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Nurses' Views About the Barriers and Facilitators to Effective Management of Pediatric Pain
Original Article Nurses’ Views About the Barriers and Facilitators to Effective Management of Pediatric Pain Alison Twycross, PhD, MSc, DMS, CertEd(HE), RGN, RMN, RSCN, and Sue Collins, DipHE RN ---
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From the Faculty of Health and Social Care Sciences, Kingston University– St. George’s University of London, London, United Kingdom; Epsom and St. Helier NHS Trust, Carshalton, Surrey. Address correspondence to Alison Twycross, PhD, MSc, DMS, CertEd(HE), RGN, RMN, RSCN, Faculty of Health and Social Care Sciences, Kingston University–St. George’s University of London, Grosvenor Wing, St. George’s Hospital, London, SW17 0RE UK. E-mail: a.twycross@ sgul.kingston.ac.uk Received May 24, 2011; Revised September 28, 2011; Accepted October 17, 2011. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2011.10.007
ABSTRACT:
Children continue to experience moderate to severe pain during hospitalization. This paper presents data from two modified focus groups undertaken as part of a larger study exploring pediatric pain management practices in one hospital in the south of England. Thirty nurses took part in the focus groups and were asked questions about their views about the barriers and facilitators to effective pain management in the hospital. Participants identified a number of barriers which related to the staff, children and parents and the organization. Nurses indicated that they and the medical staff lacked knowledge about pain management. They also felt that staff shortages and a heavy workload detracted from the quality of the care they could provide. Several participants indicated that insufficient analgesic drugs were sometimes prescribed. Many of the barriers identified related to parents and children. It appears that nurses may not take as active a role as they could do in managing pediatric pain rather seeing it as the parents and child’s responsibility to let them know when they are experiencing pain. Nurses also felt that parents exaggerate their child’s pain and ask for analgesic drugs before their child needs them. There is a need to explore the interactions between nurses, children and parents in this context in more detail. Ó 2013 by the American Society for Pain Management Nursing The knowledge to guide nurses’ pain management practices is readily available, in the form of clinical guidelines (e.g.: Association of Paediatric Anaesthetists, 2008; Australian and New Zealand College of Anesthetists, 2010; Royal College of Nursing, 2009). However, pain management practices continue to fall short of the ideal (Shrestha-Ranjit & Manias, 2010; Twycross, 2007a), with children experiencing moderate to severe unrelieved pain after surgery (Fortier, Maclaren, Martin, Perret-Karimi, & Kain, 2009; Shrestha-Ranjit & Manias, 2010; Taylor, Boyer, & Campbell, 2008). Unrelieved pain has a number of undesirable physiologic and psychologic consequences that can affect the child at the time and later in life (Saxe, Stoddard, Courtney, Cunningham, Chawla, Sheridan, & King, 2001; Taddio, Shah, Gilbert-MacLeod, & Katz, 2002). It is therefore important to ensure that pain is managed effectively. Pain Management Nursing, Vol 14, No 4 (December), 2013: pp e164-e172
Pediatric Pain Management: Barriers and Facilitators
Several factors have been postulated as contributing to suboptimal pain management practices. These relate to health care professionals, patients (children and parents), and the organization (International Association for the Study of Pain [IASP], 2010). Factors relating to health care professionals include outdated or inadequate attitudes and knowledge. Evidence that nurses believe some pain is to be expected (and accepted) during hospitalization has been found (Hamers, Abu-Saad, Halfens, & Schumacher, 1994; Woodgate & Kristjanson, 1996). Furthermore, it has been suggested that nurses may see pain management as synonymous with administering analgesia (Twycross, 2004; Woodgate & Kristjanson, 1996). Indeed, nurses may not attribute as much priority to pain management as they do to other aspects of their role (Byrne, Morton, & Salmon, 2001; Twycross, 1999; van Hulle Vincent, 2005). There is also evidence that the importance nurses attribute to pain management tasks does not reflect the likelihood of the task being undertaken in practice (Twycross, 2008). Gimbler-Berglund, Ljusegren, and Ensker (2008) found that when nurses had positive attitudes to pain assessment, this facilitated good practice, but when nurses did not see pain assessment as important this was a barrier to optimal practice. A number of studies have examined nurses’ theoretical knowledge regarding managing pediatric pain and found knowledge deficits in basic pharmacologic principles (Manworren, 2000), pharmacologic interventions (Manworren, 2000; Rieman & Gordon, 2007; Salantera, Lauri, Salmi, & Helenius, 1999a; Salantera & Lauri, 2000), nonpharmacologic methods (Manworren, 2000; Salantera et al., 1999a; Twycross, 2004), pain assessment (Salantera & Lauri, 2000; Manworren, 2000), and the physiology of pain (Twycross, 2004). A lack of knowledge among nurses has also been identified as a barrier to optimal pain management in other studies (Gimbler-Berglund et al., 2008; van Hulle Vincent, 2005). When considering barriers in relation to managing pediatric postoperative pain management, clinical decision making needs to be taken into account; there is evidence that the strategies used by pediatric nurses are suboptimal (Twycross & Powls, 2006). Parents are seen by many nurses as reluctant for their children to receive pain medications (Czarnecki, Simon, Thompson, Armus, Hanson, Berg, ....Malon 2011; Ely, 2001; van Hulle Vincent, 2005). A lack of cooperation between parents and nurses has been described in other studies. Nurses felt that parents’ reports of pain did not always match their child’s behavior (Byrne et al., 2001; Ely, 2001) and that parents did not cooperate with them
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in managing their child’s pain (Gimbler-Berglund et al., 2008). Children’s behavior is seen as a barrier to managing pain effectively; nurses sometimes feel that their behavior did not indicate the child was in pain (Gimbler-Berglund et al., 2008). If, however, a child has a diagnosis suggesting they should be experiencing pain, this seems to facilitate optimal pain management (Gimbler-Berglund et al., 2008). The child’s age is sometimes seen as a barrier to providing effective pain management, particularly for children unable to communicate verbally (Ely, 2001; Gimbler-Berglund et al., 2008). Children have also been described as being reluctant to report or rate their pain and as unwilling to take pain medications (Czarnecki et al., 2011; van Hulle Vincent, 2005). Organizational barriers to optimal pain management also have been identified. All of the studies in this area have reported a key barrier to be inadequate or insufficient medication orders (Czarnecki et al., 2011; Ely, 2001; Gimbler-Berglund et al., 2008; van Hulle Vincent, 2005). A lack of time and competing priorities are also seen as barriers (Czarnecki et al., 2011; Ely, 2001; Gimbler-Berglund et al., 2008; van Hulle Vincent, 2005). Inconsistency in pain management practices among staff is also seen as hindering practice (Ely, 2001; Gimbler-Berglund et al., 2008). Limited priority given to pain management by medical staff has also been shown to be a barrier (van Hulle Vincent, 2005), and in Ely’s (2001) study the amount of organizational change, falling morale, job insecurity and a perceived lack of power were seen as barriers to best practice. A pain management service was seen as facilitating optimal practice by coming to assist the nurses when they asked for help, whereas a lack of cooperation with some medical staff was seen as a hindering factor (Gimbler-Berglund et al., 2008). Organizational culture also has been found to have an impact on pain management practices. This was clearly demonstrated by the results of Lauzon Clabo’s (2008) ethnographic study on two adult wards in one hospital in the USA. Participants described a clear but different pattern of pain assessment on each ward. The social context of the ward appeared to influence nurses’ pain assessment practices. Indeed it has been postulated that pain management practices remain poor because contextual organizational factors are not taken into account (Bucknall, Manias, & Bott, 2001; Craig, 2009). The aim of the present study was to ascertain nurses’ views about the barriers and facilitators to effective pain management. More specifically, the study explored nurses’ perceptions of: 1. How well pain is assessed and managed.
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2. The barriers to managing pain effectively. 3. How useful the hospital’s clinical guidelines are.
METHODS Focus groups are in-depth open-ended group discussions that explore a chosen subject through group interaction (Goodman & Evans, 2006). Focus groups have been shown to be especially useful when the goal of the study is to identify group beliefs, norms, and culture (Krueger, 1994). Focus groups produce direct data on consensus as well as diversity by providing the opportunity for participants to reflect on and react to the opinion of others (Polit & Hungler, 1999). In the present study, the aim was to identify the views of nurses about several aspects of pain management; focus groups were thought to be an appropriate method. Focus groups are normally made up of 8-10 people (Krueger, 1994). Because there were more nurses than this attending the mandatory study days where these focus groups took place, it was decided to modify the technique to capture as many views as possible (see Procedure section). Context Clinical guidelines and protocols relating to the management of pediatric pain were implemented in August 2007 at the hospital where this study was undertaken. The guidelines include information about which pain assessment tools should be used as well as details about the different pain medications. An algorithm (pain medication flowchart) is included in the guidelines and gives details about which pain medications should be used for what type of pain (mild, moderate or severe) as well as providing details about the relevant dose. These guidelines state that an audit should be conducted once a year using a staff survey to assess knowledge, implementation, and experience of the policy and to sample audits of patients’ views and experience. Two-and-a-half years after the implementation of the clinical guidelines, it was timely to carry out such an audit. This paper describes some of the data collected while undertaking that audit. Sample Thirty nurses took part in two (modified) focus groups which were conducted during the lunch break of two mandatory study days in May and September 2010. Data Collection Tools Participants were put into small groups and given a set of flipcharts with key questions (Table 1).
TABLE 1. Focus Group Activities Activity 1: Pain assessment (n ¼ 20) How do you currently assess pain in practice? What pain assessment tools do you use at the moment? Is there anything that currently stops you assessing pain as well as you would like? What would help you assess children’s pain better? Activity 2: Pain management (n ¼ 22) What pain-relieving interventions do you use in practice? (pain medications and nonpharmacologic methods) What pain-relieving interventions do you find to be most useful? Is there anything that currently stops you from managing pain as well as you would like? What would help you to manage children’s pain better? Activity 3: Child and parent involvement (n ¼ 20) What involvement do parents have in their child’s pain management? What involvement do children have in their pain management? What information do you give parents about pain management on discharge? What would help you to involve children in their pain management? What would help you to involve parents in their child’s pain management? Activity 4: Facilitators and barriers (n ¼ 22) How useful are the Trust’s clinical guidelines and algorithm in supporting your decision making about pain management? How useful is the Trust’s algorithm in supporting your decision making about pain management? Is there anything that currently stops you from managing pain as well as you would like? What would help you to manage pain better?
Procedure Nurses were put into groups of four to six. They were provided with a set of flipcharts relating to each of the activities (Table 1). Participants were asked to write down their views about each question on the flipcharts. Due to time constraints, the groups completed three of the four activities. They were given 10 minutes to complete each activity. The procedure for this study is outlined in Fig. 1.
Ethical Issues Before starting data collection, the chair of the local Research Ethics Committee was contacted to ascertain whether ethical approval was needed. He confirmed that because this was part of an audit of practice, ethical approval was not needed. All staff attending the mandatory study days were given the chance to opt out of the focus groups. Staff were told the focus groups were part of the pain management practices
Pediatric Pain Management: Barriers and Facilitators
The aims of the focus groups were explained to the nurses attending the mandatory study day.
Participants were placed into small groups (n=4-6) and given a set of flipcharts. They were given 10 minutes to write their comments.
After 10 minutes each group received a second set of flipcharts and were again given 10 minutes to comment on them. Each group completed 3 of the 4 activities.
Data were analyzed using the principles of content analysis. FIGURE 1.
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Procedure for the study.
audit currently being conducted and that the aim of the focus groups was to ascertain their views in this context. They were told that there were no right or wrong answers; that we were simply interested in their views. They were assured that their anonymity would be maintained at all times.
RESULTS Data were analyzed using content analysis. Data from the flipcharts were collated into a Word document. These data were read several times by the author to identify recurrent responses that could be placed into themes or categories as advocated by Twycross and Shields (2008). This was done by manually highlighting the text according to themes, using different colors of highlighter pens and cutting, pasting, and collating the data. This allowed the emergent themes to be identified from the data. Five themes emerged:
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Pain assessment and management practices (with a subcategory relating to the information given to parents on discharge). Child and parent involvement in pain management. Barriers to assessing and managing pain effectively. What would help nurses assess and manage pain more effectively. The usefulness of the hospital’s clinical guidelines.
The results will now be presented under these themes. Pain Assessment and Management Practices Nurses indicated that they used several methods to assess a child’s pain, including body language, observations, and nonverbal cues. Nurses also indicated they used several pain scales, including a numeric rating scale (NRS); the Wong-Baker faces pain scale and the Face, Legs, Activity, Crying, Consolability (FLACC) scale. An NRS consists of a range of numbers (e.g., 0– 10) that can be represented in verbal or graphical format (Stinson, 2009). The Wong-Baker faces scale consists of six hand-drawn faces ranging from smiling to crying (face 1 ¼ ‘‘no hurt’’; face 2 ¼ ‘‘hurts a little bit’’; face 3 ¼ ‘‘hurts little more’’; face 4 ¼ ‘‘hurts whole lot’’; face 5 ¼ ‘‘hurts worst’’) (Wong & Baker, 1988). The FLACC is a behavioral pain assessment tool that rates five variables (facial expression, leg movement, activity, cry, and consolability) on a scale of 0-2. The total score (out of 10) provides the pain intensity score (Merkel, Voepel-Lewis, Shayevitz, & Malviya, 1997). These are the pain assessment tools included within our hospital’s guidelines. When asked which painrelieving interventions they used, nurses described a range of pharmacologic and nonpharmacologic interventions. Pharmacologic interventions, play, and distraction were seen as the most useful pain-relieving interventions. Information Given to Parents About Pain Management on Discharge. The nurses indicated that they provided parents with a significant amount of verbal information about assessing and managing their child’s pain at home after discharge from hospital. This fell into four main categories: how to assess the child’s pain, what pain medications to give and how often, nonpharmacologic methods of pain relief, and how parents could get help if needed. Regarding identifying when their child was in pain, nurses indicated that they provided information about how parents could assess the level of their child’s pain, and suggested watching the child’s body language. They also advised parents to try to recognize pain symptoms before the child became too distressed. Nurses also reported giving parents verbal information about the pain medications their child could take at
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TABLE 2. Factors that Stop Nurses from Assessing Managing Pain as Well as They Would Like Factors Relating to Staff Nurses’ personal judgments, preconceived views, and assumptions Nurses’ lack of knowledge–particularly regarding pain management generally, pain medications, and patientcontrolled analgesia Fear of overdosing the child on pain medications Nurses having to chase down doctors to ensure that analgesic drugs prescribed Insufficient analgesia prescribed by medical staff Need for education of medical staff
Factors Relating to Child and Parents Child’s age Child’s culture Noncompliance with nurses’ suggestions for pain care by child and parents Children exaggerating their pain scores Children complaining of pain when their behaviors do not indicate that they are in pain Parent/child not informing the nursing staff when the child is in pain Parents interfering and answering for their child Parents encouraging their child to have pain medication when they had not asked for it Child/parent refusing pain medication
Organizational Factors Lack of time and a heavy workload Staff shortages Insufficient supply of some medication Lack of age-appropriate pain assessment tools* Not having a flowchart of pain medications* Lack of equipment to distract children Play therapists not always available
*Note that the hospital’s guidelines for managing pain in children included recommended pain assessment tools for all ages of children and an analgesic algorithm.
home. This included the times the pain medications were last given and when they could have the next dose, as well as an explanation about how the medication works. Parents were also informed about the time and frequency that pain medications could be given and advised to give pain medications regularly. Parents were advised about the correct dosage for their child’s age and any relevant precautions—e.g., eat before or after—as well as the side effects of the pain medications. Nurses indicated that parents were given verbal information about nonpharmacologic methods of pain relief, including distraction and trying to ensure their child was in the most comfortable position. Nurses gave differing advice about what to do if the medication did not work or the child had an allergic reaction to it (e.g., go to your general practitioner, return to the accident and emergency department, or meet with the community nursing team). Child and Parent Involvement in Pain Management Regarding parents’ involvement in their child’s pain management, the nurses indicated that parents often recognize their child’s pain and know what medication works best for their child. Nurses felt that parents
usually know their own child’s pain threshold, can report any change, and assess pain more promptly because they are with the child. The nurses thought that parents should inform the nursing staff when their child was in pain, and that parents should assist nurses in managing their child’s pain and encourage compliance with staff. Parents were also seen to have a role in distracting their child from their pain through comforting them, playing, watching TV, and talking with their child. However, nurses also felt that parents encouraged children to have pain medication even if the child had not asked for it: ‘‘Parents always come first to ask for analgesia.’’ When asked what involvement children have in their pain management, the nurses indicated that children should recognize when they are in pain, verbalize this when symptoms begin, and ask for pain medications when they need them. Nurses also thought children could suggest to staff what could be done to help them when they are in pain, and could engage in play therapy. Barriers to Assessing and Managing Pain Effectively Responses as to whether there was anything that currently stops nurses from assessing and managing pain
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TABLE 3. Things that Nurses Felt Would Help Them to Assess and Manage Pain Better Factors Relating to Staff Nurses: Using pain assessment tools Reassessment of pain after administration of pain medications Taking a patient history Having more time Teaching for nurses Doctors: Doctors writing the correct prescriptions for pain medications
Factors Relating to Child and Parents Children and parents verbalizing their concerns about pain Parents informing the nurses when their child is in pain Parental involvement in pain care
as well as they would like fell into three categories: issues relating to child and parents, nursing and medical staff, and organizational factors (Table 2).
Things That Would Help Nurses Assess and Manage Pain More Effectively The things that nurses felt would help them to assess and manage pain better again fell into three categories relating to child and parents, nursing and medical staff, and organizational factors. These are outlined in Table 3.
The Usefulness of the Hospital’s Clinical Guidelines Nurses were asked how useful the hospital’s clinical guidelines and algorithm (an analgesia flowchart) were in supporting their decision making about pain management. Nurses indicated that these were very useful in convincing junior doctors about the correct/maximum doses of pain medication as well as being a good learning tool for students and junior doctors/new staff. The algorithm was thought to work well, although one group commented that it was simplistic. To explore whether the hospital’s guidelines and algorithm were used to support decision making, nurses were asked to comment on the resources available to support them in this context. Responses included the use of assessment tools such as the Wong-Baker faces pain scale and the Pediatric Early Warning Score (PEWS) chart. The algorithm was seen as helpful, as was the pain team. The use of pain plans (e.g., for procedural pain) was also seen as a way to guide decision making.
Organizational Factors
Better assessment tools An improved scoring system Improved staffing levels Preprinted prescription charts Having a preoperative questionnaire for parents Availability of equipment for distraction, e.g., dolls, teddies Increased availability of a play therapist (child life worker)
DISCUSSION Nurses described using appropriate strategies to assess and manage children’s pain using a range of pain assessment tools as well as pharmacologic and nonpharmacologic interventions. Parents appeared to be given detailed information about how to assess and manage their child’s pain after discharge from hospital. However, the observational data collected in the hospital at the same time indicates that these pain management practices were not used consistently (Twycross & Collis, 2010). A similar incongruence between actual and reported practices has been seen in other studies (Jacob & Puntillo, 1999; Salantera, Lauri, Salmi, & Aantaa, 1999b; Twycross, 2004). It is noteworthy that participants felt that using pain assessment tools, reassessing pain, and taking a patient history were factors that would help them manage pain more effectively. Nurses may, therefore, know what they should be doing but not be using this knowledge in practice. This reflects the findings of Twycross (2007b), who found no positive relationship between nurses’ level of knowledge and how well they actually managed pain. The impact of organizational culture on practice has been suggested as an explanation for such discrepancies as was clearly demonstrated by the results of Lauzon Clabo’s (2008) study. This needs exploring further. Data collected pertaining to nurses’ perceptions of children’s and parents’ role in pain management suggest that participants do not consider it to be their role to be proactive in managing pediatric pain. Nurses appeared, for example, to expect the child and/or parent to inform them when they are in pain. This is similar to the findings of Woodgate and Kristjanson (1996), who found that nurses tended to concentrate on the
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technical aspects of care and considered pain management to be the parents’ role. Simons, Franck, and Roberson (2001) also found that nurses expected parents to tell them if their child was in pain. However, neither of these studies found evidence that nurses negotiated with parents about this role or even communicated with them about their expectations. Indeed, Twycross (2007a) found that nurses rarely initiated discussion with parents about their child’s pain; communication about pain was usually instigated by parents. Furthermore, Simons et al. (2001) found that parents were reluctant to ask for more information about their child’s pain management in case this might be perceived as challenging the clinical judgment of the nurses. This was the case even if parents felt that their child’s pain was not being managed effectively. Earlier research has also suggested that children do not always feel able to tell nurses that they are in pain and would like to be asked about their pain on an hourly basis (Polkki, Pietila, & Vehvilamen-Julkunen, 2003). There appears to be a need for nurses to become more proactive in managing pain and to ensure that they communicate effectively with the child and the parent. Several barriers to effective pain management were described by the participants in the present study (Table 2). These fall into the categories described by the IASP (2010) of factors relating to the staff, the child and parent, and the organization. Nurses’ personal judgments, preconceived ideas, and assumptions were seen as a barrier to the effective assessment and management of pain. This concurs with the findings of other studies (Byrne et al., 2001; Twycross, 1999; van Hulle Vincent, 2005) and is worthy of further exploration. Nurses also identified deficits in knowledge as a barrier to managing pain effectively. They felt that they lacked general knowledge about pain management and specific knowledge about pharmacologic interventions. They also felt that they had insufficient knowledge about patient-controlled analgesia and indicated that they were scared of overdosing a child on pain medication. This concurs with the findings of several other studies, which all found gaps in nurses’ knowledge about pediatric pain (Manworren, 2000; Rieman & Gordan, 2007; Salantera et al., 1999a; Salantera & Lauri, 2000; Twycross, 2004; van Hulle Vincent, 2005). There is a need to ascertain exactly where nurses’ knowledge deficits lie so that strategies can be put in place to address them. Nurses in the present study also suggested that medical staff needed educating about managing pediatric pain. This may be due in part to the fact the hospital is a district general (community) hospital, and therefore, not all medical staff caring for children are
specialized in pediatrics. Few studies have examined medical staff’s knowledge about pediatric pain. However, a recent study suggests that there are gaps in knowledge similar to those identified with nurses (Saroyan, Schechter, Tresgallo, Sun, Naqvi, & Graham, 2008). Nurses also felt that they needed to doublecheck doctors’ prescriptions to ensure that children had appropriate pain medications written up as well as having to spend time checking the doses prescribed. This could suggest that doctors do not prioritize the management of pediatric pain, and it perhaps adds to the argument that medical staff have knowledge deficits about pediatric pain. However, it is interesting, given that the hospital’s clinical guidelines include an algorithm which details the required doses of pain medications. However, it is noteworthy that observational data collected as part of the overall project indicated that when needed, pain medication had been prescribed as per the hospital’s guideline (Twycross & Collis, 2010). It is possible that this does not occur consistently. Participants in this study identified several barriers that related to the child and parent (Table 2). They suggested that parents made requests for pain medications to be administered when the child’s behavior did not appear to indicate they were in pain. This is similar to the findings of other studies (Gimbler-Berglund et al., 2008; Simons et al., 2001). However, we have known for more than two decades that there is often a dissonance between children’s self-report of pain and their behavior (Beyer, McGrath, & Berde, 1990; Stein, 1995). Nurses appear not to be aware of this. Children and parents not informing nurses when they/their child is in pain was also seen as a barrier, as was parents’ tendency to exaggerate their child’s pain. However, several studies have suggested that there is limited communication between children, parents, and nurses about pain management (Twycross, 2007a; Twycross & Collis, 2010). Paradoxically, nurses appear to see parents as being responsible for alerting them if their child is in pain but do not communicate this to the parents, and do not always believe the parents when they tell them that their child requires pain medications. Another barrier reported by nurses in this study was children and their parents refusing pain medications when they were offered. This is similar to findings of other studies (Czarnecki et al., 2011; Ely, 2001; van Hulle Vincent, 2005). Worryingly, there appears to be a perception among participants in the present study that parents should ensure that their child complies with what the nurses suggest is an appropriate way to manage their pain. This concurs with the findings of Byrne et al. (2001), who found that children in
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pain were expected to conform to what the nurse said and to comply with a set of behavioral milestones. Further research is needed to explore the interactions between children, parents, and nurses in this context. However, nurses may need to reconsider their role in pain management. Participants reported that a lack of time, a heavy workload, and a lack of staff were barriers to optimal pain management. A lack of time has been identified as a barrier to effective pain management in several other studies (Czarnecki et al., 2011; GimblerBerglund et al., 2008; van Hulle Vincent, 2005). These findings could add weight to the argument that nurses do not see the need to proactively manage pain, because Twycross (2004) found that even when the ward was relatively quiet and nurses had only one or two patients to care for, pain was not managed effectively. That pain management is not seen as a priority by nurses is supported by the findings of Twycross (1999). Nurses reported that sometimes there was an insufficient supply of some medication. It is worth noting that observational data collected in parallel with the focus groups did not find any evidence that this was the case (Twycross & Collis, 2010). However, the observational data were collected on the wards, and these issues may relate to other areas, such as the pediatric emergency department. This issue needs exploring in more depth at a local level. Another barrier listed by the participants is the need for age-appropriate pain assessment tools. Interestingly, there are three different recommended pain assessment tools listed in the hospital’s clinical guidelines (Wong and Baker faces scale, NRS, and FLACC). However, only the Wong-Baker faces scale is included in the nursing paperwork. The nurses may be unaware that other tools are available. There is a need to make sure that all three pain assessment tools are accessible. Alternatively, the nurses may not be aware of the clinical guidelines or feel that they do not meet their needs. Furthermore, evidence suggests that just having clinical guidelines available does not mean that practice will conform to them (Grimshaw, Eccles, & Tetro, 2004). This needs further consideration at a local
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level. Nurses also stated that they would like a flowchart of pain medications; again, this is available as part of the hospital’s clinical guidelines. This lends support to the conjecture that nurses may not be aware of the clinical guidelines. Study Limitations There are several limitations of the data presented in this paper. The style of the focus groups meant it was not possible to probe responses to explore what was meant in depth. An example of this is that despite participants being asked about both barriers and facilitators to effective pain management, the data collected related primarily to barriers. However, the findings of this study concur with those of earlier studies in this area and provide insight into what nurses see as the barriers to effective pain management in children. The data also provide some clear directions for changes in practice, such as making the pain assessment tools more accessible.
CONCLUSION Participants identified a number of barriers, which related to the staff, children and parents, and the organization. A paradox appears to exist in that nurses see parents as being responsible for many aspects of their child’s pain management but do not communicate this to the parents nor always believe parents when they suggest that their child requires pain medication. This needs exploring further, but nurses may need to become more proactive in managing pediatric pain. The results presented in this paper suggest that there may be some knowledge deficits among nurses and medical staff about pediatric pain management. These need exploring further. There is also a need to identify strategies to ensure that staff are aware of the hospital’s clinical guidelines and use them in practice, as well as to examine the impact of organizational culture on practice further. This study provides evidence about nurses’ perceptions regarding barriers to assessing and managing pain effectively and indicates areas for improvements in practice and further research.
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responses to children’s postoperative pain. Journal of Psychosomatic Research, 50, 69–76. Craig, K. D. (2009). The social communication module of pain. Canadian Psychologist, 20, 22–32. Czarnecki, M. L., Simon, K., Thompson, J. J., Armus, C. L., Hanson, T. C., Berg, K. A., Petrie, J. L., Xiang, Q., & Malin, S. (2011). Barriers to pediatric pain management: A nursing perspective. Pain Management Nursing, 12(3), 154–162. Ely, B. (2001). Pediatric nurses’ pain management practices: Barriers to change. Pediatric Nursing, 27(5), 473–480. Fortier, M. A., MacLaren, J. E., Martin, S. R., Perret-Karimi, D., & Kain, Z. V. (2009). Pediatric pain after ambulatory surgery: Where’s the medication? Pediatrics, 124, e588–e595. Gimbler-Berglund, I., Ljusegren, G., & Ensker, K. (2008). Factors influencing pain management in children. Paediatric Nursing, 20(10), 21–24. Goodman, C., & Evans, C. (2006). Focus groups. In G. Gerrish, & A. Lacey (Eds.), The Research Process in Nursing (pp. 353–366). Oxford: Blackwell. Grimshaw, J., Eccles, M., & Tetroe, J. (2004). Implementing clinical guidelines: Current evidence and future implications. Journal of Continuing Education in the Health Professions, 24(S1), S31–S37. Hamers, J., Abu-Saad, H., Halfens, R. J. G., & Schumacher, J. N. M. (1994). Factors influencing nurses’ pain assessment and interventions in children. Journal of Advanced Nursing, 20, 853–860. International Association for the Study of Pain (IASP) (2010). Why the gaps between evidence and practice. Seattle: IASP. Jacob, E., & Puntillo, K. A. (1999b). A survey of nursing practice in the assessment and management of pain in children. Pediatric Nursing, 25(3), 278–286. Krueger, R. (1994). Focus groups: A practical guide for applied research, (2nd ed.) California: Sage, LA. Lauzon Clabo, L. M. (2008). An ethnography of pain assessment and the role of the social context on two postoperative units. Journal of Advanced Nursing, 61, 531–539. Manworren, R. C. B. (2000). Pediatric nurses’ knowledge and attitudes survey regarding pain. Pediatric Nursing, 26(6), 610–614. Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., & Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23(3), 292–297. Polit, F., & Hungler, P. (1999). Nursing research: Principles and method (p. 194). New York: Lippincott, Williams & Wilkins. Polkki, T., Pietila, A. M., & Vehvilamen-Julkunen, K. (2003). Hospitalized children’s descriptions of their experiences with postsurgical pain relieving methods. International Journal of Nursing Studies, 40, 33–44. Rieman, M. T., & Gordon, M. (2007). Pain management competency evidenced by a survey of pediatric nurses’ knowledge and attitudes. Pediatric Nursing, 33(4), 307–312. Salantera, S., & Lauri, S. (2000). Nursing students’ knowledge of and views about children in pain. Nurse Education Today, 20, 537–547. Salantera, S., Lauri, S., Salmi, T. T., & Helenius, H. (1999a). Nurses’ knowledge about pharmacological and nonpharmacological pain management in children. Journal of Pain and Symptom Management, 18(4), 289–299. Salantera, S., Lauri, S., Salmi, T. T., & Aantaa, R. (1999b). Nursing activities and outcomes of care in the assessment, management and documentation of children’s pain. Journal of Pediatric Nursing, 14(6), 408–415.
Saroyan, J. M., Schechter, W. S., Tresgallo, M. E., Sun, L., Naqvi, Z., & Graham, M. J. (2008). Assessing resident knowledge of acute pain: Management in hospitalized children: A pilot study. Journal of Pain and Symptom Management, 36(6), 628–638. Saxe, G., Stoddard, F., Courtney, D., Cunningham, K., Chawla, N., Sheridan, R., King, D., & King, L. (2001). Relationship between acute morphine and the course of PTSD in children with burns. Journal of the American Academy of Child & Adolescent Psychiatry, 40(8), 915–921. Shrestha-Ranjit, J. M., & Manias, E. (2010). Pain assessment and management practices in children following surgery of the lower limb. Journal of Clincial Nursing, 19, 118–128. Simons, J., Franck, L., & Roberson, E. (2001). Parent involvement in children’s pain care: Views of parents and nurses. Journal of Advanced Nursing, 36(4), 591–599. Stein, P. R. (1995). Indices of pain intensity: Construct validity among preschoolers. Pediatric Nursing, 21(2), 119–123. Stinson, J. (2009). Pain assessment in children. In A. Twycross, S. J. Dowden, & L. Bruce (Eds.), Pain management in children: A clinical manual (pp. 85–108). Oxford: Wiley-Blackwell. Taddio, A., Shah, V., Gilbert-MacLeod, C., & Katz, J. (2002). Conditioning and hyperalgesia in newborns exposed to repeated heel lances. Journal of the American Medical Association, 288(7), 857–861. Taylor, E. M., Boyer, K., & Campbell, F. A. (2008). Pain in hospitalized children: A prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital. Pain Research and Management, 13(1), 25–32. Twycross, A. (1999). Pain management: A nursing priority? Journal of Child Health Care, 3(3), 19–25. Twycross, A. (2004). Children’s nurses’ pain management practices: Theoretical knowledge, perceived importance and decision-making. Unpublished PhD thesis, University of Central Lancashire. Twycross, A. (2007a). Children’s nurses’ postoperative pain management practices: An observational study. International Journal of Nursing Studies, 44(6), 869–881. Twycross, A. (2007b). What is the impact of theoretical knowledge on children’s nurses’ post-operative pain management practices? An exploratory study. Nurse Education Today, 27(7), 697–707. Twycross, A. (2008). Does the perceived importance of a pain management task affect the quality of children’s nurses’ post-operative pain management practices? Journal of Clinical Nursing, 17(23), 3205–3216. Twycross, A., & Collis, S. (2010). Results of an audit of pain management practices. Internal audit report (Trust name withheld). Twycross, A., & Powls, L. (2006). How Do children’s nurses make clinical decisions? Two preliminary studies. Journal of Clinical Nursing, 15, 1324–1335. Twycross, A., & Shields, L. (2008). Content analysis. Paediatric Nursing, 20(6), 38. van Hulle Vincent, C. (2005). Nurses’ knowledge, attitudes, and practices regarding children’s pain. The American Journal of Maternal Child Nursing, 30(3), 177–183. Wong, D. L., & Baker, C. M. (1988). Pain in children: Comparison of assessment scales. Pediatric Nursing, 14(1), 9–17. Woodgate, R., & Kristjanson, L. (1996). A young child’s pain: How parents and nurses ‘‘take care.’’ International Journal of Nursing Studies, 33(3), 271–284.
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From the Faculty of Health and Social Care Sciences, Kingston University– St. George’s University of London, London, United Kingdom; Epsom and St. Helier NHS Trust, Carshalton, Surrey. Address correspondence to Alison Twycross, PhD, MSc, DMS, CertEd(HE), RGN, RMN, RSCN, Faculty of Health and Social Care Sciences, Kingston University–St. George’s University of London, Grosvenor Wing, St. George’s Hospital, London, SW17 0RE UK. E-mail: a.twycross@ sgul.kingston.ac.uk Received May 24, 2011; Revised September 28, 2011; Accepted October 17, 2011. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2011.10.007
ABSTRACT:
Children continue to experience moderate to severe pain during hospitalization. This paper presents data from two modified focus groups undertaken as part of a larger study exploring pediatric pain management practices in one hospital in the south of England. Thirty nurses took part in the focus groups and were asked questions about their views about the barriers and facilitators to effective pain management in the hospital. Participants identified a number of barriers which related to the staff, children and parents and the organization. Nurses indicated that they and the medical staff lacked knowledge about pain management. They also felt that staff shortages and a heavy workload detracted from the quality of the care they could provide. Several participants indicated that insufficient analgesic drugs were sometimes prescribed. Many of the barriers identified related to parents and children. It appears that nurses may not take as active a role as they could do in managing pediatric pain rather seeing it as the parents and child’s responsibility to let them know when they are experiencing pain. Nurses also felt that parents exaggerate their child’s pain and ask for analgesic drugs before their child needs them. There is a need to explore the interactions between nurses, children and parents in this context in more detail. Ó 2013 by the American Society for Pain Management Nursing The knowledge to guide nurses’ pain management practices is readily available, in the form of clinical guidelines (e.g.: Association of Paediatric Anaesthetists, 2008; Australian and New Zealand College of Anesthetists, 2010; Royal College of Nursing, 2009). However, pain management practices continue to fall short of the ideal (Shrestha-Ranjit & Manias, 2010; Twycross, 2007a), with children experiencing moderate to severe unrelieved pain after surgery (Fortier, Maclaren, Martin, Perret-Karimi, & Kain, 2009; Shrestha-Ranjit & Manias, 2010; Taylor, Boyer, & Campbell, 2008). Unrelieved pain has a number of undesirable physiologic and psychologic consequences that can affect the child at the time and later in life (Saxe, Stoddard, Courtney, Cunningham, Chawla, Sheridan, & King, 2001; Taddio, Shah, Gilbert-MacLeod, & Katz, 2002). It is therefore important to ensure that pain is managed effectively. Pain Management Nursing, Vol 14, No 4 (December), 2013: pp e164-e172
Pediatric Pain Management: Barriers and Facilitators
Several factors have been postulated as contributing to suboptimal pain management practices. These relate to health care professionals, patients (children and parents), and the organization (International Association for the Study of Pain [IASP], 2010). Factors relating to health care professionals include outdated or inadequate attitudes and knowledge. Evidence that nurses believe some pain is to be expected (and accepted) during hospitalization has been found (Hamers, Abu-Saad, Halfens, & Schumacher, 1994; Woodgate & Kristjanson, 1996). Furthermore, it has been suggested that nurses may see pain management as synonymous with administering analgesia (Twycross, 2004; Woodgate & Kristjanson, 1996). Indeed, nurses may not attribute as much priority to pain management as they do to other aspects of their role (Byrne, Morton, & Salmon, 2001; Twycross, 1999; van Hulle Vincent, 2005). There is also evidence that the importance nurses attribute to pain management tasks does not reflect the likelihood of the task being undertaken in practice (Twycross, 2008). Gimbler-Berglund, Ljusegren, and Ensker (2008) found that when nurses had positive attitudes to pain assessment, this facilitated good practice, but when nurses did not see pain assessment as important this was a barrier to optimal practice. A number of studies have examined nurses’ theoretical knowledge regarding managing pediatric pain and found knowledge deficits in basic pharmacologic principles (Manworren, 2000), pharmacologic interventions (Manworren, 2000; Rieman & Gordon, 2007; Salantera, Lauri, Salmi, & Helenius, 1999a; Salantera & Lauri, 2000), nonpharmacologic methods (Manworren, 2000; Salantera et al., 1999a; Twycross, 2004), pain assessment (Salantera & Lauri, 2000; Manworren, 2000), and the physiology of pain (Twycross, 2004). A lack of knowledge among nurses has also been identified as a barrier to optimal pain management in other studies (Gimbler-Berglund et al., 2008; van Hulle Vincent, 2005). When considering barriers in relation to managing pediatric postoperative pain management, clinical decision making needs to be taken into account; there is evidence that the strategies used by pediatric nurses are suboptimal (Twycross & Powls, 2006). Parents are seen by many nurses as reluctant for their children to receive pain medications (Czarnecki, Simon, Thompson, Armus, Hanson, Berg, ....Malon 2011; Ely, 2001; van Hulle Vincent, 2005). A lack of cooperation between parents and nurses has been described in other studies. Nurses felt that parents’ reports of pain did not always match their child’s behavior (Byrne et al., 2001; Ely, 2001) and that parents did not cooperate with them
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in managing their child’s pain (Gimbler-Berglund et al., 2008). Children’s behavior is seen as a barrier to managing pain effectively; nurses sometimes feel that their behavior did not indicate the child was in pain (Gimbler-Berglund et al., 2008). If, however, a child has a diagnosis suggesting they should be experiencing pain, this seems to facilitate optimal pain management (Gimbler-Berglund et al., 2008). The child’s age is sometimes seen as a barrier to providing effective pain management, particularly for children unable to communicate verbally (Ely, 2001; Gimbler-Berglund et al., 2008). Children have also been described as being reluctant to report or rate their pain and as unwilling to take pain medications (Czarnecki et al., 2011; van Hulle Vincent, 2005). Organizational barriers to optimal pain management also have been identified. All of the studies in this area have reported a key barrier to be inadequate or insufficient medication orders (Czarnecki et al., 2011; Ely, 2001; Gimbler-Berglund et al., 2008; van Hulle Vincent, 2005). A lack of time and competing priorities are also seen as barriers (Czarnecki et al., 2011; Ely, 2001; Gimbler-Berglund et al., 2008; van Hulle Vincent, 2005). Inconsistency in pain management practices among staff is also seen as hindering practice (Ely, 2001; Gimbler-Berglund et al., 2008). Limited priority given to pain management by medical staff has also been shown to be a barrier (van Hulle Vincent, 2005), and in Ely’s (2001) study the amount of organizational change, falling morale, job insecurity and a perceived lack of power were seen as barriers to best practice. A pain management service was seen as facilitating optimal practice by coming to assist the nurses when they asked for help, whereas a lack of cooperation with some medical staff was seen as a hindering factor (Gimbler-Berglund et al., 2008). Organizational culture also has been found to have an impact on pain management practices. This was clearly demonstrated by the results of Lauzon Clabo’s (2008) ethnographic study on two adult wards in one hospital in the USA. Participants described a clear but different pattern of pain assessment on each ward. The social context of the ward appeared to influence nurses’ pain assessment practices. Indeed it has been postulated that pain management practices remain poor because contextual organizational factors are not taken into account (Bucknall, Manias, & Bott, 2001; Craig, 2009). The aim of the present study was to ascertain nurses’ views about the barriers and facilitators to effective pain management. More specifically, the study explored nurses’ perceptions of: 1. How well pain is assessed and managed.
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2. The barriers to managing pain effectively. 3. How useful the hospital’s clinical guidelines are.
METHODS Focus groups are in-depth open-ended group discussions that explore a chosen subject through group interaction (Goodman & Evans, 2006). Focus groups have been shown to be especially useful when the goal of the study is to identify group beliefs, norms, and culture (Krueger, 1994). Focus groups produce direct data on consensus as well as diversity by providing the opportunity for participants to reflect on and react to the opinion of others (Polit & Hungler, 1999). In the present study, the aim was to identify the views of nurses about several aspects of pain management; focus groups were thought to be an appropriate method. Focus groups are normally made up of 8-10 people (Krueger, 1994). Because there were more nurses than this attending the mandatory study days where these focus groups took place, it was decided to modify the technique to capture as many views as possible (see Procedure section). Context Clinical guidelines and protocols relating to the management of pediatric pain were implemented in August 2007 at the hospital where this study was undertaken. The guidelines include information about which pain assessment tools should be used as well as details about the different pain medications. An algorithm (pain medication flowchart) is included in the guidelines and gives details about which pain medications should be used for what type of pain (mild, moderate or severe) as well as providing details about the relevant dose. These guidelines state that an audit should be conducted once a year using a staff survey to assess knowledge, implementation, and experience of the policy and to sample audits of patients’ views and experience. Two-and-a-half years after the implementation of the clinical guidelines, it was timely to carry out such an audit. This paper describes some of the data collected while undertaking that audit. Sample Thirty nurses took part in two (modified) focus groups which were conducted during the lunch break of two mandatory study days in May and September 2010. Data Collection Tools Participants were put into small groups and given a set of flipcharts with key questions (Table 1).
TABLE 1. Focus Group Activities Activity 1: Pain assessment (n ¼ 20) How do you currently assess pain in practice? What pain assessment tools do you use at the moment? Is there anything that currently stops you assessing pain as well as you would like? What would help you assess children’s pain better? Activity 2: Pain management (n ¼ 22) What pain-relieving interventions do you use in practice? (pain medications and nonpharmacologic methods) What pain-relieving interventions do you find to be most useful? Is there anything that currently stops you from managing pain as well as you would like? What would help you to manage children’s pain better? Activity 3: Child and parent involvement (n ¼ 20) What involvement do parents have in their child’s pain management? What involvement do children have in their pain management? What information do you give parents about pain management on discharge? What would help you to involve children in their pain management? What would help you to involve parents in their child’s pain management? Activity 4: Facilitators and barriers (n ¼ 22) How useful are the Trust’s clinical guidelines and algorithm in supporting your decision making about pain management? How useful is the Trust’s algorithm in supporting your decision making about pain management? Is there anything that currently stops you from managing pain as well as you would like? What would help you to manage pain better?
Procedure Nurses were put into groups of four to six. They were provided with a set of flipcharts relating to each of the activities (Table 1). Participants were asked to write down their views about each question on the flipcharts. Due to time constraints, the groups completed three of the four activities. They were given 10 minutes to complete each activity. The procedure for this study is outlined in Fig. 1.
Ethical Issues Before starting data collection, the chair of the local Research Ethics Committee was contacted to ascertain whether ethical approval was needed. He confirmed that because this was part of an audit of practice, ethical approval was not needed. All staff attending the mandatory study days were given the chance to opt out of the focus groups. Staff were told the focus groups were part of the pain management practices
Pediatric Pain Management: Barriers and Facilitators
The aims of the focus groups were explained to the nurses attending the mandatory study day.
Participants were placed into small groups (n=4-6) and given a set of flipcharts. They were given 10 minutes to write their comments.
After 10 minutes each group received a second set of flipcharts and were again given 10 minutes to comment on them. Each group completed 3 of the 4 activities.
Data were analyzed using the principles of content analysis. FIGURE 1.
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Procedure for the study.
audit currently being conducted and that the aim of the focus groups was to ascertain their views in this context. They were told that there were no right or wrong answers; that we were simply interested in their views. They were assured that their anonymity would be maintained at all times.
RESULTS Data were analyzed using content analysis. Data from the flipcharts were collated into a Word document. These data were read several times by the author to identify recurrent responses that could be placed into themes or categories as advocated by Twycross and Shields (2008). This was done by manually highlighting the text according to themes, using different colors of highlighter pens and cutting, pasting, and collating the data. This allowed the emergent themes to be identified from the data. Five themes emerged:
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Pain assessment and management practices (with a subcategory relating to the information given to parents on discharge). Child and parent involvement in pain management. Barriers to assessing and managing pain effectively. What would help nurses assess and manage pain more effectively. The usefulness of the hospital’s clinical guidelines.
The results will now be presented under these themes. Pain Assessment and Management Practices Nurses indicated that they used several methods to assess a child’s pain, including body language, observations, and nonverbal cues. Nurses also indicated they used several pain scales, including a numeric rating scale (NRS); the Wong-Baker faces pain scale and the Face, Legs, Activity, Crying, Consolability (FLACC) scale. An NRS consists of a range of numbers (e.g., 0– 10) that can be represented in verbal or graphical format (Stinson, 2009). The Wong-Baker faces scale consists of six hand-drawn faces ranging from smiling to crying (face 1 ¼ ‘‘no hurt’’; face 2 ¼ ‘‘hurts a little bit’’; face 3 ¼ ‘‘hurts little more’’; face 4 ¼ ‘‘hurts whole lot’’; face 5 ¼ ‘‘hurts worst’’) (Wong & Baker, 1988). The FLACC is a behavioral pain assessment tool that rates five variables (facial expression, leg movement, activity, cry, and consolability) on a scale of 0-2. The total score (out of 10) provides the pain intensity score (Merkel, Voepel-Lewis, Shayevitz, & Malviya, 1997). These are the pain assessment tools included within our hospital’s guidelines. When asked which painrelieving interventions they used, nurses described a range of pharmacologic and nonpharmacologic interventions. Pharmacologic interventions, play, and distraction were seen as the most useful pain-relieving interventions. Information Given to Parents About Pain Management on Discharge. The nurses indicated that they provided parents with a significant amount of verbal information about assessing and managing their child’s pain at home after discharge from hospital. This fell into four main categories: how to assess the child’s pain, what pain medications to give and how often, nonpharmacologic methods of pain relief, and how parents could get help if needed. Regarding identifying when their child was in pain, nurses indicated that they provided information about how parents could assess the level of their child’s pain, and suggested watching the child’s body language. They also advised parents to try to recognize pain symptoms before the child became too distressed. Nurses also reported giving parents verbal information about the pain medications their child could take at
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TABLE 2. Factors that Stop Nurses from Assessing Managing Pain as Well as They Would Like Factors Relating to Staff Nurses’ personal judgments, preconceived views, and assumptions Nurses’ lack of knowledge–particularly regarding pain management generally, pain medications, and patientcontrolled analgesia Fear of overdosing the child on pain medications Nurses having to chase down doctors to ensure that analgesic drugs prescribed Insufficient analgesia prescribed by medical staff Need for education of medical staff
Factors Relating to Child and Parents Child’s age Child’s culture Noncompliance with nurses’ suggestions for pain care by child and parents Children exaggerating their pain scores Children complaining of pain when their behaviors do not indicate that they are in pain Parent/child not informing the nursing staff when the child is in pain Parents interfering and answering for their child Parents encouraging their child to have pain medication when they had not asked for it Child/parent refusing pain medication
Organizational Factors Lack of time and a heavy workload Staff shortages Insufficient supply of some medication Lack of age-appropriate pain assessment tools* Not having a flowchart of pain medications* Lack of equipment to distract children Play therapists not always available
*Note that the hospital’s guidelines for managing pain in children included recommended pain assessment tools for all ages of children and an analgesic algorithm.
home. This included the times the pain medications were last given and when they could have the next dose, as well as an explanation about how the medication works. Parents were also informed about the time and frequency that pain medications could be given and advised to give pain medications regularly. Parents were advised about the correct dosage for their child’s age and any relevant precautions—e.g., eat before or after—as well as the side effects of the pain medications. Nurses indicated that parents were given verbal information about nonpharmacologic methods of pain relief, including distraction and trying to ensure their child was in the most comfortable position. Nurses gave differing advice about what to do if the medication did not work or the child had an allergic reaction to it (e.g., go to your general practitioner, return to the accident and emergency department, or meet with the community nursing team). Child and Parent Involvement in Pain Management Regarding parents’ involvement in their child’s pain management, the nurses indicated that parents often recognize their child’s pain and know what medication works best for their child. Nurses felt that parents
usually know their own child’s pain threshold, can report any change, and assess pain more promptly because they are with the child. The nurses thought that parents should inform the nursing staff when their child was in pain, and that parents should assist nurses in managing their child’s pain and encourage compliance with staff. Parents were also seen to have a role in distracting their child from their pain through comforting them, playing, watching TV, and talking with their child. However, nurses also felt that parents encouraged children to have pain medication even if the child had not asked for it: ‘‘Parents always come first to ask for analgesia.’’ When asked what involvement children have in their pain management, the nurses indicated that children should recognize when they are in pain, verbalize this when symptoms begin, and ask for pain medications when they need them. Nurses also thought children could suggest to staff what could be done to help them when they are in pain, and could engage in play therapy. Barriers to Assessing and Managing Pain Effectively Responses as to whether there was anything that currently stops nurses from assessing and managing pain
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TABLE 3. Things that Nurses Felt Would Help Them to Assess and Manage Pain Better Factors Relating to Staff Nurses: Using pain assessment tools Reassessment of pain after administration of pain medications Taking a patient history Having more time Teaching for nurses Doctors: Doctors writing the correct prescriptions for pain medications
Factors Relating to Child and Parents Children and parents verbalizing their concerns about pain Parents informing the nurses when their child is in pain Parental involvement in pain care
as well as they would like fell into three categories: issues relating to child and parents, nursing and medical staff, and organizational factors (Table 2).
Things That Would Help Nurses Assess and Manage Pain More Effectively The things that nurses felt would help them to assess and manage pain better again fell into three categories relating to child and parents, nursing and medical staff, and organizational factors. These are outlined in Table 3.
The Usefulness of the Hospital’s Clinical Guidelines Nurses were asked how useful the hospital’s clinical guidelines and algorithm (an analgesia flowchart) were in supporting their decision making about pain management. Nurses indicated that these were very useful in convincing junior doctors about the correct/maximum doses of pain medication as well as being a good learning tool for students and junior doctors/new staff. The algorithm was thought to work well, although one group commented that it was simplistic. To explore whether the hospital’s guidelines and algorithm were used to support decision making, nurses were asked to comment on the resources available to support them in this context. Responses included the use of assessment tools such as the Wong-Baker faces pain scale and the Pediatric Early Warning Score (PEWS) chart. The algorithm was seen as helpful, as was the pain team. The use of pain plans (e.g., for procedural pain) was also seen as a way to guide decision making.
Organizational Factors
Better assessment tools An improved scoring system Improved staffing levels Preprinted prescription charts Having a preoperative questionnaire for parents Availability of equipment for distraction, e.g., dolls, teddies Increased availability of a play therapist (child life worker)
DISCUSSION Nurses described using appropriate strategies to assess and manage children’s pain using a range of pain assessment tools as well as pharmacologic and nonpharmacologic interventions. Parents appeared to be given detailed information about how to assess and manage their child’s pain after discharge from hospital. However, the observational data collected in the hospital at the same time indicates that these pain management practices were not used consistently (Twycross & Collis, 2010). A similar incongruence between actual and reported practices has been seen in other studies (Jacob & Puntillo, 1999; Salantera, Lauri, Salmi, & Aantaa, 1999b; Twycross, 2004). It is noteworthy that participants felt that using pain assessment tools, reassessing pain, and taking a patient history were factors that would help them manage pain more effectively. Nurses may, therefore, know what they should be doing but not be using this knowledge in practice. This reflects the findings of Twycross (2007b), who found no positive relationship between nurses’ level of knowledge and how well they actually managed pain. The impact of organizational culture on practice has been suggested as an explanation for such discrepancies as was clearly demonstrated by the results of Lauzon Clabo’s (2008) study. This needs exploring further. Data collected pertaining to nurses’ perceptions of children’s and parents’ role in pain management suggest that participants do not consider it to be their role to be proactive in managing pediatric pain. Nurses appeared, for example, to expect the child and/or parent to inform them when they are in pain. This is similar to the findings of Woodgate and Kristjanson (1996), who found that nurses tended to concentrate on the
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technical aspects of care and considered pain management to be the parents’ role. Simons, Franck, and Roberson (2001) also found that nurses expected parents to tell them if their child was in pain. However, neither of these studies found evidence that nurses negotiated with parents about this role or even communicated with them about their expectations. Indeed, Twycross (2007a) found that nurses rarely initiated discussion with parents about their child’s pain; communication about pain was usually instigated by parents. Furthermore, Simons et al. (2001) found that parents were reluctant to ask for more information about their child’s pain management in case this might be perceived as challenging the clinical judgment of the nurses. This was the case even if parents felt that their child’s pain was not being managed effectively. Earlier research has also suggested that children do not always feel able to tell nurses that they are in pain and would like to be asked about their pain on an hourly basis (Polkki, Pietila, & Vehvilamen-Julkunen, 2003). There appears to be a need for nurses to become more proactive in managing pain and to ensure that they communicate effectively with the child and the parent. Several barriers to effective pain management were described by the participants in the present study (Table 2). These fall into the categories described by the IASP (2010) of factors relating to the staff, the child and parent, and the organization. Nurses’ personal judgments, preconceived ideas, and assumptions were seen as a barrier to the effective assessment and management of pain. This concurs with the findings of other studies (Byrne et al., 2001; Twycross, 1999; van Hulle Vincent, 2005) and is worthy of further exploration. Nurses also identified deficits in knowledge as a barrier to managing pain effectively. They felt that they lacked general knowledge about pain management and specific knowledge about pharmacologic interventions. They also felt that they had insufficient knowledge about patient-controlled analgesia and indicated that they were scared of overdosing a child on pain medication. This concurs with the findings of several other studies, which all found gaps in nurses’ knowledge about pediatric pain (Manworren, 2000; Rieman & Gordan, 2007; Salantera et al., 1999a; Salantera & Lauri, 2000; Twycross, 2004; van Hulle Vincent, 2005). There is a need to ascertain exactly where nurses’ knowledge deficits lie so that strategies can be put in place to address them. Nurses in the present study also suggested that medical staff needed educating about managing pediatric pain. This may be due in part to the fact the hospital is a district general (community) hospital, and therefore, not all medical staff caring for children are
specialized in pediatrics. Few studies have examined medical staff’s knowledge about pediatric pain. However, a recent study suggests that there are gaps in knowledge similar to those identified with nurses (Saroyan, Schechter, Tresgallo, Sun, Naqvi, & Graham, 2008). Nurses also felt that they needed to doublecheck doctors’ prescriptions to ensure that children had appropriate pain medications written up as well as having to spend time checking the doses prescribed. This could suggest that doctors do not prioritize the management of pediatric pain, and it perhaps adds to the argument that medical staff have knowledge deficits about pediatric pain. However, it is interesting, given that the hospital’s clinical guidelines include an algorithm which details the required doses of pain medications. However, it is noteworthy that observational data collected as part of the overall project indicated that when needed, pain medication had been prescribed as per the hospital’s guideline (Twycross & Collis, 2010). It is possible that this does not occur consistently. Participants in this study identified several barriers that related to the child and parent (Table 2). They suggested that parents made requests for pain medications to be administered when the child’s behavior did not appear to indicate they were in pain. This is similar to the findings of other studies (Gimbler-Berglund et al., 2008; Simons et al., 2001). However, we have known for more than two decades that there is often a dissonance between children’s self-report of pain and their behavior (Beyer, McGrath, & Berde, 1990; Stein, 1995). Nurses appear not to be aware of this. Children and parents not informing nurses when they/their child is in pain was also seen as a barrier, as was parents’ tendency to exaggerate their child’s pain. However, several studies have suggested that there is limited communication between children, parents, and nurses about pain management (Twycross, 2007a; Twycross & Collis, 2010). Paradoxically, nurses appear to see parents as being responsible for alerting them if their child is in pain but do not communicate this to the parents, and do not always believe the parents when they tell them that their child requires pain medications. Another barrier reported by nurses in this study was children and their parents refusing pain medications when they were offered. This is similar to findings of other studies (Czarnecki et al., 2011; Ely, 2001; van Hulle Vincent, 2005). Worryingly, there appears to be a perception among participants in the present study that parents should ensure that their child complies with what the nurses suggest is an appropriate way to manage their pain. This concurs with the findings of Byrne et al. (2001), who found that children in
Pediatric Pain Management: Barriers and Facilitators
pain were expected to conform to what the nurse said and to comply with a set of behavioral milestones. Further research is needed to explore the interactions between children, parents, and nurses in this context. However, nurses may need to reconsider their role in pain management. Participants reported that a lack of time, a heavy workload, and a lack of staff were barriers to optimal pain management. A lack of time has been identified as a barrier to effective pain management in several other studies (Czarnecki et al., 2011; GimblerBerglund et al., 2008; van Hulle Vincent, 2005). These findings could add weight to the argument that nurses do not see the need to proactively manage pain, because Twycross (2004) found that even when the ward was relatively quiet and nurses had only one or two patients to care for, pain was not managed effectively. That pain management is not seen as a priority by nurses is supported by the findings of Twycross (1999). Nurses reported that sometimes there was an insufficient supply of some medication. It is worth noting that observational data collected in parallel with the focus groups did not find any evidence that this was the case (Twycross & Collis, 2010). However, the observational data were collected on the wards, and these issues may relate to other areas, such as the pediatric emergency department. This issue needs exploring in more depth at a local level. Another barrier listed by the participants is the need for age-appropriate pain assessment tools. Interestingly, there are three different recommended pain assessment tools listed in the hospital’s clinical guidelines (Wong and Baker faces scale, NRS, and FLACC). However, only the Wong-Baker faces scale is included in the nursing paperwork. The nurses may be unaware that other tools are available. There is a need to make sure that all three pain assessment tools are accessible. Alternatively, the nurses may not be aware of the clinical guidelines or feel that they do not meet their needs. Furthermore, evidence suggests that just having clinical guidelines available does not mean that practice will conform to them (Grimshaw, Eccles, & Tetro, 2004). This needs further consideration at a local
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level. Nurses also stated that they would like a flowchart of pain medications; again, this is available as part of the hospital’s clinical guidelines. This lends support to the conjecture that nurses may not be aware of the clinical guidelines. Study Limitations There are several limitations of the data presented in this paper. The style of the focus groups meant it was not possible to probe responses to explore what was meant in depth. An example of this is that despite participants being asked about both barriers and facilitators to effective pain management, the data collected related primarily to barriers. However, the findings of this study concur with those of earlier studies in this area and provide insight into what nurses see as the barriers to effective pain management in children. The data also provide some clear directions for changes in practice, such as making the pain assessment tools more accessible.
CONCLUSION Participants identified a number of barriers, which related to the staff, children and parents, and the organization. A paradox appears to exist in that nurses see parents as being responsible for many aspects of their child’s pain management but do not communicate this to the parents nor always believe parents when they suggest that their child requires pain medication. This needs exploring further, but nurses may need to become more proactive in managing pediatric pain. The results presented in this paper suggest that there may be some knowledge deficits among nurses and medical staff about pediatric pain management. These need exploring further. There is also a need to identify strategies to ensure that staff are aware of the hospital’s clinical guidelines and use them in practice, as well as to examine the impact of organizational culture on practice further. This study provides evidence about nurses’ perceptions regarding barriers to assessing and managing pain effectively and indicates areas for improvements in practice and further research.
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