Effectiveness of pain and symptom management training for paediatric clinicians

Abstract

Pain and symptom management is the most important area of paediatric palliative care, but clinicians often receive little training in this area. Our research evaluated the effectiveness of pain and symptom management training among paediatric professionals. A quasi-experimental pretest–posttest study was used. Fifty-three paediatric nurses and 18 paediatricians participated in this study for a response rate of 80%. Results showed significant main effects of training on confidence levels (p < 0.001), and attitude scores (p < 0.001) among paediatric clinicians in a variety of areas, with no differences in scores between paediatricians and nurses. This suggests that education can effectively increase paediatric clinicians’ confidence in and attitudes towards providing pain and symptom management for children with severe illness. Further training is needed to promote interdisciplinary healthcare team work to improve the effectiveness of pain and symptom management.

Keywords

education pain management paediatric clinicians paediatric palliative care symptom management

Background

Paediatric palliative care is an approach which focuses on improving the quality of life for severely ill children and their families, through the prevention and relief of suffering through early identification and assessment, and the treatment of pain and other distressing symptoms, physical, psychosocial and spiritual (American Academy of Pediatrics, 2013; World Health Organization, 2010). The management of pain and symptoms is essential in paediatric palliative care and is closely related to the quality of life of patients and their families (World Health Organization, 2010). Although providing appropriate pain and symptom management for dying children is a key responsibility of healthcare providers, misconceptions and the insufficient management of paediatric pain and symptoms has been repeatedly documented (Czarnecki et al., 2014; Drake et al., 2003; McCallum et al., 2000; Peng et al., 2012). In order to assess and relieve pain and treat symptoms effectively, paediatric professionals require specific knowledge and the appropriate skills, attitudes, and confidence in providing such care (Drake et al., 2003; Peng et al., 2012; Williams-Reade et al., 2015).

One common obstacle to adequate paediatric pain and symptom management is a lack of professional knowledge and skills among clinicians (Galloway and Yaster, 2000; Jacobs et al., 2009). The evidence is clear that paediatric clinicians’ inadequate education may result in insufficient confidence to provide pain and symptom management, and an unwillingness to provide the interventions of pain and symptom management for children (Ekim et al., 2013). Research in Taiwan, where little paediatric palliative care training is available, is consistent with this finding (Peng et al., 2013), confirming that neonatal clinicians seem to lack confidence in pain and symptom management (Lee et al., 2016).

Previous researchers have recommended that paediatric clinicians learn to assess and manage these distressing symptoms in a more appropriate manner (Meyer et al., 2006). A recent study found that pain and symptoms management was the area of paediatric palliative care that was most deficient among paediatric clinicians in Taiwan (Lee et al., 2016). Another study found that many paediatric nurses lacked adequate knowledge regarding pain management for children, identifying an urgent need for further education in this area (Babgi et al., 2008; Downing et al., 2015). Nevertheless, in Taiwan only rudimentary training in pain and symptom management for paediatric palliative care is provided to paediatric clinicians (Peng et al., 2013). This study evaluates the effectiveness of paediatric palliative care pain and symptom management training for paediatricians and nurses in Taiwan.

Purpose

This study evaluated the impact of training on paediatric professionals’ confidence, and on attitudes related to the provision of pain and symptom management for children with life-limiting or life-threatening conditions.

Research methods

A quasi-experimental pretest–posttest design was used to assess the research purposes of this study.

Research intervention

Research intervention consisted of a five-hour training course on pain and symptom management in paediatric palliative care for paediatricians and nurses. We designed the education of pain and symptom management based on the recommendations from previous researchers (Ekim and Ocake, 2013; Habich et al., 2012; Meyer et al., 2006). Table 1 shows the topics of training.

Table 1.

Training curriculum (5 hours).

Sections	Topic
Curriculum 1	International trends of palliative care management in paediatric and neonatal patients
Curriculum 2	Pain and symptom management in dying neonates
Curriculum 3	Pain management and invasive interventions
Curriculum 4	Panel discussion: how we can handle pain and symptoms
Curriculum 5	Non-pharmacological techniques for pain and symptom relief in paediatric palliative care

In this research, paediatricians and nurses were invited to participate in the training together because they are significant in the multidisciplinary pain management teamwork for providing a quality of care (Odell and Logan, 2013).

Because the native language of the lecturers was English, translation was provided for the lecturers and participants, and all materials were translated from English into Chinese. The curriculum included pharmacological treatments and non-pharmacological techniques for pain and symptom relief in paediatric palliative care. Various educational strategies were used, including didactic lectures, case study discussions, role-play and video viewings. Table 1 presents details of the curriculum.

Research participants and setting

This study took place at the Department of Pediatrics of the Taichung Veterans General Hospital in Taichung City in Taiwan. Participants were recruited via convenience sampling; paediatricians and paediatric nurses who were currently working in paediatric wards and who completed the entire training programme were invited to participate in this study. Institutional review board approval was obtained from the participating hospital and a consent form was obtained from each participant before data were collected.

Research instrument

A research questionnaire was administered before and after the training to survey participants’ confidence levels and attitudes regarding the provision of pain management to dying children.

The questionnaire consisted of seven questions related to demographic information, three questions in a six-item Likert format regarding confidence in the provision of pain and symptom management, and eight questions in a five-item Likert format pertaining to attitudes towards the provision of pain and symptom management to ill children. Confidence levels were coded as follows: 1 = never; 2 = rarely; 3 = sometimes; 4 = often; 5 = always; 6 = unsure. Attitude levels were coded as: 1 = strongly disagree; 2 = somewhat disagree; 3 = unsure; 4 = somewhat agree; and 5 = strongly agree.

This questionnaire was adapted from previous studies and other literature, the three questions evaluating clinicians’ confidence were mainly derived from the questionnaire, Comfort Level Caring for Dying Infants (CLCDI), by Babgi et al. (2008) and the eight questions concerning attitudes were derived from the Neonatal Palliative Care Attitude Scale (Kain et al., 2009) and another previous study (Burns et al., 2001). The content validity index (CVI) was developed by seven experts, four clinical experts and three paediatric scholars in the field of end-of-life care for children. The attitude towards caring for dying children (CVI = 0.84) and the confidence in caring for dying children (CVI = 0.89) sub-constructs revealed high content validity. An overall content validity index (CVI = 0.85) was used to determine the validity of the structured questionnaire. Some of the questions were originally prepared in English and subsequently translated into traditional Chinese for the benefit of the research subjects, who were Taiwanese. The translation accuracy was checked by a forward–backward translation procedure. Reliability testing was conducted by applying the questionnaire to five nurses and five physicians using test–retest Cronbach’s α (0.8) to determine the reliability of the results.

Statistical analysis

Data management and statistical analysis were performed using SPSS version 16.0 (SPSS Inc., Chicago, IL, USA). The demographic data were described by number and frequency. To consider the inherent subject dependency due to repeated measurements, the generalised estimating equation (GEE) method’s multiple linear regression model was used to determine the effect of the training programme on pretest and posttest of attitudes and levels of confidence after adjusting for the effects of confounding variables. Statistical significance was defined as p < 0.05.

Research results

In total, 85 eligible paediatric clinicians were invited and of these 71 (18 paediatricians and 53 nurses) agreed to participate in this research, giving an overall response rate of 80%. Table 2 shows the distribution of sociodemographic and professional characteristics of the participants. Most participants (77.5%) had received no paediatric palliative care education before attending this training.

Table 2.

Demographic data (N = 71, physicians 18, nurses 53).

	Number (%)
Characteristic	Paediatricians	Nurses	Total
Age (years)
20–30	9 (50%)	18 (34%)	27 (38%)
31–40	7 (38.9%)	24 (45.3%)	31 (43.7%)
Over 40	2 (11.1%)	11 (20.7%)	13 (18.3%)
Gender
Female	8 (44.4%)	53 (100%)	61 (85.9%)
Male	10 (14.1%)	0	10 (14.1%)
Marital status
Married	13 (72.2%)	31 (58.5%)	44 (62%)
Unmarried	5 (27.8%)	22 (41.5%)	27 (38%)
Religion
Buddhist and Taoism	8 (44.4%)	24 (45.3%)	32 (45%)
Christian or Catholic	3 (16.2%)	1 (1.9%)	3 (4.2%)
None	7 (38.9%)	28 (52.9%)	36 (50.8%)
Professional degree
Associate degree in nursing	0	3 (5.7%)	3 (4.2%)
Bachelor’s degree	16 (88.9%)	45 (84.9%)	61 (85.9%)
Master’s degree	2 (11.1%)	5 (9.4%)	7 (9.9%)
Experience in paediatric profession (years)
Less than 1	7 (38.9%)	6 (11.3%)	13 (18.3%)
1–5	7 (38.9%)	15 (28.3%)	22 (31%)
Over 6	4 (22.2%)	32 (60.4%)	36 (50.7%)
Previous education on paediatric palliative care
None	17 (94.4%)	38 (71.7%)	55 (77.5%)
8 hours	0	9 (17%)	9 (12.7%)
Over 9 hours	1 (5.6%)	6 (11.3%)	7 (9.8%)

This research showed a significant effect of training on the confidence level and attitudes of paediatric clinicians. As shown in Table 3, after adjusting for the effects of baseline score and occupation, the changes in confidence levels after training (posttest) were significant, on average, 0.859 units higher than the baseline (pretest), with a significant p value (0.006). After adjusting for the effects of baseline score and time, there was no significant difference in confidence levels between paediatricians and nurses (p = 0.956). Similarly, as shown in Table 4, the average scores of attitudes on the posttest were 1.563 units significantly higher than those on the pretest (p < 0.001), after adjusting for the effects of baseline score and occupation. Once again, there was no significant difference in attitude scores between paediatricians and nurses (p = 0.615), after adjusting for the effects of baseline score and time.

Table 3.

Comparison of the confidence scores pretest and posttest (N = 71, physicians 18, nurses 53).

Variables	B^d	SE	95% Wald CI	Wald χ²	p value
Intercept	2.452	0.841	(0.803, 4.101)	8.492	0.004
Baseline score of confidence	0.751	0.083	(0.588, 0.913)	81.856	0.000*
Time 2 vs. time 1^a	0.859	0.31	(0.25, 1.468)	7.647	0.006*
Group2 vs. group1^b	0.016	0.285	(–0.544, 0.576)	0.003	0.956

Dependent variable: total score of confidence.

Model: (intercept); baseline score of confidence, occupations, time.

Time 1 = baseline (pretest); time 2 = posttest.

Group 1 = paediatricians; group 2 = nurses.

Table 4.

Comparing the attitude scores between pretest and posttest.

Variables	B	SE	95% Wald CI	Wald χ²	p value
Intercept	8.150	1.7852	(4.651, 11.648)	20.84	0.000
Baseline score of attitude	0.773	0.052	(0.671, 0.875)	220.684	0.000*
Time 2 vs. time 1^a	1.563	0.353	(0.872, 2.255)	19.636	0.000*
Group 2 vs. group 1^b	–0.137	0.273	(–0.673, 0.398)	0.253	0.615

Dependent variable: total score of attitude.

Model: (intercept); total score of attitude, time.

Time 1 = baseline (pretest); Time 2 = posttest.

Group 1 = paediatricians; group 2 = nurses.

After receiving the training, participants reported increased confidence in providing pain management (pretest = 3.07, posttest = 3.46; Table 5) and providing comfort interventions for a variety of symptoms (pretest = 3.28, posttest = 3.62; Table 5). Moreover, after training, participants more strongly agreed that the goal of palliative care is to provide the best life quality possible for dying patients and their families (pretest = 4.7, posttest = 4.85; Table 6), and the majority strongly agreed that the provision of pain relief is a top priority in nursing care for dying children/babies (pretest = 4.25, posttest = 4.51; Table 6). After training, the majority of participants changed their attitudes and supported the use of narcotic pain medicine to relieve physiological suffering of terminally ill children (pretest = 4.27, posttest = 4.54). However, the attitudes of some participants changed from ‘somewhat agree’ to ‘somewhat disagree’ with the decision to explain the respiratory depressing effects of narcotic medicines to parents and patients (Table 6; pretest = 4.21, posttest = 4.61).

Table 5.

Distribution of changes in confidence levels (N = 71, physicians 18, nurses 53).

Item	Pretest	Posttest
1. I am confident in my ability to provide pain relief to infants/children with life-threatening condition. (M/SD^a: Pretest = 3.07/1.087; posttest = 3.46/1.093)
Never/rarely	20 (28.1%)	13 (18.3%)
Sometimes	29 (40.8%)	19 (26.8%)
Often/always	21 (29.5%)	38 (53.5%)
Unsure	1 (1.4%)	1 (1.4%)
2. I am confident in my ability to provide relief from a variety of symptoms to infants/children with life-threatening conditions. (M/SD^a: Pretest = 3.28/1.058; posttest = 3.62/1.061)
Never/rarely	15 (21.13%)	12 (16.9%)
Sometimes	28 (39.44%)	15 (21.13%)
Often/always	27 (38.02%)	43 (60.56%)
Unsure	1 (1.4%)	1 (1.4%)
3. I am able to contribute and make a difference in my work for children with life-threatening conditions. (M/SD^a: Pretest = 3.54/1.193; posttest = 3.66/1.013)
Never/rarely	12 (16.9%)	9 (12.68%)o.
Sometimes	20 (28.17%)	14 (19.72%)
Often/always	33 (46.48%)	46 (64.79%)
Unsure	6 (8.45%)	2 (2.82%)

Code 1–2 = never/rarely; code 3 = sometimes; code 4–5 = often/always; code 6 = unsure.

Table 6.

Analysis of changes in attitudes (N = 71, physicians 18, nurses 53).

Item	Pretest	Posttest
1. The goal of palliative care is to provide the best life quality for dying patients and families but not to cure the patients’ illness.(M/SD^a: Pretest = 4.70/0.46; posttest = 4.85/0.364)
Strongly/somewhat disagree	0	0
Unsure	0	0
Somewhat agree	21 (29.6%)	11 (15.5%)
Strongly agree	50 (70.4%)	60 (84.5%)
2. The principle of palliative care is to respect the inescapable nature of death but not to shorten the life of patients (M/SD^a: Pretest = 4.9/0.3; posttest = 4.9/0.318)
Strongly/somewhat disagree	0	0
Unsure	0	0
Somewhat agree	7 (9.9%)	8 (11.3%)
Strongly agree	64 (90.1%)	63 (88.7%)
3. I have a desire to provide palliative care for dying children and their families. (M/SD^a: Pretest = 4.2/1.077; posttest = 4.45/0.858)
Strongly/somewhat disagree	9 (12.7%)	4 (5.6%)
Unsure	2 (2.8%)	2 (2.8%)
Somewhat agree	24 (33.8%)	22 (31%)
Strongly agree	36 (50.7%)	43 (60%)
4. When babies/children are dying, providing pain relief is a priority for me. (M/SD^a: Pretest = 4.25/0.857; posttest = 4.51/0.734)
Strongly/somewhat disagree	5 (7%)	2 (2.8%)
Unsure	1 (1.4%)	1 (1.4%)
Somewhat agree	35 (49.3%)	26 (36.6%)
Strongly agree	30 (42.3%)	42 (59.2%)
5. Adolescents should be told their own prognosis and possible death. (M/SD^a: Pretest = 4.42/0.839; posttest = 4.48/0.734)
Strongly/somewhat disagree	6 (8.4%)	4 (5.6%)
Unsure	0	0
Somewhat agree	24 (33.8%)	26 (36.6%)
Strongly agree	41 (57.7%)	41 (57.7%)
6. I always assess symptoms of pain/distress in dying children, discuss the results of assessment with colleagues and then apply possible interventions to relieve pain and symptoms for dying children. (M/SD^a: Pretest = 4.27/0.675; posttest = 4.54/0.629)
Strongly/somewhat disagree	2 (2.8%)	3 (4.2%)
Unsure	3 (4.2%)	0
Somewhat agree	40 (56.3%)	26 (36.6%)
Strongly agree	26 (36.6%)	42 (59.2%)
7. I would suggest narcotic medicines and explain the respiratory depressing effects of medicine to families with terminally ill children. (M/SD^a: Pretest = 4.21/0.984; posttest = 4.61/0.573)
Strongly disagree	1 (1.4%)	3 (4.2%)
Somewhat disagree	7 (9.9%)	22 (31%)
Unsure	1 (1.4%)	0
Somewhat agree	29 (40.8%)	0
Strongly agree	33 (46.5%)	46 (64.8%)
8. I would suggest using narcotic pain relief medicine for terminally ill children for relief of physiological suffering. (M/SD^a: Pretest = 4.51/0.652; posttest = 4.72/0.484)
Strongly/somewhat disagree	1 (1.4%)	0
Unsure	0	1 (1.4%)
Somewhat agree	31 (43.7%)	18 (25.4%)
Strongly agree	39 (54.9%)	52 (73.2%)

Code 1 = strongly disagree; code 2 = somewhat disagree; code 3 = unsure; code 4 = somewhat agree; code 5 = strongly agree.

Median/standard deviation.

Discussion

This research, in which most participants reported having received minimal or no previous training in paediatric palliative care, is consistent with a previous study (Lee et al., 2016). Clinicians’ insufficient education and resulting lack of knowledge may cause them to lack the confidence and willingness to provide pain/symptom management for dying children, forming a barrier to effective pain management in practice (Czarnecki et al., 2014; Ekim and Ocake, 2013).

Discussion of results

Overall, paediatric clinicians showed significant improvements in confidence and attitudes regarding pain and symptom management for infants or children with life-threatening conditions. These training outcomes were consistent with previous studies (Baker et al., 2007; Habich et al., 2012; McCabe et al., 2007; Michelson et al., 2009).

The research findings demonstrated that education can increase the confidence of paediatric clinicians regarding the provision of pain and symptom management for children with life-threatening conditions. After training, participants stated that they more often assessed dying children’s pain and distressed symptoms and discussed possible interventions with colleagues, revealing an increased willingness to cooperate across disciplines with other healthcare providers, as has been recommended by other researchers and professionals (Czarnecki et al., 2014; Grégoire and Frager, 2006; Habich et al., 2012). In a previous study, paediatric nurses cited physicians’ prescription patterns as a barrier to effective pain management (Lee et al., 2016), but since our research demonstrated that trained physicians and nurses may share similar attitudes and confidence levels regarding pain and symptom management, we propose that joint training sessions may be a good opportunity to promote a coordinated, unified approach to pain/symptom management within the healthcare team. The American Academy of Pediatrics (2000) and researchers (Wager et al., 2013) also recommended multimodal, interactive and integrative approaches to paediatric pain and symptom management. Therefore, education in interprofessional collaboration is critically required to provide successful paediatric pain and symptom management (Watt-Watson et al., 2012). Further studies are needed to survey the outcomes of interprofessional education regarding paediatric pain and symptom management (Wager, et al., 2013; Watt-Watson, et al., 2012).

In addition, after training, a majority of the respondents strongly/somewhat agreed that narcotic pain medication should be suggested to terminally ill children for the relief of physiological suffering. Although most participants would suggest narcotic medicines and explain their respiratory depressing effects to patients and families, the attitudes of some participants after training switched from agreement to somewhat/strong disagreement. This may indicate that paediatric clinicians harbour fears of the adverse effects of analgesic medications, including respiratory depression and addiction. Compounding this problem, for paediatric clinicians in Taiwan, discussing death and pain medication with patients or parents may be the most difficult issue in paediatric palliative care practice (Galloway and Yaster, 2000; Williams-Reade, et al., 2015).

Limitations

As this course was the first ever instance of pain and symptom management in paediatric palliative care training for paediatric clinicians in Taiwan, the five-hour course was insufficient to cover the topic adequately. Further training in clinical skills may be needed. The sample size was possibly too small to detect significant differences accurately between the attitudinal changes of paediatricians and nurses. In addition, clinicians’ attitudes and confidence levels were self-reported; there were no observations of behaviour to measure resulting changes in patient care. It would be informative to survey the patients’ responses after receiving pain/symptom management from clinicians after training. Further studies should include qualitative research data to determine which confidence levels and attitudes were most improved as a result of training and to reveal which paediatric patients benefit most from interventions.

Conclusion

Pain and symptom management is a vital part of paediatric palliative care. Paediatricians and paediatric nurses in this research after receiving training reported increased levels of confidence and improved attitudes towards providing pain and symptom management for children with severe illness. Future training for paediatric clinicians is needed, with a clear focus on emphasising the importance of the role of opioid therapy for dying children and providing information on pain assessment and management strategies. In addition, education in paediatric palliative care should focus content on effective ways to communicate with dying children and their families regarding pain management strategies, and should promote interdisciplinary healthcare teamwork to improve the effectiveness of pain and symptom management.

Key points for policy, practice and/or research

Providing adequate pain relief and symptom control in paediatric palliative care is a challenging area for paediatric clinicians.

The evidence is clear that paediatric clinicians’ inadequate education may result in insufficient confidence to provide pain, symptom management, and an unwillingness to provide the interventions of pain and symptom management for children.

Education in paediatric palliative care should promote interdisciplinary healthcare teamwork to improve the effectiveness of pain and symptom management.

Footnotes

Acknowledgements

The authors would like to acknowledge the lecturers of education: Ms Kathy Perko, Ms Joetta DeSwarte Wallace and Dr Dominic Wilkinson.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Young-Chuan Chen is a senior nurse and also the head nurse of neonatal intensive unit in Taichung Veterans General Hospital, Taiwan (ROC), and her major interest is in neonatal nursing care. She worked closely with Dr Peng in conducting this research.

Niang-Huei Peng is an assistant professor at the School of Nursing, National Yang-Ming University. She is the principal investigator in this research.

Chao-Huei Chen is a neonatologist and also is the director of the Center for Faculty Development, Taichung Veterans General Hospital, Taiwan (ROC).

Frank Leigh Lu is a paediatrician and also chief of the Diversion of Pediatric Pulmonology and Critical Care Medicine, Department of Pediatrics, National Taiwan University Children’s Hospital, Taiwan (ROC). He holds a doctoral degree from the Medical School of National Taiwan University.

Yue-Cune Chang is a professor in the Department of Mathematics, Tamkang University, Tamsui, Taiwan (ROC). He worked on the statistical data in this research.

Hsin-Li Liu is an Instructor at the Nursing College in the Central Taiwan University of Science and Technology, Taiwan (ROC). She is an assistant researcher in this research.

Mark Yeats is a lecturer in the Department of Applied Foreign Languages, Takming University of Science and Technology. He undertook translating and proofreading work.

References

American Academy of Pediatrics (2013) American Academy Pediatrics Pediatric Palliative Care and Hospice Care Commitments Guidelines, and Recommendations. Pediatrics 132: 966–972.

Babgi

Rogers

Gomez

et al. (2008) Educational interventions in end-of-life care: Part II: Psychometric development of an instrument to measure nursing comfort after an educational intervention in end-of-life care: The “Comfort Level Caring for Dying Infants” (CLCDI). Advances in Neonatal Care 8(1): 66–70.

Baker

Torkildson

Baillargeon

et al. (2007) National survey of pediatric residency program directors and residents regarding education in palliative medicine and end-of-life care. Journal of Palliative Medicine 10(2): 420–429.

Burns

Mitchell

Griffith

et al. (2001) End-of-life care in the pediatric intensive care unit: Attitudes and practices of pediatric critical care physicians and nurses. Critical Care Medicine 29: 658–664.

Czarnecki

Salamon

Thompson

et al. (2014) Do barriers to pediatric pain management as perceived by nurses change over Time? Pain Management Nursing 15(1): 292–305.

Downing

Jassal

Mathew

et al. (2015) Pediatric pain management in palliative care. Pain Management 5(1): 23–35.

Drake

Frost

Collins

(2003) The symptoms of dying children. Journal of Pain Symptom Management 26: 594–603.

Ekim

Ocakc

(2013) Knowledge and attitudes regarding pain management of pediatric nurses in Turkey. Pain Management Nursing 14(4): e262–e267.

Galloway

Yaster

(2000) Pain and symptom control in terminally ill children. Pediatric Clinical North American 47: 711–746.

10.

Grégoire

Frager

(2006) Ensuring pain relief for children at the end of life. Pain Research Management 11(3): 161–171.

11.

Habich

Wilson

Thielk

et al. (2012) Evaluating the effectiveness of pediatric pain management guidelines. Journal of Pediatric Nursing 27: 336–345.

12.

Jacobs

Ferrell

Viani

et al. (2009) Appraisal of the pediatric end-of-life nursing education consortium training program. Journal of Pediatric Nursing 24(3): 216–221.

13.

Kain

Gardner

Yates

(2009) Neonatal palliative care attitude scale: Development of an instrument to measure the barriers to and facilitators of palliative care in neonatal nursing. Pediatrics 132(2): e207–e213.

14.

Lee

M-C

Chen

Y-C

Chen

C-H

et al. (2016) Comparison of the educational needs of neonatologists and neonatal nurses regarding palliative care in Taiwan. American Journal of Hospice and Palliative Medicine 33(3): 264–271.

15.

McCabe

Hunt

Serwint

(2008) Pediatric residents’ clinical and educational experiences with end-of-life care. Pediatrics 121(4): e731–e737.

16.

McCallum

Byrne

Bruera

(2000) How children die in hospital. Journal of Pain and Symptom Management 20: 417–423.

17.

Meyer

Ritholz

Burns

et al. (2006) Improving the quality of end-of-life care in the pediatric intensive care unit: Parents’ priorities and recommendations. Pediatrics 117: 649–657.

18.

Michelson

Ryan

Jovanovic

et al. (2009) Pediatric residents’ and fellows’ perspectives on palliative care education. Journal of Palliative Medicine 12(5): 451–457.

19.

Odell

Logan

(2013) Pediatric pain management: The multidisciplinary approach. Journal of Pain Research 6: 785–790.

20.

Peng

N-H

Chen

C-H

Huang

L-C

et al. (2013) The educational needs of neonatal nurses regarding neonatal palliative care. Nurse Education Today 33(12): 1506–1510.

21.

Peng

N-H

Chen

C-H

Liu

H-L

et al. (2012) To explore the conditions of dying infants in NICU in Taiwan. Journal of Critical Care 27(1): 102e7–102e13.

22.

Wager

Zernikow

Drake

et al. (2013) International multiprofessional course in pediatric palliative care: Benefits and challenges. Journal of Palliative Medicine 16(1): 96–99.

23.

Watt-Watson

Siddall

Carr

(2012) Interprofessional pain education: The road to successful pain management outcomes. Pain Management 2(5): 417–420.

24.

Williams-Reade

Lamson

Knight

et al. (2015) Paediatric palliative care: S review of needs, obstacles and the future. Journal of Nursing Management 23(1): 4–14.

25.

World Health Organization (2010) WHO definition of palliative care. 2010. Available at: http://www.who.int/cancer/palliative/definition/en (accessed 14 January 2017).