Factors influencing the expectation of pain among patients in a children's burns unit

Burns, 9, 187-l

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Printedin GreatBritain

Factors influencing the expectation of pain among patients in a children’s burns unit J. G. Beales Department of Rheumatology, University of Manchester Medical School, Manchester

Summary

The study was undertaken to identify factors increasing anxiety, fear and anticipation of pain among patients in a children’s Burns Unit and to establish means of modifying such factors in order to reduce the

children’s experience of pain during nursing and treatment sessions. Sixty patients were observed and, where possible, interviewed at periods throughout their stay in the unit. The results indicated that expectation of pain might be reduced by correcting the child’s erroneous beliefs about the nature of the healing process and the role of clinical therapy, and by undertaking certain changes in the manner in which treatment and nursing procedures upon the conscious patient were normally conducted. INTRODUCTION FOR many children

admitted to hospital with severe burns the period spent in hospital is associated with the suffering of considerable pain-pain produced not only directly by the injury, but also by the clinical treatment and nursing ofthe wound. Medical staff may become feared as torturers (Long and Cope, 196 1; Bernstein, 1963) and the emotional strain on burns unit personnel as a result of regularly inflicting substantial pain on their young patients can be considerable. There is increasing evidence of the extent to which psychological factors such as anxiety and the expectation of pain can influence pain experience (Melzack, 1973; Beales, in press), and pain has been successfully reduced among children with severe burns by the reduction of anxiety and the provision of reassurance (Bernstein, 1963, 1965). It has also been shown that, whereas causing an individual’s attention to be focused on the source of his pain may in-

crease pain experience, using distraction to draw attention away from the noxious stimulus may reduce the level of pain (Blitz and Dinnerstein, 197 1; Barber and Cooper, 1972). However, a study conducted in the casualty department of a children’s hospital revealed that the circumstances and manner in which the treatment of injuries was undertaken frequently had the unintended effect of focusing the child’s attention upon the pain source and increased the child’s fear and anticipation of pain (Beales, 1980). The study reported here represents a practical attempt to identify factors increasing anxiety, fear and expectation of pain among patients in a Children’s Burns Unit and to establish means of modifying such factors with the aim of minimizing the children’s pain experience. SAMPLE

AND METHODS

The study was conducted over a six-month period and involved 60 randomly selected patients whose ages on admission to the Burns Unit ranged from 4 weeks to 15 years. Approximately two-thirds of these children (41) were boys. Injuries ranged from minor burns and scalds requiring minimal treatment and involving admission of only a few days, to severe, life-threatening injury, demanding extensive surgery and many weeks’ hospital stay, and resulting in severe permanent disfiguration. Observation ofeach child was made during his reception into the unit, during bed rest and whilst engaged in play activities, whilst he was alone and in conversation with visitors, other patients and unit staff, as weil as during such potentially painful procedures as the changing

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of dressings, cleaning of wounds, removal of sutures and giving of injections. Informal, depth interviews were conducted among all children aged 5 and over (exactly 50 per cent of the sample), each of these patients being interviewed on several occasions. The interviews were non-directive, children being encouraged to talk freely and fully about matters which were of concern to them and which they themselves introduced into the conversation. RESULTS Children’s recovery

beliefs about therapy

and

Interviews, together with observation of younger children, indicated that the patients’ beliefs about their injury and its repair were a principal source of anxiety and anticipation of pain. According to their everyday experience of minor cutaneous injury, healing and recovery were accomplished by resting the affected body part and leaving it undisturbed. They had learned that moving and disturbing an injured limb increased pain and aggravated the injury. Therefore, when admitted to the Burns Unit, they expected that any interference of the damaged area by Burns Unit staff would be painful. Instead of appreciating that manipulation and movement of the wound by medical personnel was necessary for optimum recovery, they perceived such interference as likely to set back the healing process and therefore as something to be resisted. An atmosphere of conflict, rather than cooperation, therefore tended to be generated between the patient and unit staff. For example, a 3-year-old girl hysterically refused to put her weight on her badly scalded leg in compliance with the physiotherapist’s instructions. The child insisted that any disturbance of her leg would cause great pain and aggravate the existing damage and when the physiotherapist firmly repeated the instruction, the child became so afraid that she soiled herself. The use of restraint

As a result oftheir beliefs about the nature ofthe healing process and their fear of being hurt, patients frequently begged doctors and nurses not to undertake treatment procedures upon them. When such pleadings were disregarded, the children commonly attempted to physically resist what was being done to them. Unit staff responded to this resistance by holding the patient down and reinforcements were sometimes called in to aid those already dealing with the child and to ensure that he or she was en-

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tirely helpless. Observation and interviews indicated that such use of total restraint and the feeling of complete powerlessness induced in the child, invariably augmented fear and increased the young patient’s anticipation of pain. Communication

between

patients

When a child cried or screamed during treatment or nursing of his injury, the layout of the unit made it possible for most of the other patients to hear. Consequently, new arrivals were confirmed in their belief that pain was produced whenever dressings were removed and a damaged area touched by nurse or doctor. In addition, and for very sound reasons, all but the youngest patients were encouraged to play and talk together. However, observation and interview showed that when patients were in contact with each other, the pain inflicted by unit staff was a common topic of conversation. New arrivals were provided with detailed, and often exaggerated accounts of what established patients had suffered in the course of dressings being changed, wounds bathed, or sutures removed. Exposure to the sight of instruments

When preparations were being made for some nursing or therapy procedure the child was frequently exposed to the sight of the loaded instrument trolley for several minutes before the procedure was actually commenced. During this time all but the youngest children took great interest in the equipment on the trolley and the majority clearly displayed increasing apprehension, repeatedly pointing to instruments and asking the doctor or nurse what they were to be used for. The preparation period provided an opportunity for most children to build up anxiety and expectation of pain. Exposure to sight of the injured area

Virtually all the children clearly welcomed the initial bandaging of their affected skin areas when admitted to the hospital, since the bandages were perceived as restoring the integrity 01 the body surface. Bandages, in fact, tended to become part of the child’s body image and their removal by unit staff was almost always resisted The covering of the injury allowed the patien to cope with the psychological strain associatec with the physical insult by denying its existence or severity and putting it ‘out of mind’. Wher dressings were taken down the child was con fronted with the damage his body had sustainec and compelled to acknowledge it.

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Eeales: Children’s Expectation of Pain

Furthermore, on the basis oftheir previous experience of minor cutaneous injury, the patients generally anticipated rapid healing of affected tissue and expected that the affected skin area would at least show signs of improvement when bandages were removed after a few days in order for the wound to be bathed or examined. In fact the visual appearance of the damaged area often seemed worse to the child when dressings were taken down than it had done when first admitted to the unit and the dressings were initially applied. For many children the sight of their affected skin when the bandages were removed came as something of an unpleasant shock. They already anticipated that pain would be caused when the wound was touched or bathed. Having concluded that the damage was even more serious than they had imagined it to be, they expected even greater pain to result from the wound’s disturbance.

0 bservation

of the procedure

Except in the small minority of cases where the location of the injury made this physically impossible, the patient was able to observe what was being done when dressings were changed, wounds bathed or sutures removed. In addition to their seeing the area of damage itself, the children were able to anticipate pain on each occasion that, for example, a difficult suture or piece of dressing was removed. Their expectation and apprehension of pain on such occasions was indicated by facial gestures, anticipatory gasps and cries and pleas to be left alone. Provision of a verbal commentary

Even in those few cases where the child was not able to observe what was being done to his damaged tissue, the conversation of unit staff made it difficult for him to be unaware of the proceedings. When two or more staff were engaged in the nursing or therapeutic procedure, it was usual for them to comment to each other on the progress they were making or on anticipated difficulties. Consequently, and unintentionally they warned the patient in advance that, for example, a firmly adhering dressing or a particularly tricky suture was about to be removed, producing specific expectation of pain. On overhearing such conversation and receiving such advance warning, the child frequently cried out or attempted to persuade the nurse or doctor not to go ahead.

Availability

of distraction

During most of the treatment and nursing procedures observed, some distraction ofthe patient was attempted by unit staff, by engaging the child in conversation, introducing a toy or telling a story. As long as such attempts at distraction continued, they were usually successful, to some extent, in diverting the child’s attention away from the pain source. But because the distraction was unsystematic and unprepared, it was on no occasion sustained throughout the procedure and consequently there were always periods during which the patient was allowed to concentrate on the damaged area and on what was being done to it. During several observations, distraction was actually interrupted and the child’s attention drawn away from the conversation, toy or story in which he had been engrossed, by a staff member shouting a request for something needed to a colleague in the corridor outside, or by other staff coming into the room in order to confer with those dealing with the child. DISCUSSION Modifying the child’s beliefs

The results indicate that, for many burns patients, anxiety and anticipation of pain could be reduced by modifying their beliefs about the healing process and the role of clinical therapy-by causing them to perceive nursing and treatment procedures as desirable and beneficial, rather than as constituting physical assault. In this way the child might be motivated to cooperate with staff during nursing and therapy sessions, rather than such sessions being times of escalating conflict, with the child increasingly expecting to be hurt. Certainly, medical staff cannot take it for granted that the young burns patient enters hospital already equipped with a simplified version of that model of injury and recovery which they themselves hold. The chances are that he will have very different ideas and that his communication with other young patients in the Burns Unit will cause those ideas to be embellished and reaffirmed. In resisting the attempts of unit staff to remove their bandages and disturb their wounds, the children involved in this study may, in fact, have been expressing an inherent response to injury which is found not only in humans but also in some animal species. Wall (1979) has suggested that pain has a basically recuperative function,

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and operates in a 3-phase sequence when physical trauma takes place. In the first phase, during which the injury actually occurs, fight or flight may have priority-an attacker may have to be resisted, or danger fled from-and pain may be inhibited in order to allow the necessary behavioural response. (Wall’s thesis is perhaps supported by the fact that of the 14 young burns patients interviewed in the course of this study whose injuries had been produced by their clothing catching fire, only 2 reported experiencing pain at the time ofthe actual incident and immediately afterwards. Nine of these children reported extinguishing flames with their hands, and running, sometimes several hundred yards, to reach home without significant pain.) In the second phase identified by Wall, pain combines with anxiety to motivate the seeking of aid and a safer place in which to rest and (hopefully) recover. Pain and depression occur in the third phase in order to facilitate healing by discouraging movement and disturbance of the wound. It is only in his most recent history that man has developed more effective means of promoting recovery from injury-means which frequently require that an affected limb be moved and damaged tissue disturbed. The observed conflict between Bums Unit staff and their young patients during the course of treatment and nursing procedures might therefore be seen as representing a clash between Nature’s response to injury and that of a sophisticated medical science. Throughout the burned child’s stay in hospital, medical staff should take every opportunity to explain and justify to the patient what is being done, and will be done, to him. It is important that wherever possible, the purpose of individual procedures be explained to the child well in advance. It is no good waiting until, for example, the removal of sutures is about to commence, or is actually under way, and then attempting to provide reassurance. Children already in a state of heightened anxiety and apprehension are unlikely to be responsive to any such attempt. They may well view the explanation with deep suspicion, believing that it has been invented on the spur of the moment, purely to dissuade them from resisting. Having said that, Burns Unit staff should endeavour to modify their patients’ incorrect beliefs about the role and value of therapy, it has to be admitted that this is not necessarily an easy or straightforward task. The style of explanation which is appropriate for one child may not be suitable for another, and use of words which a

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young patient cannot understand may have the opposite effect to that intended by promoting further erroneous beliefs and aggravating existing fears. It is evident that children’s capacity to comprehend physical pathology and clinical treatment is primarily determined by age (Campbell, 1975; Steward and Regalbuto, 1975; Neuhauser et al., 1978) and a number of comparatively recent studies (Simeonsson et al., 1979; Whitt et al., 1979; Bibace and Walsh, 1980; Perrin and Gerrity, 198 1; Beales et al., in preparation) suggest that such capability proceeds through a series of discrete stages broadly in accordance with the theoretical framework of intellectual development set out by Piaget (Piaget and Innhelder, 1969). According to Piaget, between the ages of2 and 7 years, a child is in the ‘pre-operational’ stage ofcognitive development. In this stage, a child is incapable of reasoning beyond his own immediate experience and beyond appearances. Things are as they seem to be rather than as they logically must be. Consequently, a child in this stage will report that a tall, thin glass contains more liquid than a short, wide one because the level of the liquid is higher, even when he has seen equal amounts poured into them. Words are assumed to have only a single meaning and tend to be interpreted literally. Appreciation of physical causality is extremely limited, and when called upon to explain why one event gives rise to others, the child is likely to express a belief in the power of magic. Minor skin damage may be assumed to be transformed into healthy tissue under the bandage by a similar process to that employed by the television magician who covers one object with a cloth and then removes the cloth to reveal something entirely different. At around the age of 7 years, Piaget states that the child progresses into a qualitatively different style of thinking-the ‘concrete operational’ stage-which continues up to the age ofapproximately 11. The child can now use elementary logic and is capable of developing simple causal explanations to account for ill-health and recovery. Thought, however, remains substantially limited to the child’s own concrete experience of objects and events. It is only in the stage of ‘formal operations’ (which commences at around the age of 12) that the child becomes fully capable of abstract thought, of appreciating objects and relationships which exist outside his immediate, personal experience, and of understanding bodily dysfunction and recovery in physiological and causal terms.

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Expectatm

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of Pain

This would suggest that a young burns patient in the 12 + age category is likely to be capable of comprehending a fairly straightforward clinical explanation of the purpose of his therapy, provided that it is phrased in reasonably simple terms. It is necessary to check, however, that the child really does understand what he has been told. A 13-year-old boy who was informed that the burns on his leg would require him to have ‘an operation’ became confused and alarmed as a result because, in his vocabulary, the word ‘operation’ described surgical opening of the abdominal cavity in order to remedy some defect of the internal organs. Between the ages of 7 and 12, a patient may be helped to understand the aims of therapy by illustrating a factual description with analogies drawn from the child’s personal experience. In fact, the use of analogies may even allow certain treatment procedures to be presented to the child in a humorous, rather than a coldly clinical light. Whilst a child in the 7-12 age group is unlikely to be able to grasp a purely abstract account of the process of skin grafting, he might understand the basic principles more readily if, for example, certain aspects of the process are likened to applying a patch to damaged clothing-a patch which will ultimately become ‘glued’ into place, but which has to be temporarily ‘stitched’ into position until the adhesive ‘sets’. Below the age of 7 years, use of such analogies is likely to be much less effective in enabling a burns patient to understand the purpose of what is being done to him. Analogies might even confuse an under-7 and cause him additional distress, because there is a danger that he will interpret what he is told quite literally: that, for example, his damaged body surface really is going to be repaired by attaching a cloth patch. Instead of seeking to communicate medical facts and relationships of physical causality to an under-7, it is therefore more advisable to justify treatment procedures by reference to the kind of ‘magic’ that the child believes in. Burns Unit personnel have to be prepared to present themselves as fairy godmothers, the drugs they administer as magic potions and the clinical procedures they undertake as magical performances. Age, however, is only an approximate indicator of a child’s level of intellectual development. An especially intelligent 6-year-old and a 13-year-old of less tQan average mental ability may both require the style of explanation generally appropriate to the 7-12 age group.

Involving the child in his therapy

If the child’s beliefs about his injury and treatment can be successfully modified, and a willingness to cooperate with therapy produced in the young patient, the child may actually be allowed and encouraged to ‘lend a hand’ during certain procedures. Allowing the child to participate in the cleaning of his wound or the removal of his dressings, for example, may have a beneficial effect on pain experience by giving the child a greater sense of personal control over what is being done to him and (paradoxically) by causing the child to become so engrossed in the actual mechanics of the treatment procedure, that he pays less attention to pain. Certainly, it does seem that an individual experiences less pain as a result of a certain noxious stimulus if he feels that he has a measure of control over the stimulus. Pain is maximized when he feels that he is powerless to interfere with the pain source as, for example, when he is physically restrained. Achieving

distraction

from the pain source

If it is not possible to successfully modify the child’s beliefs in the required way-if the patient resists all attempts at persuasion or is simply too young to ‘make sense’ of any explanation-pain is most likely to be minimized if the child’s attention is drawn away from the treatment and nursing procedures performed upon him, rather than allowed to be focused upon them. In practice, this means that preparations for any procedure should, whenever possible, be undertaken out of the child’s sight. The patient should not be allowed to contemplate a loaded instrument trolley for several minutes before things actually get under way. When dressings are taken down, steps should be taken to ensure that the damaged area, and any work undertaken upon it. are hidden from the child’s sight. Staff should avoid conversation during the treatment session which might cause the child specific expectation of pain. Finally, if distraction is to be effective in combating the child’s pain, it has to be properly prepared in advance. It should commence a few minutes before disturbance of the injured area begins and be continued right through the proceedings without pause or interruption. In the case of very young children, appropriate music, perhaps combined with a moving toy, would seem most suitable: otherwise a story is likely to be the most effective means of achieving distraction. Using a tape-recorded story, played through earphones instead of using a nurse as a storyteller, would not only make better use of

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personnel, but would also reduce the risk of the patient overhearing conversation between Burns Unit staff which might cause him alarm and expectation of pain. CONCLUSION

Acknowledgements

acknowledged.

Dis.

of burned chilBernstein N. R. (19r63) wt dren with the ai,d of hypmniis. J. Child Psychol.

Psychiatry4,93.

Even in a highly e&ient, specialized Burns Unit, with a caring anal conscientious staff, it is clear &at several factm-s can opera& to increase the ,patient’s anticipation and experience usf pain. Much can be &me at the tinme of the in&vidual treatment praedure to redluce the lik&hood or severity 0f!pain being experienced by the patient. But minimizing fear and expectatin of pain also requ& that Burns ‘Unit staff make deliberate effort t0 inform and reassure the chiild throughout his period in hospital.

The enthusiastic staff involved

Beales J. G., Holt P. J. L., Kaan J.W.et al. (in press). Children with ju.venile clrcniic arthritis. Their beliefs about their illness and %huzapy. Ann Rheum

cooperation of the Bums Unit in this study is gratellly Thanks are also due to Dm

P. J. L. Holt and J. H. Keen and to Mrs V. P. Mellor. The research was supported by a grant from the William Hewitt Trust.

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Barber T. X. and Cooper B. J. (1972) E&facts on pain of experimentally induced and spontaneous distraction. Psycho!. Rep. 31, 647. Beales J. G. (1980)The>effects of attention and distraction on pain among children attending a hospital casualty department. ;In: Oborne D. J., Cjrruneberg M. M. and Eiser J.. R. (eds), Psych&gy and Medicine. London, Academic Press. &&es J. G. (in press) The assessment and nmanagement of pain in children. In: Karoly P. andgteffen J. J. (eds), Advances in
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Long R. T. amd Cope 0. (1961) Ematjonal problems of burned children. N. Engl. J. Med. 264, 1121. Melzack R. (1973) The Puzzle of P&n. Harmondsworth, Penguin. Neuhauser C, Hines P. and Steward M. (1978) Children’s concepts of .healing: cognitive development .and locus of control,factors. Am. J. Orthopsyohiatry 448,335.

&rrin E. C. and Gert&y P. S. (198 1) ThereTs ademon iin your belly: children’s understanding of ihness. J?ediatrics 67, 84 1. Met J. and Innhe& B. (1969) The Psy&o@y of :#he child. New York, Basic Books. SiFneonsson R. J., Buctiey L., Monson L. (1979) Con,ceptions of illness cau4ity in hospital&d children. g. Pediatr. Pswhol. 4,77. Steward M. and Regalbuto 33 (1975)Do doctors know what children know? Am. J. Orthupsychiatry 45, 146..

Wall ID.D. (1979) On the relation of injury to pain Pain 6, 253.

Whitt J. K., Dykstra W. and Taylor C. A. (1979) Children’s conceptions of illness and cognitive development: implications for pediatric practitioners. C/in. Pediatr. (Phila.) 18, 327.

Paper accepted 7 June 1982.

Reque@lfs for reprinfs should be addressed to: Dr J. G. Beales, Department SchoolL Wanchester.

of Rheumatology,

University of Manchester Medical