Reliability And Validity Of Three Scales For Assessment Of Heel Lance Pain In Neonates

BackgroundNewborns suffered from repeated and extended pain stimuli during their hospitalization.Pain would cause a series of short and long-term adverse effects;however,neonatal pain was still undertreated.Reliable pain assessment tools were strongly recommended by evidence-based guidelines to assess and manage neonatal pain.The use of an effective scale to monitor pain is helpful for adjusting neonatal analgesic measures to relieve their pain.According to changes of neonatal facial expressions,body movements and physiological indexes under pain stimuli,foreign authors had designed some pain assessment scales:Neonatal Facial Coding System(NFCS),Neonatal Infant Pain Scale(NIPS),and Neonatal Infant Acute Pain Assessment Scale(NIAPAS).Some Chinese authors used the Neonatal Facial Coding System and the Neonatal Infant Pain Scale to evaluate the effects of nursing interventions in painful situations,but studies on the reliability and validity of pain assessment scales in China have not been reported yet.The effectiveness of pain assessment tools and unfamiliarity with pain tools among medical staff were obstacles to the assessment of neonatal pain.Therefore,it is necessary to translate these foreign neonatal pain assessment scales to examine their reliability and validity when used in Chinese vulnerable newborns at high risk of pain stimuli.ObjectivesTo evaluate the reliability and validity of the Neonatal Facial Coding System,Neonatal Infant Pain Scale and Neonatal Acute Pain Assessment Scale for assessment of lances pain in neonates.Methods1.ParticipantsFrom February to April 2016,neonates born over 72 hours in a children's hospital,hospitalized in the Neonatal Intensive Care Unit(NICU),and screened for inherited metabolic diseases through heel lances were recruited.2.MeasurementsPain assessment tools included:Neonatal Facial Coding System(NFCS)had 10 terms with total score of 0?10.Neonatal Infant Pain Scale(NIPS)had 6 terms with total score of 0?7.Neonatal Infant Acute Pain Assessment Scale(NIAPAS)had 9 terms with total score of 0?18.The neonatal critically ill scale was used to assess the severity of the disease.3.Study ProceduresThe study was approved by the hospital ethics committee.The written informed consents were obtained from the parents of infants.For those who meet the inclusion criteria,two nurses recorded the whole process of heel prick(1 minute before the procedure,during the procedure,and 1 minute after the procedure).After viewing recording videos,pain assessment were made independently by three nurses using the NFCS,the NIPS,and the NIAPAS in randomized order.4.Statistical AnalysisInternal consistency of the three instruments was evaluated by Cronbach's a.Reliability of different raters' scores was evaluated by the correlation coefficient(Intraclass correlation coefficient,ICC).Multiple correlation nonparametric test was used to compare differences of the pain score before,during,and after the procedure.The correlations between the scale scores were evaluated by Spearman correlation coefficient.Using the rater's score which was closest to the average level as the standard,sensitivity and specificity of the Neonatal Facial Coding System and the Neonatal Infant Acute Pain Assessment Scale were analyzed.Results1.Clinical Characteristics of newbornsA total of 102 neonates were recruited.Of them,46 were males(45.1%)and 56 were females(54.9%).Birth weight ranged from 1620 to 4050 g(2744.6±75.5).Gestational age:58 were over 37 weeks,42 were 32 to 36 weeks +6 days,and 2 were 28 to 31 weeks + 6 days.Postnatal age ranged from 3 to 13 days.There were 13 critically ill neonates and 89 non-critically ill neonates.2.Comparison of the mean scores before,during,and after the painful procedure.Scores of the three scales during the painful procedures were highest,with the NFCS 6.525±2.626,the NIPS 5.461±1.993,and the NIAPAS 10.216±3.979,respectively.Scores by the same scale differed significantly before,during,and after the procedure(P<0.001).3.ReliabilityThe Cronbach's a(internal consistency coefficient)of the NFCS,the NIPS and the NIAPAS were 0.663?0.942,0.286?0.924,and 0.215?0.873,respectively.ICC values of three raters were 0.841?0.938,0.674?0.948,and 0.740?0.948,before,during and after the procedure,respectively,P<0.001.4.ValiditySpearman correlation coefficients of the NFCS and the NIPS were 0.181,0.835,and 0.794,respectively,before,during and after the procedure.Spearman correlation coefficients of the NIAPAS and the NIPS were 0.259,0.856,and 0.805,respectively before,during and after the procedure.Spearman correlation coefficients of the NFCS and the NIAPAS were 0.227,0.832,and 0.759,respectively,before,during and after the procedure.5.Cutoff pointsBy using 4 and 6 points as the pain threshold of the NFCS and the NIAPAS,respectively,sensitivity of the NFCS and the NIAPAS were 94.3%and 95.4%,respectively,and specificity of the NFCS and the NIAPAS were 93.3%and 86.7%,respectively.ConclusionsAll the three pain scales have good validity and reliability for pain assessment during and after heel lance procedure.In addition,the Neonatal Facial Coding Systems could be used to assess pain at rest before the procedure.