A dor está presente na vida de crianças que passam pelo processo de hospitalização e, embora existam meios para o seu tratamento, muitas continuam vivenciando-a desnecessariamente. O enfermeiro por estar em contato direto com esses pacientes, deve realizar a avaliação e estabelecer tratamentos adequados, compreendendo o fenômeno doloroso em suas múltiplas dimensões, pessoais, culturais e sociais. Diante disso, os objetivos deste estudo são identificar os conhecimentos dos estudantes de enfermagem e dos enfermeiros sobre o manejo da dor pediátrica e os significados atribuídos à dor pediátrica por esses estudantes e enfermeiros à luz do referencial teórico do Social Communication Model of Pain, que explora as características dos pacientes em situações de dor, junto com os indivíduos que os assistem. A abordagem metodológica qualitativa foi adotada e a Análise Temática Híbrida foi utilizada como referencial metodológico. Foram realizadas entrevistas semiestruturadas com seis estudantes da Escola de Enfermagem da Universidade de São Paulo (EEUSP) que estavam realizando o estágio curricular no Hospital Universitário da Universidade de São Paulo (HUUSP) nas seguintes áreas: unidade de internação pediátrica, pronto socorro pediátrico e berçário, e com seis enfermeiras egressas dessa Escola, que trabalhavam em instituições nas áreas de neonatologia e pediatria. A análise dos dados permitiu a identificação de três temas e nove sub-temas: Experiência de dor: subjetividade, sentimentos e prejuízos; Avaliação do cuidado: capacitação, conhecimento e escuta; e Conhecimento sobre a dor: conteúdo, interesse pelo tema e busca pelo conhecimento. Os resultados possibilitaram uma compreensão ampliada da experiência dolorosa, revelando questões importantes quanto ao caráter subjetivo e individual da dor, além de destacar as alterações e prejuízos na rotina dos indivíduos que a sentem. Quanto ao cuidado realizado pelos enfermeiros diante da avaliação e do manejo da dor, evidenciou-se a necessidade de oferecer-lhes capacitação, haver comprometimento no manejo da dor da criança e, sobretudo, ouvir seus próprios relatos acerca da experiência dolorosa. Quanto aos conhecimentos relacionados ao ensino do tema, a formação do enfermeiro quanto ao manejo e avaliação da dor pediátrica está relacionada com os conteúdos transmitidos durante o curso de graduação, com a importância atribuída ao tema pelos docentes e pela própria constituição da grade curricular. / Pain is present in the lives of children who go through the hospitalization process and while there are ways to treat it, many of them still living it unnecessarily. Nurses for being directly in contact with these patients, should carry out the assessment and establish appropriate treatments, including the painful phenomenon in its various dimensions, personal, cultural and social. In view of this, the objectives of this study are to identify the knowledge of nursing students and nurses about pediatric pain management and the meanings attributed to pediatric pain for these students and nurses in the light of the theoretical framework of Social Communication Model of Pain, which explores the characteristics of patients in situations of pain, along with individuals who assist them. The qualitative approach was adopted and Hybrid Thematic Analysis was used as a methodological framework. Semi-structured interviews were conducted with six nursing students from the School of Nursing, University of Sao Paulo (EEUSP) who were on internship at the University Hospital of the University of Sao Paulo (HUUSP) in the following areas: pediatric inpatient, pediatric emergency and baby nursery and with six egresses of this school who worked at institutions in the areas of neonatology and pediatrics. Data analysis enable the identification of three themes and nine sub-themes: Experience of pain: subjectivity, feelings and prejudices; Care evaluation: training, knowledge and listening; and Knowledge about pain: content, interest in the topic and search for knowledge. The results allowed an expanded understanding of the painful experience revealing important questions about the subjective and individual nature of pain, while also highlighting the changes and losses in the routine of individuals who feel it. Regarding care provided by the nurses on the assessment and management of pain, it highlighted the need to offer them training, of having commitment in the management of pain in children, and especially to hear their own stories about the painful experience. With regard to knowledge related to teaching the subject, the education of nurses regarding the management and assessment of pediatric pain is related with the content broadcast during the undergraduate course, with the importance given to the subject by professors and by the constitution of the curriculum.

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No. of bitstreams: 2 Dissertação - Julyana Calatayud Carvalho - 2017.pdf: 3964594 bytes, checksum: 9436130a52a4288a36984d7bd2ca0bcc (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2017-07-03 / Conselho Nacional de Pesquisa e Desenvolvimento Científico e Tecnológico - CNPq / There are strategies and interventions with proven effectiveness for the adequate management of neonatal pain. However, the simple dissemination of knowledge at the end of a research and/or training do not guarantee the use of knowledge by health professionals in clinical practice, resulting in a gap between knowing and doing. Given the frequent and repeated exposure of newborns to painful procedures in the neonatal unit and the deleterious consequences of untreated pain, it is urgent to implement innovative actions that promote changes in clinical practice to transform the available evidence into action. Thus, the objective of this study was to evaluate the effect of a multifaceted Knowledge Translation (KT) intervention to improve the management of neonatal pain. It is a quasi-experimental study, with no control group, of pre- and posttest type, performed at the neonatal unit of a public maternity hospital in Goiás, Brazil, from February 2015 to March 2016. The intervention used was Evidence-Based Practice for Improving Quality (EPIQ), which was divided into two phases: preparation and implementation, and change. A Research and Practice Council consisting of health professionals of the neonatal unit led and facilitated the proposed changes. Implementation was carried out in three rapid cycles, with one target for each cycle being established. Several KT strategies were used in combination, according to what the goal and barriers indicated, such as: reminders, bedside training, videos, educational leaflets, auditing and feedback, clinical protocols and didactic presentation. In Cycle 1, all professionals were sensitized to the adequate management of neonatal pain, and 89.4% of the professionals considered it possible to use the presented strategies. In cycle 2, the PIPP-R and EDIN scales were used to assess pain. At the first audit of cycle 2, of the total of 64 painful procedures (aspiration, blood collection and catheter insertion), the PIPP-R scale was applied in 30.8% of these procedures and EDIN in 26.2%. In the second audit of cycle 2, from 38 painful procedures, the PIPP-R scale was registered in 23.7% and EDIN, 23.8%. In cycle 3, the goals of cycle 2 were maintained and 20% oral glucose administration was included for relief of acute pain during peripheral catheter insertion and blood collection. In the audit of cycle 3, glucose was administered in 29.6% from the total of 54 painful procedures. After the completion of the implementation process, a final audit was carried out for 25 days. From the total of 444 painful procedures, the PIPP-R scale was applied in 26.6% and the EDIN scale was applied 50.7%; and glucose was 17 administered in 25.1% of these procedures. We conclude that, while faced with a challenging context and with the multifaceted KT intervention used in this study (EPIQ), it was possible to observe a significant increase, by health professionals, in the use of scales to assess pain and oral glucose administration to relieve neonatal pain. However, strategies to improve and sustain these outcomes are needed to ensure that every newborn has their pain evaluated and treated. / Existem estratégias e intervenções com efetividade comprovada para o manejo adequado da dor neonatal. No entanto, a simples disseminação do conhecimento no término de uma pesquisa e/ou em capacitações não garantem a utilização do conhecimento pelos profissionais de saúde na prática clínica, resultando em uma lacuna entre o saber e o fazer. Diante da exposição frequente e repetida dos recém-nascidos a procedimentos dolorosos na unidade neonatal e, as consequências deletérias da dor não tratada, é urgente a implementação de ações inovadoras que promovam mudanças na prática clínica transformando a evidência disponível em ação. Assim, este estudo objetivou avaliar o efeito de uma intervenção multifacetada de Knowledge translation (KT), para melhorar o manejo da dor neonatal. Tratase de um estudo quase experimental, sem grupo controle, do tipo pré e pós-teste, realizado na unidade neonatal de uma maternidade pública de Goiás, Brasil, no período de fevereiro de 2015 a março de 2016. A intervenção utilizada foi a Evidence-Based Practice for Improving Quality (EPIQ), dividida em duas fases: preparação e implementação e mudança. Um Conselho de Pesquisa e Prática constituído pelos profissionais de saúde da unidade neonatal liderou e facilitou as mudanças propostas. A implementação foi realizada em três ciclos rápidos, sendo estabelecida uma meta para cada ciclo. Foram utilizadas diversas estratégias de KT combinadas, de acordo com a meta e barreiras apontadas, tais como: lembretes, treinamento a beira leito, vídeos, folhetos educativos, auditoria e feedback, protocolos clínicos e apresentação didática. No Ciclo 1, todos os profissionais foram sensibilizados para o manejo adequado da dor neonatal, sendo que 89,4% dos profissionais consideraram possível utilizar as estratégias apresentadas. No Ciclo 2, foram implementadas as escalas PIPP-R e EDIN para a avaliação da dor. Na primeira auditoria do ciclo 2, do total de 64 procedimentos dolorosos (aspiração, coleta de sangue e inserção de cateter), a escala PIPP-R foi aplicada em 30,8% destes procedimentos e a EDIN 26,2%. Na segunda auditoria do ciclo 2, dos 38 procedimentos dolorosos, a escala PIPP-R foi registrada 23,7% vezes e a escala EDIN, 23,8%. No ciclo 3, foram mantidas as metas do ciclo 2 e incluída a administração de glicose oral 20% para alívio da dor aguda durante a inserção de cateter periférico e coleta de sangue. Na auditoria do ciclo 3, a glicose foi administrada em 29,6% do total de 54 procedimentos dolorosos. Após o término do processo de implementação, foi realizada uma auditoria final durante 25 dias. Do total de 444 procedimentos dolorosos, a escala PIPP-R foi aplicada em 26,6% 15 e a escala EDIN foi aplicada 50,7%; e a glicose foi administrada em 25,1% desses procedimentos. Concluímos que, diante de um contexto desafiador e com a intervenção multifacetada de KT utilizada neste estudo (EPIQ) foi possível observar um aumento significativo pelos profissionais de saúde no uso das escalas para avaliar a dor e a administração de glicose oral para aliviar a dor neonatal. No entanto, são necessárias estratégias para melhorar e sustentar esses resultados, no sentido de garantir que todo recém-nascido tenha sua dor avaliada e tratada.

Toda cirurgia implica em lesão de tecidos, manipulação de estruturas e órgãos, sendo a dor uma conseqüência desse processo, que pode, porém, ser minimizada. O presente estudo tem como objetivos caracterizar o processo de manejo da dor aguda na criança no período pós-operatório a partir dos registros contidos nos seus prontuários, identificar como as enfermeiras cuidam das crianças com dor no período pós-operatório e quais fatores influenciam sua prática. Para tanto, foram analisados, retrospectivamente, os registros sobre dor pós-operatória de 300 prontuários de 280 crianças de 0 a 14 anos submetidas à cirurgia no ano de 2004 em três hospitais de uma cidade do interior do Paraná. Também foram ouvidas, por meio de entrevista, as 15 enfermeiras que trabalhavam nas unidades pediátricas dos três hospitais. A caracterização do manejo da dor a partir dos registros dos prontuários indicou a existência de poucos registros sobre dor pós-operatória realizados por enfermeiras, sendo que a grande maioria deles foi realizada por auxiliares ou técnicos de enfermagem, com alguma variação entre os hospitais pesquisados. Procedeu-se a análise qualitativa dos dados, os quais foram agrupados ao redor de três temas: as experiências de dor e suas repercussões; a atuação da enfermeira no manejo da dor pós-operatória; formação, aquisição e disseminação de conhecimentos sobre dor pediátrica. O estudo mostrou que as enfermeiras avaliam a dor pós-operatória de forma assistemática e, em geral, limitam-se ao controle farmacológico da dor. Realizam o manejo da dor na dependência da conduta e prescrição médicas, utilizando forma limitada as estratégias não-farmacológicas de alívio. Demonstraram interesse em ampliar seus conhecimentos na área e na formação de grupos de dor nas instituições em que trabalham. Consideramos que os resultados do estudo podem provocar a discussão do tema nos hospitais pesquisados e, numa visão otimista, podem contribuir para deflagrar e estimular a implementação da avaliação sistematizada da dor em crianças e adolescentes nesses locais. / ABSTRACT TACLA, T. G. M. Care of children with post-operative pain: Pediatric nurses experiences. 2006. 251p. PhD Dissertation ¾ Escola de Enfermagem de Ribeirão Preto. Universidade de São Paulo, 2006. All surgical procedures involve tissue lesions, manipulation of structures and organs, causing pain which can be minimized during the process. The objectives of this study are to characterize the process of managing post-operative acute pain in children based on their medical records, to identify how nurses care for children in pain during the post-operative period, and which factors affect their practices. The study evaluated 300 medical records on post-operative pain of 280 children, 0-4 y. o., who underwent surgery in 2004, in 3 hospitals located in a city in the interior of the state of Paraná. An interview with 15 nurses who worked in the Pediatric Ward of these hospitals was also carried out. Characterization of pain management from the medical records revealed that only a few nurses make notes of post-operative pain, and that the majority of the records were made by nursing aides and technicians, with some variations among the researched hospitals. Data were analyzed qualitatively and grouped into three topics: the experiences of pain and its consequences, nurses? performance during post-operative pain management, and pediatric pain knowledge development, acquisition and dissemination. Results from the study showed that nurses evaluate post-operative pain a-systematically, which, in general, is limited to pharmacological pain control. Their management depends on the doctor?s prescription, thus using limited non-pharmacological pain-relief strategies. They show interest in broadening their knowledge in the area and in developing pain groups in their institutions. We believe that the results from this study may generate a discussion on the topic in these hospitals, and, consequently, contribute to the implementation of a systematic evaluation of pain in children and adolescents in these places.

Os recém-nascidos internados em unidades neonatais são expostos a inúmeros procedimentos potencialmente dolorosos durante sua hospitalização, e há desconhecimento de tal exposição e das práticas para o manejo da dor, na maioria dos serviços brasileiros de referência neonatal. Este estudo descritivo exploratório foi realizado em três etapas, com os objetivos de avaliar o conhecimento e as práticas dos profissionais de saúde que atuam em unidades neonatais de um hospital estadual do interior paulista quanto à avaliação e ao manejo da dor no recém-nascido (etapa 1), identificar os registros de avaliação da dor e de intervenções farmacológicas e não farmacológicas para o alívio da dor, feitos pelos profissionais em prontuários neonatais nesse hospital (etapa 2) e dimensionar a exposição dos neonatos a procedimentos de dor aguda, durante os primeiros sete dias de internação nessas unidades neonatais (etapa 3). Os 15 médicos, 8 enfermeiras e 34 auxiliares de enfermagem preencheram um questionário contendo dados relacionados ao conhecimento e às práticas de avaliação e manejo da dor neonatal. Na etapa 2, foi feito um estudo retrospectivo em fonte secundária, utilizando dados dos prontuários de 115 recém-nascidos internados nas unidades de cuidados intensivos e intermediários neonatais do hospital, no período de 12 meses. Na etapa 3, foi realizado registro à beira do leito de todos os eventos potencialmente dolorosos a que os recém-nascidos foram submetidos, durante a primeira semana de internação nessas unidades, no período de setembro a dezembro de 2011. Constatou-se que apenas uma auxiliar de enfermagem acredita que o neonato não sente dor. Todas as enfermeiras e a grande maioria dos médicos e auxiliares de enfermagem afirmaram que avaliam a dor no recém-nascido, tendo como parâmetros de avaliação mais frequentes o choro e a mímica facial; os parâmetros fisiológicos, especialmente o aumento da frequência cardíaca, foram os mais mencionados pelos médicos. Nenhum dos profissionais de saúde conhecia escalas para a avaliação de dor no recém-nascido. Entre as medidas não farmacológicas para o alívio da dor neonatal, citadas pelos profissionais de saúde, predominou o uso da glicose com ou sem a sucção não nutritiva, enquanto as medicações mais referidas como adequadas para o alívio da dor neonatal foram o fentanil e o paracetamol. Os registros sobre a avaliação e as intervenções para o alívio da dor neonatal constavam apenas nas prescrições médicas e nos diagnósticos, prescrições e anotações de enfermagem. Os recém-nascidos participantes da etapa 3 foram submetidos a 1.316 procedimentos potencialmente dolorosos, durante a primeira semana de internação; a média foi de 5,9 ± 4,7 procedimentos por dia, variando de 9,4 ± 6,2 no primeiro dia a 3,8 ± 3,2 procedimentos no sétimo dia de internação. Os procedimentos dolorosos mais frequentes foram as punções de calcâneo e venosa. Concluiu-se que há desconhecimento dos profissionais de saúde e sub-registro sobre a avaliação e o manejo adequados da dor aguda no recém- nascido e que os neonatos são submetidos a inúmeros procedimentos potencialmente dolorosos, durante sua hospitalização. Recomenda-se a capacitação profissional e a elaboração de protocolos de cuidado para a avaliação adequada e o tratamento efetivo da dor, nessas unidades neonatais. / The neonates hospitalized in neonates\' unities are exposed to a countless potentially painful procedures during hospitalization and there is no knowledge of this exposure and the practices to handling this pain in most cases of Brazilian neonates referring. This descriptive exploratory study was made in three stages, in purpose to evaluate the knowledge and the practices of the health professionals who work in neonates\' unities of a state hospital in the São Paulo interior that concerns to evaluation and handling of pain in neonates (stage 1), identify the evaluation records of pain and pharmacologic and non-pharmacologic interventions for pain relief done by the professionals in neonates\' records in this hospital (stage 2) and dimensioning the exposure of the neonates to acute pain procedures during the first seven days of hospitalization in these unities (stage 3). The 15 physicians, 8 nurses and 34 nursing assistants filled a questionnaire related to knowledge and practices of evaluation and handling of neonate pain. On stage 2 was made a retrospective study in secondary sources using data from records of 115 hospitalized neonates in intermediary and intensive and care unities in 12 months. On stage 3 was made a record on the bedside of all the potentially painful events that the neonates underwent during the first week of hospitalization from September to December of 2011. When It comes to believing that the neonates don\'t feel any pain, just one nursing assistant believed that. All the nurses and the most part of physicians asserted that they evaluate the pain taking into consideration the weeping and facial expressions; the physiologic parameters, like heart rate increasing, were mentioned specially by the physicians. None of the professionals knew the scale of evaluation of a pain in neonates. Among the mentioned non- pharmacologic procedures, the glucose use with or without non- nutritive suction, while the most mentioned adequate medicine were fentanyl and paracetamol. In the records about evaluation and intervention for pain relief were present only medical prescriptions and in diagnosis, prescriptions and nursing notes. The participating neonates from stage 3 were submitted to 1,316 potentially painful procedures during the first week of hospitalization; the mean was 5.9 ± 4.7 procedures per day, varying from 9.4 ± 6.2 in the first day to 3.8 ± 3.2 procedures in the seventh day of hospitalization. The more frequent painful procedures were calcaneus and venous puncture. We concluded that there is ignorance by the health professionals and under-register about the evaluation and handling of acute pain in neonates and that the neonates are submitted to a countless potentially painful procedures during their hospitalization. We recommend the professional capacitation and elaboration of care protocols for the evaluation and effective treatment of pain in these neonates\' unities.

Philosophiae Doctor - PhD / Literature on post-operative pain indicates that post-operative pain is inadequately managed in many countries including Ghana. Little was also known about post-operative pain (POP) response and management in Ghana. This study sought to describe post-operative pain response and management among Ghanaian surgical nurses and post-operative patients within the medico-socio-cultural context. It also explored factors that influenced POP response and management and subsequently aimed to develop clinical guidelines within which post-operative pain could be managed in the medico-socio-cultural context. Research questions answered included: „what are the factors influencing post-operative pain responses among surgical patients and nurses; what clinical guidelines would be appropriate to guide post-operative pain management within the medico-socio-cultural context of Ghana?‟The study was designed as a multi-step focused ethnography which allowed the exploration of a specific sub-culture such as the surgical environment. The philosophical underpinnings of ethnography permit the investigator to use different data collection methods to fully understand the phenomenon investigated. Data collection during the ethnographic exploration phase involved individual interviews, clinical observations, and review of patients‟ clinical charts. At the stage of guideline development, data was collected through participant/expert review, systematic literature review, and consensus forum. Participants were sampled purposively and included 53 interview participants, 27 expert reviewers, and 29 consensus panel members. Also, there were 16 sections of clinical observation and review of 44 charts. The participants included nurses, patients and their relatives, the multidisciplinary team, key informants, experts, and stakeholders. The study was conducted at the Korle-Bu Teaching Hospital (KBTH) and Ridge Hospital, in Accra, Ghana. Appropriate ethical clearance was sought and individual informed consent was obtained.Concurrent analysis of data was done applying the principles of thematic content analysis and data was managed with NVivo 9. Themes that emerged from the patients‟ data were subjectivism which described pain dimensions and expressions and factors that influenced patients‟ pain experience were psycho-socio-cultural factors such as personal inclinations and socio-cultural background; and health system factors such as personnel attitude and health financing.The study also found that nurses perceived POP as an individual phenomenon and responded to pain by administering analgesics and by employing non-pharmacologic measures such as positioning and reassurance. Factors that influenced the nurses‟ pain response were individual factors such as commitment, discretion, and fear of addiction; and organizational factors such as organizational laxity and challenges of teamwork. Patients‟ relatives were also influenced by empathy, faith, and commitment to care for their post-operative patients. The multidisciplinary team and key informants were influenced by knowledge and experience in their respective specialty areas. Subsequently, the clinical guideline developed had four dimensions which highlighted patient and family education,effective teamwork, effective leadership and monitoring, and use of contemporary evidence for POP management.The study recommended that health professionals should be conscious of the subjectivenature of pain and they should educate and involve the patient on pain management decisions. Also, hospital leadership and the multidisciplinary team should be actively involved in pain management.

Bakgrund: Smärta är en subjektiv känsla där varje individ lär sig betydelsen av ordet genom egna erfarenheter. Smärta är något nästan alla upplever efter ett kirurgiskt ingrepp och där otillräcklig smärtlindring i den akuta fasen kan leda till svåra komplikationer vilket skapar lidande för patienten samt stora samhällsekonomiska kostnader. Syfte: Att beskriva patienters upplevelse av postoperativ smärtbehandling. Metod: Litteraturstudie med deskriptiv design av 11 kvalitativa originalartiklar från databaserna PubMed, CINAHL och PsycINFO vars innehåll analyserades i fem steg. Resultat: Patienter var överlag tillfredsställda trots smärta. Det fanns delade åsikter om nyttan av NRS (numerisk skala). Patienter hade en rad föreställningar om läkemedel som ledde dem till att undvika analgetika. Information ansågs vara huvudsakligen hjälpsamt, framför allt skriftlig, dock upplevde patienter att informationen var bristfällig. Attityd, tillit och kommunikation spelade en viktig roll för relationen mellan personal och patient. Patienter som genomgått dagkirurgi och behandlade sin smärta ensamma i hemmet med mycket begränsad kontakt med vårdpersonal, upplevde svårigheter att ta beslut och följa sin smärtbehandlingsplan. Patienter uppskattade att bli inkluderade och delaktiga i sin vård, även om det kunde upplevas som en börda, och tog många egna initiativ och egna strategier under sin behandling, ofta för att slippa använda analgetika. Tidigare erfarenheter var också något som ofta hjälpte patienter i deras smärtbehandling. Slutsats: Patienter var ofta nöjda med sin smärtbehandling trots att de fortfarande upplevde smärta, viktigast för att uppnå detta var en känsla av trygghet. Viktiga faktorer för detta var utförlig skriftlig och upprepad information om smärta, smärtbehandling och analgetika samt ett gott, professionellt, inkluderande och individanpassat bemötande från vårdpersonalen. Brister inom dessa områden ledde till oro och rädsla för det okända, vilket försvårade smärtupplevelsen. Patienter upplevde sällan fullgod smärtlindring. / Background: Pain is a subjective feeling where each individual learns the meaning of the word through their own experiences. Pain is something almost everyone experiences after a surgical procedure and where insufficient pain relief in the acute phase can lead to severe complications, which creates suffering for the patient and large socio-economic costs. Aim: To describe patients' experience of postoperative pain management. Method: Literature review with descriptive design of 11 qualitative original articles from the databases PubMed, CINAHL and PsycINFO whose contents were analyzed in five steps. Result: Patients were generally satisfied despite pain. There were different opinions about the benefits of the NRS (numeric rating scale). Patients had a number of conceptions about drugs that led them to avoid analgesics. Information was considered to be mainly helpful, especially written, however patients felt that the information was deficient. Attitude, trust and communication played an important role in the relationship between staff and patient. Patients who underwent day surgery and treated their pain alone in the home with very limited contact with health care professionals experienced difficulties in making decisions and following their pain management plan. Patients appreciated being included and involved in their care, although it could be perceived as a burden, and took many own initiatives and strategies during their treatment, often to avoid using analgesics. Previous experience was also something that often helped patients in their pain management. Conclusion: Patients were often satisfied with their pain management even though they were still experiencing pain, most important to achieve this was a peace of mind. Important factors for this were detailed written and repeated information about pain, pain treatment and analgesics as well as a good, professional, inclusive and individualized response from the care staff. Deficiencies in these areas led to worrying and fear of the unknown, which made the pain experience more difficult. Patients rarely experienced adequate pain relief.

Syfte: Denna studie syftar till att undersöka vilken behandlingsmetod, plasticitetsgrundad eller icke-invasiv neuromodulering som presenterar bäst resultat av smärtlindring hos personer som upplever fantomsmärtor efter en amputation. Metod: Litteraturundersökningen utfördes i 3 databaser; MEDLINE, CINAHL och PsycINFO. Inkluderingskriterier användes för urval av studier. Bedömning av studiernas risk för bias gjordes med hjälp av mallar från Joanna Briggs Institut. Relevant data kopplad till frågeställningen extraherades och analyserades. Resultat: Totalt åtta artiklar inkluderades, där två presenterade resultat från icke-invasiv neuromodulering och sex studier inkluderade plasticitetsgrundade metoder. Smärtskalor mellan 0-10 användes för att mäta förändringen av smärtan. Den kritiska bedömningen drog slutsatsen att det saknades studier av hög kvalitet som inkluderar kontrollgrupper. Bevisen som analyserats i den aktuella studien indikerar att plasticitetsgrundade metoder tycks ge bättre smärtreduktion jämfört med icke-invasiv neuromodulering. Slutsats: Baserat på resultaten kan inte denna studie presentera bevis starka nog för att avgöra vilken grupp av metoder som har bäst smärtlindrande effekt. Brist av högkvalitativa studier inom området, i kombination med heterogenitet mellan inkluderade studier resulterar i att ingen slutsats kan dras. / Aim: This study aims to determine which treatment method, plasticity guided or non-invasive neuromodulation, presents the best result in reducing pain for amputees experiencing phantom limb pain. Method: Literature search was performed in 3 databases; MEDLINE, CINAHL and PsycINFO. Eligibility criteria were used for study selection. Critical appraisal tool by Joanna Briggs institute was used to assess the included articles’ risk of bias. Data relevant to the research question were extracted and analyzed. Result: A total of eight articles were included, where two presented results from non-invasive neuromodulation and six studies included plasticity guided methods. Pain scales ranging from 0-10 were applied as outcome measures to monitor improvements in phantom limb pain. The critical appraisal concluded lack of high-quality study designs including control groups. The evidence analysed in the present study indicate that plasticity guided methods appear to provide the best pain reduction when compared to non-invasive neuromodulation. Conclusion: Based on the results, this study does not present evidence strong enough to state which methods present the best pain reduction. Due to low amount of research within the field, combined with heterogeneity between included studies, no conclusion can be made.

The overall aim of this doctoral research was to study competitive and high performance endurance athletes’ experiences and management of exercise-induced pain (EIP), mental performance (i.e., self-regulation, mindfulness), mental health, and mental illness symptoms. A mixed methods experimental design guided by the pragmatic stance was employed across three studies to (a) investigate how elite endurance athletes experience and manage EIP (Study 1), (b) compare the effectiveness of an online self-regulation and mindfulness intervention in improving EIP catastrophizing, mental performance (i.e., self-regulation, mindfulness), mental health, and mental illness symptoms in middle-distance runners (Study 2), and (c) qualitatively examine the impact of the online intervention focusing on self-regulation or mindfulness and designed to help endurance athletes improve EIP management, mental performance (i.e., self-regulation and mindfulness), and mental health (Study 3). Study 1. With a paucity of research investigating EIP management in elite endurance sports, the purpose of Study 1 was to examine how elite endurance athletes experience and manage EIP, using an applied self-regulation lens to help inform the work of Mental Performance Consultants (MPCs). Individual semi-structured interviews were conducted with 12 female and 3 male athletes (Mage = 23.73, SD = 2.31) competing in track and field (i.e., 600-1500 m; n = 5), swimming (i.e., 200-400 m; n = 5), and canoe kayak (i.e., 500-1000 m; n = 5). Given the centrality of self-regulation and the necessity to effectively manage internal states (e.g., EIP) in elite sport, the social cognitive model of self-regulation was employed to guide Study 1. The codebook thematic analysis generated two themes and six subthemes (i.e., sensations [burning, tightness, heaviness], beliefs [detrimental, mental, progressive]) related to the experience of EIP as well as three themes and 17 subthemes (i.e., preparation [accept and commit to EIP, recall sources of self-efficacy, develop a segmented performance plan, be accountable to training partners or coach, expose yourself to EIP when training, expose yourself to EIP when warming up, use imagery, implement typical pre-performance routine; execution [direct attention away from EIP, use instructional/motivational self-talk, implement a segmented performance plan, regulate breathing and relax, accelerate pace, self-monitor]; evaluation [reflect using a training journal, identify possible explanations, talk with a coach]) related to the management of EIP. Findings suggest that the experience of EIP is highly cognitive and generally perceived as detrimental to performance if not effectively managed. Athletes used several psychological strategies to prepare to experience EIP, reduce the aversive effects of EIP while performing, and learn from their EIP management strategies to improve their coping capacity. In terms of the number of reported psychological strategies, findings suggest that those used to prepare to experience EIP seem to be a priority. In general, the most popular strategies pertained to accepting and committing to experiencing EIP and directing attention away from EIP. Novel strategies not typically reported in the literature included exposing oneself to EIP when warming up, being accountable to training partners or coaches, using imagery to rehearse reactions to EIP, and accelerating one’s pace. Importantly, combining self-regulation and mindfulness strategies appears to be key to effectively manage EIP. Study 2. No research has compared the impact of online sport psychology interventions on various outcomes affecting endurance athletes while employing an active control group. The purpose of Study 2 was therefore to compare the effectiveness of an online self-regulation and mindfulness intervention in improving EIP catastrophizing, mental performance (i.e., self-regulation, mindfulness), mental health, and mental illness symptoms in middle-distance runners. Using a pre-post experimental design, 61 middle-distance runners competing at provincial to international levels were allocated to either a self-regulation, mindfulness, or active control group using stratified randomization. They completed a pre-intervention survey measuring EIP catastrophizing, mental performance (i.e., self-regulation capacity, dispositional mindfulness), mental health, and mental illness symptoms (i.e., anxiety, depression, and eating disorder). A final sample of 52 participants (i.e., 17 self-regulation, 19 mindfulness, and 16 active control) completed the interventions and a post-intervention survey measuring the same outcomes addressed in the pre-intervention survey. Contrary to hypotheses, results from multiple mixed ANOVAs indicated that while mean scores trended in the positive direction between Time 1 and Time 2, the self-regulation and mindfulness interventions did not significantly differ from the active control intervention on the targeted outcomes. Interestingly, when excluding athletes who screened positive for mental illness symptoms (i.e., anxiety, depression, and/or eating disorder), the active control intervention was more effective in reducing anxiety symptoms than the mindfulness intervention. Overall, the self-regulation and mindfulness interventions were not any more effective than the active control intervention in improving the selected outcomes. Study 3. The purpose of this study was to qualitatively examine the impact of the online sport psychology intervention from Study 2, which focused on either self-regulation or mindfulness and was designed to help endurance athletes improve EIP management, mental performance (i.e., self-regulation, mindfulness), and mental health. A sample of 16 middle-distance runners (i.e., 11 women and 5 men) aged between 18 to 25 years old (Mage = 21.31, SD = 2.18) who participated in the eight-module SI or MI were purposefully selected based on their high, moderate, and low pre-post evolution scores. The codebook thematic analysis generated three themes and 13 subthemes (i.e., EIP management [reframing, understanding, self-talk, segmented performance plan]; mental performance [attention regulation, motivation, self-monitoring, self-efficacy, acceptance, defusion]; mental health [self-compassion, autonomy, support]) related to the participants’ perceived changes as well as three themes and seven subthemes (i.e., delivery format [asynchronous, synchronous], content [applicability, audio and video files, examples, metaphors], timing [alignment with competitive season]) related to participants’ recommendations. Findings suggest that both the self-regulation and mindfulness intervention positively impacted EIP management, mental performance, and mental health. Self-regulation and mindfulness should therefore be seen as complementary rather than conflicting or incompatible approaches. Furthermore, athletes reported that their EIP literacy and EIP management skills were limited at the onset of the intervention. Consequently, an educational component should continue to be integrated in future interventions to provide an overview of EIP and relevant mental performance skills to manage it. Given the prevalence of stressors and mental health challenges in competitive and high performance sport, screening for both positive mental health and mental illness symptoms at the onset of interventions is recommended so that athletes partaking in applied sport psychology studies can obtain appropriate mental health care and support as needed. Lastly, a hybrid delivery format incorporating both asynchronous and synchronous options may be the most effective when providing online sport psychology interventions. Overall, the findings of the current doctoral research suggest that both self-regulation and mindfulness strategies positively impact EIP management, mental performance, and mental health in endurance athletes. This inquiry is also the first to quantitatively and qualitatively compare the effectiveness of an online asynchronous self-regulation and mindfulness intervention in improving key outcomes affecting endurance athletes. With increased applied research and mental performance consulting occurring virtually due to the COVID-19 pandemic, it is vital to continue examining the quality and impact of online interventions on athletes.

Bakgrund: En av de vanligaste orsakerna till att patienter söker kontakt med hälso- och sjukvård är smärta. Smärta är en individuell och subjektiv upplevelse och definieras internationellt som en obehaglig sensorisk och emotionell upplevelse associerad med faktisk och potentiell vävnadsskada, eller beskriven i termer av sådan skada. Icke-farmakologiska smärtlindring definieras genom terapi som inte involverar intag av medicin eller andra aktiva substanser. Det råder brist på information kring förekomsten av icke-farmakologisk smärtlindring prehospitalt. Specialistsjuksköterskans upplevelser av användandet av icke-farmakologisk smärtlindring prehospitalt kan bidra till att skapa nya perspektiv och kunskaper inom området.  Syfte: Syftet var att beskriva specialistsjuksköterskors erfarenheter av att använda icke-farmakologisk smärtlindring prehospitalt. Metod: Datainsamlingen genomfördes genom semistrukturerade intervjuer. Insamlade data analyserades med kvalitativ innehållsanalys. Totalt intervjuades nio specialistsjuksköterskor som arbetade kliniskt inom ambulanssjukvård. Resultat: Analysen resulterade i tre kategorier med subkategorier; professionellt bemötande, metoder och tekniker samt utmaningar med icke-farmakologisk smärtlindring.  Slutsats: Den här studien visar att specialistsjuksköterskor inom ambulanssjukvård har olika erfarenheter och upplevelser av att använda icke-farmakologisk smärtlindring prehospitalt. Resultaten visar att ett professionellt bemötande och metoder, tekniker och åtgärder lindrar smärta men också att det finns utmaningar i att använda sig av icke-farmakologisk smärtlindring. Några slutsatser är att det krävs mer utbildning och forskning inom området icke-farmakologisk smärtlindring, samt ökad implementering i lokala behandlingsriktlinjer. En annan slutsats är att icke-farmakologisk smärtlindring redan används av många, om än omedvetet. / Background: Pain counts as one of the most common reasons as to why patients contact their healthcare providers in the first place. While pain constitutes an individual and subjective experience, it is defined internationally as an unpleasant sensory and emotional experience, in turn associated with actual and potential tissue damage, or described in terms of such damage. Non-pharmacological pain management constitutes forms of therapy that do not involve the administration of drugs or other active substances. There is a lack of information on the prevalence of prehospital non-pharmacological pain management. Specialist nurses’ experiences of the use of prehospital non-pharmacological pain management, can contribute to the creation of new perspectives and knowledge in the field. Aim: The aim of the study was to describe specialist nurses’ experiences of using prehospital non-pharmacological pain management. Method: Data was collected through semi-structured interviews. The collected data was then analysed, using a qualitative content analysis method. A total of nine specialist nurses, all of whom worked clinically in ambulance care, were interviewed. Results: The analysis resulted in three categories with subcategories; meeting professionalism, methods and techniques, and challenges with non-pharmacological pain management. Conclusion: This study shows that specialist nurses in ambulance care have different types of experiences and premediated knowledge of using non-pharmacological pain management methods prehospitally. The results show that a professional approach towards the administration of different methods, techniques and measures relieve pain, but also that there are challenges stemming from the use of non-pharmacological pain management methods. Consequently, an increase in both research and education is needed within the field of non-pharmacological pain management, as well as an increased implementation of local treatment guidelines. Furthermore, it can be concluded that non-pharmacological pain management methods are already being used by many healthcare providers, albeit subconsciously.

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