment and intervention,
receiving emotional support and training, and building up a rapport with parents are urgent needs for
nurses to provide better care to infants having pain.
© 2022 The authors. Published by Elsevier B.V. on behalf of the Chinese Nursing Association. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

What is known?

● Preterm infants experience enormous pain during their early life

* Corresponding author. School of Nursing, University of Connecticut, Storrs, CT,
USA.
E-mail addresses: tingting.zhao@uconn.edu (T. Zhao), xiaomei.cong@yale.edu
(X. Cong).
Peer review under responsibility of Chinese Nursing Association.
in the neonatal intensive care unit (NICU), which may cause
adverse consequences that may persist into adulthood.
● Timely and effective pain assessment and intervention provided
by NICU nurses to preterm infants will benefit their health
outcomes.

https://doi.org/10.1016/j.ijnss.2022.09.003
2352-0132/© 2022 The authors. Published by Elsevier B.V. on behalf of the Chinese Nursing Association. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
T. Zhao, A.R. Starkweather, A. Matson et al.
What is new?
● This review thoroughly summarizes NICU nurses’ lived experi-
ence in their assessment and management of neonatal pain,
which provides new insights into nurses’ concerns and research
gaps in NICU standard nursing care.
● The findings indicate nurses’ experiences with the adverse
consequences of unrelieved pain, barriers to managing pain,
concerns about current approaches for pain relief, and urgent
needs to work with parents when caring for preterm infants
with pain.
1. Introduction
Approximately 15 million infants are born each year prema-
turely worldwide, defined as <37 weeks gestational age [1]. As part
of lifesaving treatment, these preterm infants are exposed to more
than 300 necessary but invasive procedures during an average
neonatal intensive care hospital stay [2]. Our recent study showed
that during the first 28 days of hospital stay, averagely preterm
infants experienced 614.12 acute pain/stress events (e.g., mouth
care, diaper change, position change, heel-stick, suctioning) and
1,023.65 h of chronic pain/stress stimulation (e.g., nasogastric and
orogastric tube in situ, continuous positive airway pressure
manipulation, chest tube placed on wall suction) [3]. Repetitive
pain-induced stresses have been shown to sensitize the nervous
system of preterm infants [4] through enhanced nociceptor exci-
tation [5] and reduced inhibitory transmission in the spinal cord
dorsal horn [6]. Altered pain sensitivity [7] has been associated
with significant changes in the somatosensory function, increasing
vulnerability to chronic pain [8], and neurodevelopmental impair-
ments [9,10]. The adverse consequences of repetitive pain-induced
stresses can persist through childhood and even into adulthood
[11,12].
Pediatric nurses are playing a pivotal role in caring for preterm
infants in pain. Nurses take charge of pain assessment, pain man-
agement, infants and parents advocacy, and parents’ education.
However, due to preterm infants’ immature nervous system [13]
and challenging work environments in a newborn intensive care
unit (NICU) such as infants’ medical complexity, demand for care,
and lack of resources [14e16], there is limited evidence to inform
the effectiveness in infants’ pain assessment and management.
Thus, the synthesis of nurses’ experiences and perspectives caring
for infants in pain will help provide novel insights to improve pain
assessment and management for this vulnerable population.
Although a previous qualitative study revealed some themes
and metaphors regarding nursing experiences in pain assessment
and management in infants [13], there is a lack of summary of
nurses’ lived experience in pain assessment and management. We
thus conducted this review to thoroughly summarize nurses’ con-
cerns in infants’ pain assessment and management in each study.
Therefore, we can discover the patterns among those findings;
identify the research gap; better understand the existing knowl-
edge; interpret and develop the new theory; improve the nursing
care standards and strengthen the health services [17]. The purpose
of this review is to develop a synthesis of qualitative studies to
provide in-depth insight into nurses’ perceptions of pain assess-
ment and alleviation in preterm infants. Our research question was
developed according to the SPIDER model [18]: What are the
nurses’ perceptions of pain assessment and alleviation in preterm
infants at clinical settings?
534
International Journal of Nursing Sciences 9 (2022) 533e541
2. Methods
2.1. Study design
Noblit and Hare’s [19] method of meta-ethnography was chosen
because it is a well-developed methodology, has been widely used
in health-related meta-synthesis, and its great potential for quality
improvement in health service and public health [20]. Enhancing
transparency in reporting qualitative research synthesis (ENTREQ)
was used to guide the data collection and synthesis reporting [21].
2.2. Procedure to locate qualitative studies
Articles were searched in PubMed, CINAHL, PsycINFO, Scopus,
BIOSIS, and ProQuest Dissertation and Theses Database within the
past 10 years (2012-07-01 to 2022-06-30). Five key terms were
searched: nurses, pain, preterm infant, method, and settings. The
categories were searched as follows, nurses: pediatric nurses, NICU
nurses, nurses, nursing, pediatric nursing, neonatal nurses, nursing
care, health professionals; pain: procedure pain, chronic pain, acute
pain, pain assessment, pain intervention, pain management; pre-
term infant: preemie, infant, preterm, young gestational age,
neonatal, premature, babies; method: qualitative study, experi-
ence, perspective, perceptions, ethnography, descriptive, phenom-
enology and mixed methods; settings: NICU, hospital, clinic,
intensive care.
The target findings were grouped into five main parts: (a) pain
in preterm infants; (b) the impact of pain on their health outcomes;
(c) nurses’ stress; (d) challenges of pain assessment and manage-
ment; (e) partner with parents.
2.3. Sample
Qualitative studies published within 10 years (2012e2022) were
included if they addressed the nurses’ caring for premature infants
in pain and comprised the sample of this meta-synthesis.
2.3.1. Inclusion and exclusion criteria
Qualitative studies were included in the meta-synthesis if they
met the following inclusion and exclusion criteria. Inclusion
criteria: (a) primary qualitative studies (using any type of quali-
tative method including qualitative investigation in mixed methods
studies) focused on the lived experience of nurses caring for pre-
mature infants with pain in the NICU; (b) published in English
within the last 10 years (2012e2022). Exclusion criteria: (a)
qualitative data cannot be extracted from the findings; (b) articles
that did not discuss nurses’ experiences.
2.3.2. Quality appraisal
The quality appraisal was conducted by using the Critical
Appraisal Skills Programme [22]. Ten items checklist evaluated the
research: the appropriation of research method, design, recruit-
ment, data collection, the relationship between researcher and
participants, the ethical consideration, data analysis, clarity, and
value of findings. Qualitative studies were excluded from the re-
view if they did not match any requirement of 10 questions [23].
2.4. Data extraction and analysis
Noblit and Hare’s seven steps of meta-ethnography approach
[19] was used in this review including: 1) Getting started. Conduct a
literature review of nurses’ experiences and perspectives in caring
T. Zhao, A.R. Starkweather, A. Matson et al.
for preterm infants with pain, consider whether the meta-synthesis
is really needed to be conducted to find the gap or what meta-
synthesis can contribute to the current knowledge system; 2)
Deciding what is relevant. Determine qualitative studies relevant to
the meta-ethnography topic: the nurses’ perceptions of caring for
infants in pain; 3) Reading and rereading the studies. Develop the key
concepts through reading and rereading the studies which are
included in this meta-synthesis. Locate the key metaphors and
themes of each study by making a list or table. Modify and finalize
the list and table. Develop a general map of the whole data; 4)
Determining how the studies are related. Extract key metaphors from
each study, compare each theme and each metaphor with others,
and find the patterns; 5) Translating the studies into one another.
Compare themes and metaphors between and within each study;
6) Synthesizing translations. Translate the individual metaphors into
the generalized themes; 7) Expressing the synthesis. Disseminate the
work and present the findings to a target audience, including
nurses, other health care professionals and parents, policymakers,
and nursing researchers. By conducting these seven steps methods,
the final key metaphors were selected.
To examine the accuracy of data extraction, two researchers (T.Z.
and X.C.) independently screened the studies by title, year, the
contents of abstracts, inclusion and exclusion criteria, and data
extraction and synthesis. During these search and review proced-
ures, two researchers consistently compared and discussed their
results. For any disagreements that occurred, a further discussion
with other authors helped reach the final agreement. All metaphors
were carefully compared and grouped by identifying the similar-
ities and differences until the final themes emerged.
3. Results
After carefully searching the articles in the database, a total of
4,911 studies were identified of which 108 duplicates were
removed. After reviewing all 4,803 abstracts, 59 papers were left.
After reviewing these 59 full articles, 51 articles were excluded
based on the inclusion and exclusion criteria: they are not the
research about nurses’ experience; qualitative data cannot be
extracted from the findings. Finally, eight articles [13,24e30] were
included in the meta-ethnography (see Fig. 1). Data were retrieved
from eight articles which were published between 2013 and 2018.
Authors, year of publication, sample size, age, sex, country, years of
experience, education status, discipline, research design, and data
analysis were extracted from the articles (see Tables 1 and 2).
3.1. Characteristics of the reviewed studies
Among the eight included studies, the total number of partici-
pants was 254 nurses, from seven countries, including the United
States, Iran, Canada, Switzerland, Finland, Sweden, and Australia.
Their age ranged from 20 to 64 years old. Two studies mentioned
that their nurse subjects had bachelor’s degrees [24,25], while
other studies did not specify their educational status. One study
included three nurses who did not have any nursing experience yet
[26]. Four studies mentioned that their nurses had more than five
years of experience in caring for preterm infants [24,25,27,28].
Other three studies specified that their nurses had an average of
12.24 yearse26.5 years of neonatal caring experience [13,29,30].
All the eight included studies had at least eight of ten items of
CASP [22] (see Table 3), which meet the quality requirement of
qualitative synthesis. Five articles clearly described all items in
their study, while the other three studies did not consider the
relationship between the researcher and participants and did not
consider ethical issues.
Within all eight publications, totally 83 key metaphors were
535
International Journal of Nursing Sciences 9 (2022) 533e541
identified, and all metaphors were compared across qualitative
studies using reciprocal translation [19]. By using reciprocal
translation comparation, authors assumed all the similar findings
from eight articles and “adding” them together [19]. Five over-
arching themes were developed by the authors after comparing the
themes and metaphors from the original articles: 1) They sense the
neonatal pain; 2) Adverse consequences of unrelieved pain; 3)
Barriers of managing pain; 4) Concerns of available approaches for
pain relief; 5) Failure to work with parents. (see Table 4). Although
not all key metaphors evenly appeared under each article’s over-
arching theme, five themes could be developed by analyzing the
significant number of metaphors.
3.2. Themes of the meta-synthesis
3.2.1. They sense the neonatal pain
Seventeen key metaphors were identified to support that pain
was true in preterm infants. It is critical that nurses accepted that
preterm infants could feel pain. Their pain indicators could be
categorized into facial expressions, body movements, and func-
tional activity, although these indicators were subtle and easy to be
ignored [13]. The nurses’ experience was critical because the cues of
pain in preterm infants were ambiguous: “… the 37 weeker can tell
us that they are not happy with what we’ve done and they commu-
nication that very well to us with their cry, with their face, with their
response to us whereas with the little ones it’s a lot harder to interpret
their facial expressions ….” [13] Infants’ cry was interpreted as
hungry, wet diaper, or stress; however, their cry was a sign of pain
to experienced neonatal nurses. One nurse stated that “they would
shake their hands or pull back their legs or cry when they feel pain.”
[25].
Other nurses understood that infants could have pain because
saving the infants’ lives creates much pain that infants could not
consent to [24]. Some nurses felt that pain experience, to infants,
just like trauma: “That mentality isn’t the same as going to war …
we’re fighting, we’re battling to save the babies’ lives … but … to me,
traumatic is just a severe word.” [24] Although nurses usually have a
hard time dealing with these feelings, the understanding that in-
fants are experiencing much pain will help nurses advocate for
their patients and their families.
Preterm infants’ characters (low gestational age, low birth
weight, immature nervous system, undeveloped immune system,
comorbidities) and pain itself would mutually influence each other,
complicating preterm infants’ pain experience. Moreover, under-
stand that the smaller the infant was, the more pain he/she was
experiencing because of their lowered pain threshold [25]. The
nurse described these as suffering: “… the smaller the infant the
more she suffers from care.” [26] Another nurse said: “I know the
researchers said that babies don’t suffer pain because the nerve tracts
aren’t myelinated. Don’t tell me that 24 weekers don’t suffer. Just
because they don’t remember it and they don’t have the language skills
to remember pain, doesn’t mean that they don’t suffer. It’s just that
they can’t communicate.” [28]
Many nurses in Korhonen’s study [26] admitted that pain is true
in preterm infants even though some preterm infants do not have
any facial expressions. They mentioned that as follows: “Her con-
dition becomes worse … if she is in very poor condition, she does not
react by a facial expression.” [26] Having low body weight was
strongly associated with pain sensitivity. The thin skin of preterm
infants with low birth weight, couldn’t protect them from all
stimulation, such as temperature variation, diaper changing, or
even touching. One nurse stated that they were sensitive to
everything: “… They have less fatty tissues, they are … like low birth
weight infants are sensitive to everything that you do to them, like the
temperature control, they’re sensitive to that …” [13]
T. Zhao, A.R. Starkweather, A. Matson et al. International Journal of Nursing Sciences 9 (2022) 533e541

Fig. 1. PRISMA flow diagram of the study selection.

Table 1
Methodological characteristic of qualitative studies in the meta-ethnography.

Study Discipline Research design Data analysis

Mehrnoush et al., 2018 Health Science Focus group Qualitative content analysis (Graneheim &
[25] Lundman, 2004)
Gibbins et al., 2015 [13] Health Service Qualitative driven mixed methods design Qualitative research practice (Ritchie et al., 2003)
D’Agata et al., 2018 [24] Perinatology Semi-structured focus group Inductive thematic analysis (Braun & Clarke,
2006)
Axelin et al., 2015 [29] Nursing Perinatology Qualitative descriptive study design Deductive and inductive thematic analysis (Braun
& Clarke, 2006)
Korhonen et al., 2013 Ethics Nursing Descriptive qualitative adapted from ethnography Inductive content analysis (Polit & Beck, 2012;
[26] Graneheim & Lundman, 2004)
Marfurt-Russenberger Gynecology Nursing Descriptive qualitative research with focus group interview Thematic content analysis (Braun & Clarke, 2006)
et al., 2016 [30] Obstetrics Perinatology
Green et al., 2016 [28] Ethics Nursing Two-phased sequential mixed methods study (purposive Thematic analysis (Braun & Clarke, 2006; Van
sampling and semi-structured interview) Manen1990)
Green et al., 2015 [27] Nursing Two-phased sequential mixed methods study (focus group and Thematic analysis (Van Manen, 1990)
single interview)

536
T. Zhao, A.R. Starkweather, A. Matson et al. International Journal of Nursing Sciences 9 (2022) 533e541

Table 2
Demographic characteristics of participants in the individual studies in the meta-ethnography.

Study Sample size Age Sex Country Years of experience Education level
(years)

Mehrnoush et al., 2018 n ¼ 30 (25 nurses) 30e40 M ¼ 4, Iran ≥ 5 years (n ¼ 20) Bachelor
[25] (n ¼ 20) F ¼ 26
Gibbins et al., 2015 [13] n ¼ 58 (33 nurses) 20e64 M ¼ 5, Canada Avg. 17.32 years Not specified
F ¼ 53
D’Agata et al., 2018 [24] n ¼ 17 (not specified 31e60 M ¼ 3, US ≥ 5 years (n ¼ 16) Bachelor and
nurses’ number) F ¼ 14 above (n ¼ 16)
Axelin et al., 2015 [29] n ¼ 87 (all nurses) Not Not Finland (47), Sweden Finland, avg. 14 years; Not specified
specified specified (14), US (26) Sweden, avg. 13.5 years;
US, avg. 26.5 years
Korhonen et al., 2013 n ¼ 19 (nurses) 20e55 Not Finland Less than 1 year (n ¼ 3); 7 years of NICU and 10 Not specified
[26] specified years pediatric nursing (n ¼ 16)
Marfurt-Russenberger n ¼ 23 (17 nurses) Avg 42.94 F Switzerland Avg. 12.24 years Not specified
et al., 2016 [30] nurses ¼ 16,
M
nurses ¼ 1
Green et al., 2016 [28] n1 ¼ 414, Not Not Australia ≥5 years of caring infants ≤24 weeks gestational Not specified
n2 ¼ 24 specified specified age
(nurses)
Green et al., 2015 [27] n1 ¼ 760, Not Not Australia ≥5 years of caring infants ≤24 weeks gestational Not specified
n2 ¼ 24 specified specified age
(nurses)

Note: M ¼ male. F ¼ female. Avg. ¼ Average. NICU ¼ Neonatal Intensive Care Units. n1 ¼ number in stage one. n2 ¼ number in stage two.

Table 3
Quality appraisal of the included studies using the Critical Appraisal Screening Programme (CASP, 2020).

Criteria/Study 1 2 3 4 5 6 7 8

1.Was there a clear statement of the aims of research? Y Y Y Y Y Y Y Y

2.Is a qualitative methodology appropriate? Y Y Y Y Y Y Y Y
3. Was the research design appropriate to address the aims of the research? Y Y Y Y Y Y Y Y
4. Was the recruitment strategy appropriate to the aims of the research? Y Y Y Y Y Y Y Y
5. Was the data collected in a way that addressed the research issue? Y Y Y Y Y Y Y Y
6. Has the relationship between researcher and participants been adequately considered? Y CT CT Y Y CT Y Y
7. Have ethical issues been taken into consideration? Y CT CT Y Y CT Y Y
8. Was the data analysis sufficiently rigorous? Y Y Y Y Y Y Y Y
9. Is there a clear statement of findings? Y Y Y Y Y Y Y Y
10. How valuable is the research? Y Y Y Y Y Y Y Y

Note: Y ¼ yes. N ¼ no. CT ¼ can’t tell.

3.2.2. Adverse consequences of unrelieved pain
Some nurses believed that pain would impact preterm infants’
physiological, neurological, and psychological development during
hospitalization and future life. These nurses stated: “Both of them
[long and short-term side effects] are expectable. Short-term effects
might be observed in slower physical development. Long-term side-
effects might appear in mental development; for instant frequent pain
influences IQ of the patient.” [25]
Physical activities were fragile in preterm infants. Painful stim-
ulation made their vital signs such as heart rate, blood pressure,
and respiratory rate very unstable. The physical changes might
cause short-term or even long-term side effects of pain in preterm
infants.
3.2.3. Barriers of managing pain
The obstacles to managing pain in preterm infants are multi-
faceted. Lacking knowledge or training in pain assessment was
mentioned by one nurse: “Another reason is lack of knowledge …. we
do not know how to deal with these cases.” [25] Nurses who had
concerns and uncertainty stated that another reason for barriers of
pain management was lacking standard policy to follow, lacking
facilities, lacking pain scales, and lacking environmental factors
control. Additionally, nurses who were taking care of preterm in-
fants were complaining that too much workload they were bearing.
The overwhelming assignment caused their ‘ignorance’ of pain
assessment and pain management in infants. In Mehrnoush’s study
[25], one nurse stated that: “There is a great workload on the nurses
and in some cases, pain is not a priority.”
Further, many nurses were blaming themselves because they
inflict painful procedures on vulnerable preterm infants. Nurses
were experiencing moral distress and anxiety when they were
providing treatment to infants. The pressure from the third party
made the nurse’s job even harder. Some nurses complained about
the stress caused by the parents’ presence, the pressure from
neonatologist, and the misleading information provided by media
complicated the misunderstanding of parents.
3.2.4. Concerns of available approaches for pain relief
Although the limited pain control strategies, nurses provided
the infants with the necessary support to alleviate their pain. Pain
intervention includes pharmaceutical and non-pharmaceutical
strategies such as non-nutritive sucking, skin-to-skin kangaroo
care, breastfeeding, touching, tucking, holding, talking, etc. Some
nurses expressed their concerns about providing both pharma-
ceutical and non-pharmaceutical interventions to preterm infants.
In Mehrnoush’s study [25], nurses described their concerns: “Add to
this the fact that it is a narcotic medicine and might cause respiratory
problems.” Nurses expressed their uncertainty about whether the
standard care would cause pain in babies:“… it is more difficult for us
to know with the tiny babies and even with the facilitated tucking, and

537
Table 4
Individual study metaphors as related to five overarching themes.

Study They sense the Adverse Barriers of Concerns of available Failure to work
neonatal pain consequences of managing pain approaches for pain relief with parents
unrelieved pain

Mehrnoush et al., · Shake hands · Short term: · Lack of · Oral dextrose

2018 [25] · Pull back their slower physical knowledge/no · Narcotic medicine might
legs development/ training cause respiratory problem/
· Cry long term: · Noise stimuli are giving the right medicine to
mental great the patients
development disturbances
· Pain influence IQ · Lack of time
· Decrease of AsO2, · Necessity of a
bradycardia or checklist/lack of
tachycardia tool
· Great workload
Gibbins et al., 2015 · Cry · Vital signs · We are limited/ · Give them breaks of time · We do not use
[13] · Facial response to pain we need some · Appropriateness of use and parents enough
expressions · Unstable education/cannot dosage of sucrose
· More sensitive · Immature generalize a tool · Concern for infants receiving
nervous system · Have trouble opioids
· Comorbidities with consistency · More difficult to get a
morphine infusion/small
increments
· Pharmacotherapeutics of the
medication
· Facilitated tucking, and
swaddling and touch
D’Agata et al., 2018 · Inflict pain · Trauma $ Overwhelmed/ · Attend to them quickly $ Scare the parents
[24] · Continuing the could not focus · Easy to forget the
trauma on what the baby parents
really needs/
don’t know how
to make this
work/unsafe
Axelin et al., 2015 · Screaming · They do bring · Pain management guidelines · ‘Please go wait
[29] · Massive pain tension and · Sucrose and pacifier/sugar outside’/never
anxiety to a covered pacifier/give sugar thought of
situation/they water including them in
are really a pain · Cuddle/hold hand/grab finger pain
management
· Respect parents
and their
knowledge in
pain
management
· Explain to them/
teach the
parents/
collaborate
Korhonen et al., · Cry piercingly · Sensitive for
2013 [26] · Over-extended handling
· Does not react by · Low pulse rate
a facial and oxygen
expression saturation
· No care without · Apneic and
reactions exhausted/stop
· The smaller the breathing
infant, the more
she suffers from
care
Marfurt- · Suffering $ “Who is going to · Oral sucrose · They do not
Russenberger poke you with a · Facilitated tucking understand what
et al., 2016 [30] needle?” · Nursed we are doing
· An eye exam · Limitations in effect pain · Involved parents
· make things even relief and it went well/
worse · Comfort parents do not
· Mother · Hold the pacifier have to suffer
screamed/really · Talk to the infant · Determine why
bothers/ they want to be
increased tension involved
Green et al., 2016 · Grimacing and · Physiology · Concerns/ · Morphine drop blood · Decision made by
[28] the drawing · A prolonged and torture/ pressure parents/from a
away painful death frustrating parents’
· Suffer · Disability · Hope they are perspective
brain dead
Table 4 (continued )
Study They sense the Adverse
neonatal pain consequences of
unrelieved pain
Green et al., 2015 · Droop on the side · Learning
[27] of the face problem
· Holding their · Neurological
hand deficits/potential
handicap
swaddling and touch we’re not really sure what these babies feel.” [13]
3.2.5. Failure to work with parents
Parents had the power of pain management in preterm infants
as well. However, parents were often excluded from pain man-
agement or treatment. Nurses pointed out the problem of missing
cooperation with parents. In Axelin’s study [29], one nurse said: “A
lot of time the doctor says, ‘can you please go wait outside?’ That way, I
never have to deal with the conflict.” The possible reason may be
because parents’ existence causes stress. One nurse described this
when she said: “ …. when I had to squeeze the heel, the mother
screamed. So it all took about twice as long as usual to fill the capillary
tube.” [30].
There was an urgent need for cooperation with parents
mentioned by some nurses. Better teamwork with parents would
positively improve pain management. In Axelin’s study [29], one
nurse stated the importance of including parents as team mem-
bers: “Mothers holding a baby for a heel stick and … I think that’s
equally or more effective than being in a warmer or in isolate with
sucrose and a pacifier.” Parents’ involvement in pain intervention
would benefit the parent-infant bond and increase the efficiency of
nurses’ jobs. However, failure working with parents is very com-
mon in the NICU and one nurse said: “I think we don’t utilize the
parents enough and all of that is getting better but we are certainly not
where we should be but I don’t think we utilize the parents enough …
and skin to skin enough and breast feeding while we are doing some of
these heel pokes or capillary bold sampling or things like that.” [13]
4. Discussion
Meta-synthesis is an important interpretive method to synthe-
size qualitative findings from primary studies [31]. Synthesis is an
activity to bring together the separate pieces to form a whole. The
synthesis of qualitative findings provides in-depth perception and
systematic understanding of the existing phenomenon, knowledge,
and experiences. This was the first meta-ethnography to the au-
thor’s knowledge focused on nurses’ own perspective of caring for
preterm infants in pain in the NICU. The findings from this syn-
thesis address on five overarching themes: They sense the neonatal
pain; Adverse consequences of unrelieved pain; Barriers of man-
aging pain; Concerns of available approaches for pain relief; and
Failure to work with parents.
The first qualitative article discussing preterm infants in pain
was published in 1993 [32]. This paper confirmed that both phy-
sicians and nurses believed that preterm infants experiencing pain
and provided proper intervention to relieve the pain [32]. Although
we excluded this study in our synthesis because it was published
Barriers of Concerns of available Failure to work
managing pain approaches for pain relief with parents
· It is agony for us
as well
· Doctor cannot
realize pain
· Gloss it over · Blunt
· Media making it · Parents sought
out information from
· That is wrong media
· Education of
outcomes and
consequences
more than ten years ago, the major findings in this article showed
the historical root of clinical professionals’ perception of pain
assessment and pain treatment in preterm infants. Consistent with
their findings, our study showed that nurses understand that pre-
term infants were more vulnerable to pain stimulation, although
the sign of pain in preterm infants was subtle or they might not
express pain due to their immature nervous system, which was
consistent with other study findings [2]. The nurses in our study
recognized neonatal pain by observing their facial expressions and
body response [33]. In addition, some nurses could identify unex-
pressed pain by assessing their heart rate, blood pressure, and
respiration rate [33].
Our study found that while most nurses are knowledgeable
about the pain in preterm infants, the adverse effects of pain are
usually overlooked during infants’ NICU care. Our findings are in
accordance with recent studies demonstrating the negative impact
of pain on infants’ growth, physical status, immune system func-
tion, psychological health, and neurodevelopment [4,33].
Although other health clinicians’ experience is important to
evaluate, it is critical to understand nurses’ own perspectives and
needs because nurses exert control in pain intervention in the NICU
[34]. Therefore, we did not include other health professional’s
perspectives in our synthesis. The nurses who stated barriers of
caring for preterm infants, including lack of education, training,
time, tool, policy, consistency, and cooperation with physicians and
parents, were consistent with other studies [2,35]. Although most
nurses showed a positive attitude in pain control in infants, the
overwhelming amount of paperwork and other workload are the
major reasons nurses ignore pain alleviation in infants, consistent
with another finding [36]. Our study found that nurses’ stress came
from their belief that they inflicted the pain and did not get enough
emotional support from other health caregivers or parents. Car-
rying too much stress without detachment could lead to nurses’
powerlessness and hopelessness, which warrants relief. This
finding is a necessary complement to other findings, focusing on
mothers’ stress and infants’ stress [37,38].
To alleviate pain in preterm infants, it is urgent to administer
effective pharmaceutical or nonpharmaceutical pain control in
preterm infants. However, our study found many challenges faced
by nurses to provide pain intervention including uncertainty and
inconsistency of medication administration and the risk of adverse
events of opioids, which were consistent with other study findings
[33,39e41].
Parents’ exclusion in caring for preterm infants in pain is not
rare due to nurses’ heavy workload, limited time, stress, and the
desire to protect parents from anxiety in our synthesis. Some
nurses in our study found that parents can facilitate pain
intervention once they were provided enough education and
training. This finding is consistent with another study that building
rapport between parents and nurses made pain intervention suc-
cessful in NICU [34]. However, some nurses stated that the parents’
absence asserted nurses’ control of pain management. This finding
may indicate the challenges that nurses and parents are facing
when establishing their partnership. Our synthesis pointed out the
limitation of nurses in providing support and education to parents,
requiring further help from other clinicians. The lack of education
and training in pain assessment and intervention for nurses
themselves also complicated this problem.
Overall, the support to the nurses caring for preterm infants
should focus on pain management education and training. The
training should also be attainable to other clinicians, including
physicians as a partner in pain treatment. To better support
powerless nurses, policy change considers optimizing neonatal
nurses’ workload, and standardized NICU pain care is urgent:
releasing nurses from the overwhelmed paperwork, providing
nurses the bedside sheets and necessary facilities, optimizing the
environment in the NICU, and offering nurses emotional support
such as psych services, and always the extra help from other col-
leagues when they are overloaded.
There are several limitations of this study. Our study only
included eight studies with 254 nurses from seven countries with
less diverse ethnicities and educational backgrounds, which cannot
be generalized to nurses worldwide. Although we would like to
involve parents as a team to help the nurses, our study only focused
on mothers’ teamwork with nurses, which excluded fathers’ role in
caring for preterm infants in pain. Additionally, this study did not
mention many pharmacological pain interventions that may need
future exploration.
5. Conclusion
This meta-ethnography identified nurses’ understanding of pain
in preterm infants that can be assessed through their facial ex-
pressions, body movement, and physiologic responses. Nurses are
acknowledged that unrelieved pain can cause developmental def-
icits in infants. Barriers and challenges when taking care of preterm
infants in pain are lack of support such as training, education, policy
change, optimized workload, and cooperation from other health
professionals. Nurses recognized that building a solid rapport with
parents will benefit preterm infants’ health outcomes. Future
studies are needed to develop age-specified pain assessment scales,
investigate effective pharmaceutical and nonpharmaceutical in-
terventions, manage nurses’ stress in caring for preterm infants,
and enhance parents’ roles, including both mother and father, to
build a healthy parent-infant bond.
CRediT authorship contribution statement
Tingting Zhao: Conceptualization, Methodology, Validation,
Formal analysis, Investigation, Data curation, Writing e original
draft, Writing e review & editing, Funding acquisition, Project
administration. Angela R. Starkweather: Conceptualization,
Methodology, Validation, Investigation, Resources, Data curation,
Writing e review & editing. Adam Matson: Conceptualization,
Methodology, Validation, Investigation, Resources, Data curation,
Writing e review & editing. Shabnam Lainwala: Conceptualiza-
tion, Methodology, Validation, Investigation, Resources, Writing e
review & editing. Wanli Xu: Conceptualization, Methodology,
Validation, Writing e review & editing. Xiaomei Cong: Conceptu-
alization, Methodology, Validation, Formal analysis, Investigation,
Writing e review & editing, Supervision, Project administration.
Funding
This study was supported by a grant from NIH/NINR Ruth L.
Kirschstein National Research Service Award (NRSA) Individual
Predoctoral Fellowship (Grant numbers: F31NR019940, PI: Tingting
Zhao) and ENRS/Council for the Advancement of Nursing
Science Dissertation Award (PI: Tingting Zhao).
Data availability statement
Authors declare the absence of shared data in the present study.
Declaration of competing interest
The authors have declared no conflict of interest.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.ijnss.2022.09.003.
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Neonatal Nurs
Titulo Nurses’ experiences of caring for preterm infants in pain: A metaethnography

Tingting Zhao, Angela R. Starkweather, Adam Matson, Shabnam Lainwala,

Autor
Wanli Xu, Xiaomei Cong.
Fuente Elsevier
Fecha De
8 de septiembre de 2022
Publicación
Unidad de cuidados intensivos neonatales, lactantes prematuros, medición
Palabras Clave
del dolor, padres, dolor, cuidados de enfermería, enfermeras.
• World Health Organization. Preterm birth. 2018. Accessed 6 June
2022, https://www.who.int/news-room/fact-sheets/detail/preterm-birth.
• Perry M, Tan ZW, Chen J, Weidig T, Xu WL, Cong XS. Neonatal pain:
perceptions and current practice. Crit Care Nurs Clin
2018;30(4):549e61. https://doi.org/10.1016/j.cnc.2018.07.013.
Fuentes Donde • Zhao TT, Griffith T, Zhang YM, Li HF, Hussain N, Lester B, et al. Early-
Se Ha Citado life factors associated with neurobehavioral outcomes in preterm infants
during NICU hospitalization. Pediatr Res 2022:1e10.
https://doi.org/10.1038/s41390-022-02021-y.
• Ranger M, Grunau RE. Early repetitive pain in preterm infants in
relation to the developing brain. Pain Manag 2014;4(1):57e67.
https://doi.org/10.2217/pmt.13.61.

Este artículo es de revisión sobre las experiencias de las enfermeras en

cuanto al dolor de los recién nacidos prematuros, en donde cada año nacen
aproximadamente 15 millones de niños prematuros en todo el mundo,
definidos como <37 semanas de edad gestacional, como parte de la vida,
estos niños prematuros se exponen a más de 300 procedimientos necesarios
durante su estadía en el hospital en cuidados intensivos neonatales (UCIN),
reciente demostró que durante los primeros 28 días de estancia en el hospital,
los neonatos prematuros experimentaron 614,12 episodios de dolor/estrés
agudo (por ejemplo cuidado de la boca, cambio de pañales, cambio de
posición, pinchazo en el talón, succión) y 1.023,65 h de estimulación crónica
de dolor/estrés (por ejemplo, sonda nasogástrica y sonda orogástrica in situ,
presión positiva continua en la vía aérea manipulación, tubo torácico colocado
en la pared de succión)
Resumen
Las enfermeras pediátricas desempeñan un papel fundamental en el cuidado
de los prematuros con dolor, ya que se encargan de la evaluación del dolor, el
tratamiento del dolor, la defensa de los bebés y los padres, y la educación de
los padres. Sin embargo, debido a la inmadurez del sistema nervioso de los
niños prematuros y los difíciles entornos de trabajo en la unidad de cuidados
intensivos de cuidados intensivos neonatales (UCIN), como la complejidad
médica de los bebés, la demanda de cuidados y la falta de recursos, hay
pocas pruebas que informen de la eficacia en la evaluación y el tratamiento
del dolor de los lactantes.

El objetivo de esta revisión es elaborar una síntesis de los estudios

cualitativos para proporcionar una visión profunda de las percepciones de las
enfermeras sobre la evaluación y el alivio del dolor en los recién nacidos
prematuros y de acuerdo a esto sale la pregunta de investigación ¿Cuáles
son las percepciones del personal de enfermería sobre la evaluación y el
alivio del dolor prematuros en el ámbito clínico?

La meta-etnografía para sintetizar e interpretar los hallazgos cualitativos de

las experiencias de las enfermeras en el cuidado de los bebés prematuros
con dolor, ya que la mayoría de los bebes prematuros pasaban por diversos
procedimientos dolorosos en la unidad de cuidados intensivos, debido a esto
y a los avances que se han tenido con el alivio del dolor, el personal de
enfermería sigue teniendo el reto de proporcionar un tratamiento oportuno y
eficaz del dolor a los bebes prematuros.

Por esta razón, se quiere tener una mayor comprensión de la experiencia

vivida por las enfermeras que atienden a los bebes prematuros con dolor que
podría aportar a nuevas ideas para mejorar el tratamiento del dolor en esta
población que es tan vulnerable.

Para ello se llevo a cabo una extensa búsqueda bibliográfica en PubMed,

CINAHL, PsycINFO, Scopus, BIOSIS and ProQuest, Dissertation and Theses,
incluyendo estudios de los últimos 10 años desde el (2012-07-01 a 2022-06-
30) en donde se buscaron cinco términos claves como: dolor, enfermera,
bebe prematuro, método y entornos.

En cuanto esto dos investigadores de enfermería realizaron la extracción y el

análisis de los datos de forma independiente. Se aplicaron criterios de
inclusión para búsqueda de estudios cualitativos de enfermeras participantes
que trabajaran en la UCIN atendiendo a bebés prematuros y se excluyeron
los estudios publicados en un idioma distinto del inglés, los artículos que no
incluían datos cualitativos y los datos cuantitativos que no pudieran extraerse
de los resultados o no hablaran de las experiencias de las enfermeras se
excluyeron.

Para la evaluación de la calidad de la literatura se utilizó el Programa de

Habilidades de Evaluación Crítica; en donde quedaron ocho estudios después
de la selección adicional de acuerdo con los criterios de inclusión y exclusión,
estos ocho estudios se llevaron a cabo entre 2013 y 2018 y reclutaron en total
a 205 enfermeras de Irán, Canadá, Estados Unidos, Finlandia, Suecia, Suiza
y Australia. Surgieron cinco temas sobre las perspectivas de las enfermeras
del cuidado de los bebés prematuros con dolor: 1) Sienten el dolor neonatal;
2) Consecuencias adversas del dolor no aliviado; 3) Obstáculos para el
tratamiento del dolor; 4) Preocupación por los métodos disponibles para alivio
del dolor; 5) Falta de colaboración con los padres.
 • Diseño de estudio método de meta-etnografía porque es una
metodología bien desarrollada, se ha utilizado ampliamente en meta
síntesis relacionadas con la salud, y su gran potencial para la mejora
de la calidad en los servicios sanitarios y la salud pública
• Investigación cualitativa se utilizó para guiar la recogida de datos y la
elaboración de informes de síntesis
• Procedimiento para localizar estudios cualitativos Se buscaron
artículos en PubMed, CINAHL, PsycINFO, Scopus BIOSIS, y ProQuest
Dissertation and Theses Database en los últimos 10 años (2012-07-01
a 2022-06-30).
• Se buscaron cinco términos clave: enfermeras, dolor, bebé prematuro,
método y entornos
• Las categorías se buscaron de la siguiente manera, enfermeras:
enfermeras pediátricas, UCIN, enfermeras, enfermeras, enfermería,
enfermería pediátrica, enfermeras neonatales, enfermería de
enfermería, profesionales de la salud; dolor: dolor de procedimiento,
dolor crónico, dolor agudo, evaluación del dolor, intervención en el
dolor, manejo del dolor; bebé prematuro: prematuro, bebé, prematuro,
edad gestacional joven, neonatal, prematuro, bebés; método: estudio
cualitativo, experiencia, perspectiva, percepciones, etnografía,
descriptivo, fenomenología y métodos mixtos; entornos: UCIN, hospital,
clínica, cuidados intensivos.
• Los resultados previstos se agruparon en cinco partes principales: (a)
METODOLOGIA
el dolor en los bebés prematuros; (b) el impacto del dolor en los
resultados de salud (c) el estrés de las enfermeras; (d) los retos de la
evaluación y el tratamiento del dolor; (e) la colaboración con los
padres.
• Muestra: Se incluyeron los estudios cualitativos publicados en los
últimos 10 años (2012e2022) se incluyeron si abordaban el cuidado de
los bebés prematuros por parte de las enfermeras con dolor y
comprendían la muestra de esta metasíntesis.
• Criterios de inclusión y exclusión: Los estudios cualitativos se
incluyeron en la metasíntesis
− criterios de inclusión: (a) estudios cualitativos primarios (que
utilizaran cualquier tipo de método cualitativo, incluida la
investigación cualitativa en estudios de métodos mixtos)
centrados en la experiencia vivida por el personal de enfermería
que atiende a los niños prematuros con dolor en el hospital.
mixtos) centrados en la experiencia vivida por el personal de
enfermería que atiende a bebés prematuros con dolor en la
UCIN; (b) publicados en inglés en los últimos 10 años
(2012e2022).
− Criterios de exclusión: (a) los datos cualitativos no pueden
extraerse de los resultados; (b) los artículos que no hablaran de
las experiencias de las enfermeras.
 Por medio de la recolección de datos se encontraron los siguientes datos:
• Después de una búsqueda cuidadosa, se identificaron 4.911 estudios,
de lo que se eliminaron 108 duplicados quedando con un total de 4.803
y se tomaron 59 artículos completos en donde se excluyeron 51
basándose en los criterios de inclusión y exclusión.
• Concluyendo con ocho artículos fueron publicados entre 2013 y 2018
que fueron añadidos en la meta etnografía.
• Los datos de estos ocho artículos fueron: los autores, el año de
publicación, el tamaño de la muestra, la edad, el sexo, el país, los años
de experiencia, estado de educación, disciplina, diseño de
investigación y análisis de datos análisis se extrajeron de los artículos
de la tabla 1 y tabla 2
• Entre los ochos estudios incluidos, el nuero total de participantes fue
de 254 enfermeras, procedentes de sietes países, entre ellos Estados
Unidos, Estados Unidos, Irán, Canadá, Suiza, Finlandia, Suecia y
Australia
• Edad oscilaba entre 20 y 64 años
• En dos de los artículos mencionaban el estudio de las enfermeras
participantes eran licenciadas mientras que en los otros estudios no
especificaban su nivel educativo.
• Un estudio incluyo a tres enfermeras que aún no tenían experiencia en
enfermería
• Cuatro estudios mencionaron que sus enfermeras tenían mas de cinco
años de experiencia en el cuidado de bebes prematuros, en los otros 3
Principales tenían una media de 12,24 años – 26.5 años de experiencia y el ultimo
Resultados tenia un año de experiencia en UCIN y 10 años en enfermería
(Hallazgos) pediátrica
• Los ocho estudios incluidos tenían al menos ocho de los diez ítems del
CASP (Critical Appraisal Skills Programme) que cumplen el requisito de
calidad de la síntesis cualitativa, entre estos cinco artículos
describieron claramente todos los ítems en su estudio, mientras en los
otros tres no tuvieron en cuenta la relación entre el investigador y los
participantes y no tuvieron en cuenta no tuvieron en cuenta las
cuestiones éticas.
• Se identificaron 83 metáforas claves, y todas las metáforas se
compararon entre los estudios cualitativos utilizando la traducción
recíproca
• Surgieron cinco temas generales tras comparar los temas y metáforas
de los artículos originales: 1) Sienten el dolor neonatal; 2)
Consecuencias adversas del dolor no aliviado; 3) Barreras del manejo
del dolor; 4) Preocupación por los enfoques disponibles para alivio del
dolor; 5) Falta de colaboración con los padres

1) Sienten el dolor neonatal: Se identificaron diecisiete metáforas

clave para apoyar que el dolor en los recién nacidos prematuros.
Las enfermeras acepten y dolor en estos bebes, sus indicadores
de dolor se clasificarían en expresiones faciales, movimientos
corporales y actividad funcional, aunque estos indicadores eran
sutiles y fáciles de ignorar

El llanto de los bebés se interpretó como hambre, pañal mojado

 o estrés; sin embargo, para las enfermeras neonatales
experimentadas su llanto era un signo de dolor. Una enfermera
afirmó que "agitaban las manos sacuden las manos o echan las
piernas hacia atrás o lloran cuando sienten dolor". Algunas
enfermeras consideraban que la experiencia del dolor, para los
lactantes es como un trauma: "Esa mentalidad no es la misma
que la de ir a la guerra...estamos luchando, estamos luchando
para salvar la vida de los bebés ... pero ... para mí traumático es
sólo una palabra severa", La enfermera lo describió como un
sufrimiento: "... cuanto más pequeño es el lactante, más sufre
los cuidados" Aunque el personal de enfermería suele tener
dificultades para afrontar estos sentimientos, comprender que
los bebés sufren mucho dolor les ayudará a defender a sus
pacientes y a sus familias.

2) Consecuencias adversas del dolor no aliviado: Algunas

enfermeras creían que el dolor repercutiría en el desarrollo
fisiológico, neurológico y psicológico de los recién nacidos.
desarrollo fisiológico, neurológico y psicológico de los durante la
hospitalización y la vida futura. Estas enfermeras afirmaron:
"Ambos [efectos secundarios a corto y largo plazo] son
esperables. Los efectos a corto plazo pueden observarse en un
desarrollo físico más lento. Los efectos secundarios a largo
plazo podrían aparecer en el desarrollo mental; por ejemplo, el
dolor frecuente influye en el coeficiente intelectual del paciente"
La estimulación dolorosa hacía que sus signos vitales, como el
ritmo cardíaco, la presión arterial y la frecuencia respiratoria
fueran muy inestables. Los cambios físicos podrían causar
efectos secundarios del dolor a corto o incluso a largo plazo en
los prematuros.

3) Barreras del manejo del dolor: Los obstáculos para el

tratamiento del recién nacido es múltiple Una enfermera
mencionó la falta de conocimientos o formación en la evaluación
del dolor "Otra razón es la falta de conocimientos no sabemos
cómo tratar estos casos", otras enfermeras tenían
preocupaciones e incertidumbre, una enfermera afirmó que "Hay
una gran carga de trabajo para las enfermeras y, en algunos
casos, el dolor no es una prioridad". Además, muchas
enfermeras se culpaban porque infligir procedimientos dolorosos
a bebés prematuros vulnerables.las enfermeras experimentaban
angustia moral y ansiedad cuando estaban tratamiento de los
niños.

4) Las estrategias de control del dolor eran limitadas, las

enfermeras proporcionan el apoyo necesario para disminuir en
gran medida el dolor de los bebés, la intervención incluye
estrategias farmacéuticas y no farmacéuticas, como la succión
no nutritiva, la piel con piel, la lactancia materna, las caricias, los
arropamientos, los abrazos, las charlas, etc. Algunas
 enfermeras expresaron su preocupación por la posibilidad de
ofrecer intervenciones farmacéuticas y no farmacéuticas a los
bebés prematuros.
En uno de los estudios una de las enfermeras comento su
preocupación al utilizar fármacos añadiendo: Si a esto le
añadimos a esto el hecho de que se trata de un medicamento
narcótico y podría causar problemas respiratorios

5) Falta de colaboración con los padres: Los padres tienen el poder

de controlar el dolor en los niños prematuros también. Sin
embargo, a menudo se excluía a los padres del manejo del dolor
o del tratamiento. una enfermera dijo: "A muchas veces el
médico dice: '¿puede ir a esperar fuera, por favor? De este
modo, yo nunca tengo que lidiar con el conflicto". La posible
razón puede ser porque la existencia de los padres provoca
estrés. Otra enfermera lo describió cuando dijo: ".... cuando
tenía que apretar el talón, la madre gritaba. Así que tardaba el
doble de lo habitual en llenar el tubo capilar".

Un mejor trabajo en equipo con los mismos mejoraría

positivamente el tratamiento del dolor. Sin embargo, el fracaso
en el trabajo con los padres es muy común en la UCIN y una
enfermera dijo "Creo que no utilizamos a los los padres lo
suficiente y todo eso está mejorando, pero ciertamente no
estamos donde deberíamos estar, pero no creo que utilicemos a
los padres lo suficiente... y piel con piel lo suficiente y la
lactancia materna, mientras que estamos haciendo algunos de
estos pinchazos en el talón o la toma de muestras capilares o
cosas así".

Para así concluir, que la meta-etnografía identifico la comprensión de las

enfermeras sobre el dolor en los recién nacidos prematuros que puede
evaluarse a través de sus expresiones faciales, movimientos corporales y
respuestas fisiológicas y reconocieron que el dolor no aliviado puede causar
déficits de desarrollo en los bebes. Las barreras y los retos de atender a los
bebes prematuros con dolor son la falta de apoyo, como la formación, la
educación de políticas, la optimización de la carga de trabajo y la cooperación
Conclusiones de otros profesionales de la salud, en cuanto a esto las enfermeras
reconocieron que establecer una relación sólida con los padres beneficiará a
los resultados de salud de los bebés prematuros. En el futuro, se necesitan
estudios futuros para desarrollar escalas de evaluación del dolor específicas
para cada edad, investigar intervenciones farmacéuticas y no farmacéuticas
eficaces, gestionar el estrés de las enfermeras en el cuidado de los bebés
prematuros y mejorar el papel de los padres para así crear un vínculo de
padres e hijos.
CUADRO COMPARATIVO

El cuadro comparative lo manejare desde las cinco metáforas comparando el manejo que se lleva
acá en Colombia
 ARTICULO COLOMBIA
1) Sienten el dolor neonatal: 1) Sientan el dolor neonatal
Las enfermeras acepten y dolor en estos En Colombia las enfermeras también
bebes, sus indicadores de dolor se clasificarían manifiestan por medio de esos indicadores por
en expresiones faciales, movimientos sus expresiones faciales, movimientos
corporales y actividad funcional, aunque estos corporales, y el llanto ya que se puede ver
indicadores eran sutiles y fáciles de ignorar reflejado en el dolor, el pañal mojado y en
procedimientos que se le vayan a ser al recién
El llanto de los bebés se interpretó como nacido.
hambre, pañal mojado o estrés; sin embargo,
para las enfermeras neonatales También en el estar separado de sus mamas
experimentadas su llanto era un signo de dolor. se les genera dolor ya que ellos crean un
Una enfermera afirmó que "agitaban las manos vínculo desde el embarazo una conexión
sacuden las manos o echan las piernas hacia mama e hijo que es irremplazable y lo que esto
atrás o lloran cuando sienten dolor". Algunas hace es generar paz y tranquilidad en el bebe.
enfermeras consideraban que la experiencia
del dolor, para los lactantes es como un
trauma: "Esa mentalidad no es la misma que la
de ir a la guerra...estamos luchando, estamos
luchando para salvar la vida de los bebés ...
pero ... para mí traumático es sólo una palabra
severa", La enfermera lo describió como un
sufrimiento: "... cuanto más pequeño es el
lactante, más sufre los cuidados" Aunque el
personal de enfermería suele tener dificultades
para afrontar estos sentimientos, comprender
que los bebés sufren mucho dolor les ayudará
a defender a sus pacientes y a sus familias.
2) Consecuencias adversas del dolor no 2) Consecuencias adversas del dolor no
aliviado: aliviado:
Algunas enfermeras creían que el dolor
repercutiría en el desarrollo fisiológico, En Colombia las enfermeras afirman que al
neurológico y psicológico de los recién bebé estar en un estado de dolor constante
nacidos. desarrollo fisiológico, neurológico y llega a crear una afección o efecto secundario
psicológico de los durante la hospitalización y a corto o largo plazo a nivel físico neurológico
la vida futura. Estas enfermeras afirmaron:
"Ambos [efectos secundarios a corto y largo
plazo] son esperables. Los efectos a corto
plazo pueden observarse en un desarrollo
físico más lento. Los efectos secundarios a
largo plazo podrían aparecer en el desarrollo
mental; por ejemplo, el dolor frecuente influye
en el coeficiente intelectual del paciente"
La estimulación dolorosa hacía que sus
signos vitales, como el ritmo cardíaco, la
presión arterial y la frecuencia respiratoria
fueran muy inestables. Los cambios físicos
podrían causar efectos secundarios del dolor a
corto o incluso a largo plazo en los prematuros.
3)Barreras del manejo del dolor:
Los obstáculos para el tratamiento del recién
nacido son múltiples Una enfermera mencionó
la falta de conocimientos o formación en la
evaluación del dolor "Otra razón es la falta de
conocimientos no sabemos cómo tratar estos
casos", otras enfermeras tenían
preocupaciones e incertidumbre, una
enfermera afirmó que "Hay una gran carga de
trabajo para las enfermeras y, en algunos
casos, el dolor no es una prioridad". Además,
muchas enfermeras se culpaban porque infligir
procedimientos dolorosos a bebés prematuros
vulnerables. Las enfermeras experimentaban
angustia moral y ansiedad cuando estaban
tratamiento de los niños.
4) Preocupación por los enfoques
disponibles para alivio del dolor:
Las estrategias de control del dolor eran
limitadas, las enfermeras proporcionan el
apoyo necesario para disminuir en gran
medida el dolor de los bebés, la intervención
incluye estrategias farmacéuticas y no
farmacéuticas, como la succión no nutritiva, la
piel con piel, la lactancia materna, las caricias,
los arropamientos, los abrazos, las charlas,
etc. Algunas enfermeras expresaron su
preocupación por la posibilidad de ofrecer
intervenciones farmacéuticas y no
farmacéuticas a los bebés prematuros.
En uno de los estudios una de las enfermeras
comento su preocupación al utilizar fármacos
añadiendo: Si a esto le añadimos a esto el
hecho de que se trata de un medicamento
narcótico y podría causar problemas
respiratorios
3)Barreras del manejo del dolor:
En Colombia estos casos tienen una afectación
negativa en las enfermeras ya que día a día
tiene que Lidia con la doble moral de hacer el
procedimiento con dolor o buscar otra
alternativa para que el bebé no se vea tan
afectado, también sucede que al tener tantos
pacientes en una unidad de cuidado intensivo
hace que se tome del caso mas grave al
menos grave y también en la falta de recursos
en Colombia nacen aproximadamente de 6 a
10 bebes prematuros y esto hace que a veces
requieran de una unidad mas avanzada
generando mas costos y recursos para el
hospital.
4)Preocupación por los enfoques
disponibles para alivio del dolor:
Nosotros como enfermeros en Colombia
usamos diferentes herramientas como los son
colocar el seno de la mamá, hacer estímulos
para lograr distraer al bebé con el fin de
disminuir en gran medida el dolor en el bebé,
colocar música ya que este proporciona una
relajación, también se maneja la
musicoterapia, en algunos hospitales se
maneja sacarosa para aliviar el dolor si por
alguna razón no se cuenta con lo anterior
mencionado se maneja el reflejo de succión.
 5) Falta de colaboración con los padres: 5)Falta de colaboración con los padres:

Los padres tienen el poder de controlar el
dolor en los niños prematuros también. Sin
embargo, a menudo se excluía a los padres del
manejo del dolor o del tratamiento. una
enfermera dijo: "A muchas veces el médico
dice: '¿puede ir a esperar fuera, por favor? De
este modo, yo nunca tengo que lidiar con el
conflicto". La posible razón puede ser porque
la existencia de los padres provoca estrés.
Otra enfermera lo describió cuando dijo: "....
cuando tenía que apretar el talón, la madre
gritaba. Así que tardaba el doble de lo habitual
en llenar el tubo capilar".
En Colombia las enfermeras manifiestan que la
presencia de los padres afecta en su medida el
tratamiento que se le brinda a los bebés
prematuros ya que los mismos no dejan que
los procesos que se brindan se manejen
satisfactoriamente dando así un resultado no
tan satisfactorio, aunque suceden casos en
dónde los padres son un factor importante para
que los recién nacidos minimicen la presencia
de dolor al estar en vínculo con su mamá

Un mejor trabajo en equipo con los mismos

mejoraría positivamente el tratamiento del
dolor. Sin embargo, el fracaso en el trabajo con
los padres es muy común en la UCIN y una
enfermera dijo "Creo que no utilizamos a los
los padres lo suficiente y todo eso está
mejorando, pero ciertamente no estamos
donde deberíamos estar, pero no creo que
utilicemos a los padres lo suficiente... y piel con
piel lo suficiente y la lactancia materna,
mientras que estamos haciendo algunos de
estos pinchazos en el talón o la toma de
muestras capilares o cosas así".