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Orthopaedic paediatric practice: An impression of pain assessment
O R I G I N A L
A R T I C L E
Orthopaedic paediatric practice: An impression of pain assessment Sonya Clarke Innovations within pain management should ensure that pain from orthopaedic surgery is minimal but ineffective pain assessment leads to unnecessary pain for children. This article identifies issues raised by the literature that affect the pain assessment process: the nurse and parent’s ability to assess pain accurately, the pain tool used and the child’s vocalisation of their pain. The review has identified gaps in the available literature, makes recommendations for future research that will build on the current results and thereby influence future practice. c 2003 Elsevier Science Ltd. All rights reserved.
Editor’s comment This article looks specifically at the literature related to paediatric pain assessment, identifying issues that need considering to ensure an evidence-based approach to assessment is used. There are lessons here for all involved in pain assessment and many of the issues raised, including the reliability of assessment tools and patient’s vocalisation of pain, are as relevant in adult as paediatric care. PD
KEY WORDS: paediatrics, orthopaedics, pain assessment, evidence-based care
INTRODUCTION
Sonya Clarke RGN, RN(child branch), BSc(Hons), PGCert Lecturer Practitioner, Orthopaedic Nursing, Queens University Belfast, Belfast, UK. Correspondence to: Sonya Clarke Lecturer Practitioner, Orthopaedic Nursing, School of Nursing and Midwifery, Queens University Belfast, 50 Elmwood Avenue, Belfast BT9 6AX, UK. Tel.: +44-2890-272048; E-mail: [email protected]
Every child admitted for orthopaedic surgery has the right to a pain free post-operative recovery period. The assessment of the child’s pain is essential to ensure the correct analgesia are prescribed and administered as ineffective pain assessment will cause unrelieved pain following orthopaedic surgery. The validity and reliability of an assessment tool are vital for ensuring that the tool will enable effective and consistently accurate measurement of pain. Questions have been raised about the validity and reliability of a nurse’s ability to accurately assess a patient’s pain following orthopaedic surgery (Field 1996, Rundshagen et al. 1999). Aspects of validity within pain assessment are the clinician’s ability to measure the intensity of a child’s pain, while reliability refers to a consistent measurement of pain intensity. Such reliability would also involve the nurse’s ability to achieve a consistent measurement of pain intensity from one pain assessment occasion to the next. These are tested through
Journal of Orthopaedic Nursing (2003) 7, 132–136 doi:10.1016/S1361-3111(03)00055-4
C
2003 Elsevier Science Ltd. All rights reserved.
repeated evaluation using the assessment tools (Chambers et al. 1999, Finley & McGrath 1998, Wong & Baker 1988). However, most of the research following orthopaedic surgery is carried out using adult patients rather than children. This article discusses how effective nurses are in carrying out pain assessment, the implications of parents’ assessment of their child’s pain, the influence of child orientated pain assessment tools and the involvement of children in the pain assessment.
PAIN ASSESSMENT Orthopaedic surgery is a known cause of severe pain (Goodarzi et al. 1993). Despite medical research providing an understanding of the mechanisms of pain, the anatomy of dermatones and the physiology of nerves, the actual experience of pain cannot be described (Schuyler 2000). An accurate assessment of pain in adults following orthopaedic surgery is “difficult, as pain is a highly subjective and personal experience”
Orthopaedic paediatric practice 133
(Rundshagen et al. 1999 p374). The same can be said of children’s pain assessment. Taylor (2000) suggests that as children differ from adults anatomically and physiologically age is a relevant factor in assessment, consequently children must not be categorised as small adults. Hamers et al. (1996) supports this by stating that assessing a child’s pain is complex, especially in young or cognitively impaired children. The assessment of pain is therefore a difficult but vital part of paediatric practice (Bulloch & Tenenbein 2002) as it provides an information base from which to provide effective pain management (Carter 1994, McGrath et al. 1995, Simons et al. 2001).
ASSESSING CHILDREN’S PAIN The Department of Health reports relating to paediatric care (DOH 1991, DOH 1996a,b) recognise the complexity of nursing children and acknowledge the need for specialist knowledge and skills. Additionally the Royal College of Nursing (Doorbar & McClarey 1999) guidelines enable paediatric nurses to better recognise and assess pain in children. Despite these documents several studies (Juhl et al. 1993, Klopenstein et al. 2000) suggest that health care professionals’ knowledge of pain assessment is inadequate with the under assessment of pain being a major contributory factor in ineffective pain management. Ideally, parents and nurses should be able to give an impartial and objective assessment of a child’s pain; however, aspects of a subjective assessment can counteract their objectivity. Twycross et al. (1998) suggests certain indicators impact on a subjective pain assessment. The negative influences include previous experiences of hospitalisation and surgery, the level of pain tolerance, the patient’s anxiety level, and the preparation for surgery. In addition, the nurse’s experience of pain management, their values and beliefs are factors that affect their impartiality in pain assessment. Current literature implies that nurses do not accurately assess patient’s pain following surgery. Rundshagen et al. (1999), Julh et al. (1993) and Smith (1989) all report adult patients continually score their pain higher in comparison to nurses’ scores for their pain. These findings correlate with Twycross et al. (1998) and Cummings et al. (1996) who compared children’s pain scores to nurses’ assessments of their pain, again the nurses underestimated the levels of the children’s pain. There appears to be no research comparing the pain assessment scores of children with assessments done by their parents and nurses
following orthopaedic surgery specifically. Such a study would provide evidence of the effectiveness of nurses and parents roles in pain assessment. By evaluating such research and the available literature (Rush & Harr 2001), an evidence-based approach to practice should be achievable.
IMPRESSIONS FROM THE LITERATURE To gain an impression of the literature on paediatric pain assessment, a search for research articles was carried out using the terms paediatric, orthopaedic, pain and nurse on the Medline (1966-present), Cinahl (1982-July 1999), Cochrane database of systematic reviews and the British Nursing Index databases, this elicited 46 relevant English language publications. In addition, the reference lists of these articles and relevant reports were searched. From these the following themes were highlighted for discussion: pain assessment, paediatric pain assessment, assessment tools and the impact of children’s vocalisation of their pain.
Pain assessment Field (1996) reported that nurses underestimated the severity of adult patient’s pain, leading to ineffective pain management. This empirical study demonstrated the inadequacy of pain assessment tools and their under use by practitioners as the main factors in poor pain management. More recently Klopenstein et al.’s (2000) survey of adult patients (n ¼ 42) and nurses (n ¼ 8) found nurses inadequately assessed pain, citing inadequate pain management training as a contributory issue. Rundshagen et al. (1999) carried out a comparative study and reported lower scores by the nurses in comparison to the adult patients. As these studies used adult patients the results need to be considered in relation to whether the same effects will be found in paediatric care. The reviewed studies show limitations in research focus, the sample groups and sizes, study methodology and the ability for the results to be generalised. Available studies report an improvement in pain assessment and management, when nurse education in this area is increased (Boonstra et al. 1992 cited in Hamers et al. 1996). Mackrodt and White (2001) suggest that nurses’ knowledge of pain was derisory, although the study on which this comment is based was limited by a small sample size. The above studies demonstrate the need for appropriate pain assessment tools to be used, particularly in orthopaedic nursing (Colwell
134
Journal of Orthopaedic Nursing
et al. 1996). As pain assessment is inadequate for adults, the additional vulnerability of children (Hamers et al. 1996) will make their pain assessment even more important to get right.
Paediatric pain assessment Harp (2002) reports a desirable correlation between the assessment of pain by the nurse and parent compared to the child. In contrast, Boonstra et al. (1992), (cited by Hamers et al. 1996) and Juhl et al. (1993) imply both nurses and parents are unable to consistently and correctly, assess a child’s pain in comparison to the child’s ‘self-report’ of their pain. Finlay et al. (1996) found that when parents were assessing their child’s pain, it led to the child receiving inadequate analgesia. Subsequently Chambers et al. (1998) found that parent’s underestimation of their child’s pain leads to inadequate pain control. Simons et al.’s (2001) results found that the level of parental involvement was superficial, passive and limited in the management of their child’s pain. This is a contributing factor in the underestimation of the child’s pain and analgesia needs. Manne et al. (1992) adds to the proposition by suggesting parents are influenced by subjective factors in the assessment of their child’s pain, while nurses are more objective than the parents in a child’s pain assessment. Alternative views on parental involvement in pain assessment demonstrate that parents’ ratings are more accurate than those given by a nurse leading to improved effectiveness of pain management when parents are involved (Craig et al. 1996, Jylli & Olsson 1995). Morgan et al. (2001) found parents were able to assess pain more objectively in younger children (aged 1–5 years) following surgery despite Hamers et al.’s (1996) view that pain assessment in this age group is more complex. Simons et al. (2001) and Morgan et al. (2001) identified a clear need for nurses to discuss parental involvement and negotiate roles in relation to pain assessment. Simons et al. (2001) advocated taking a family centred approach to pain assessment, which supports the benefits seen in other aspects of paediatric care (Guy 2001). The literature consistently agrees that nurses underestimate children’s pain, but there are different views on the ability of parents to assess their child’s pain accurately.
Pain assessment tools Optimal and accurate pain assessment is in part dependent on the use of standardised pain assessment tools of which there are a diversity of scales available for use with children in acute pain. The ideal or gold standard tool should in-
clude a self-report of pain by the child. McGrath et al. (1995), Twycross et al. (1998), Chambers et al. (1998) and Wolfe (2002) have researched the use of self-reporting in pain assessment. Finley & McGrath (1998) report there to be more than 40 published pain assessment tools available for use with children. A high rate of reliability and validity is essential for any assessment tool that is going to be effective. The tool should be simple and easy to use for the nurse, parent and child. Any scoring system should be quick, not be labour intensive and demonstrate elements of simplicity and clarity (Wolfe 2002) for patient understanding no matter what their age or level of formal education. Eland and Coy (1990) and McGrath et al. (1995) suggest children from the age of two are able to report pain, however, it is not until they are four to five years of age that they can use a standardised measurement tool effectively. Wong and Baker’s (1988) face rating scale is established as valid and reliable (Hicks et al. 2001, Hunter et al. 2000). However, Chambers et al. (1999) surmised that variations in the faces used could influence a child and parent’s ratings of pain thus affecting the reliability and validity of a face rating scale. Chambers et al. found evidence of bias when smiling faces were used rather than the neutral ‘no pain’ face. Although Wong and Baker’s study provides evidence to support the use of an appropriate pain scale within paediatric practice, the faces used need to be considered in relation to any potential bias that may appear. The smiling faces scale is widely used in practice within Northern Ireland, as children appear to assess their pain more reliably as they associate a smiling face with having no pain. Bijur et al. (2001) suggests a visual analogue scale (VAS) is sufficiently reliable for the assessment of orthopaedic pain. Paul-Dauphin et al. (1999) suggest that researchers should attempt to reach a consensus on what type of VAS to use, this would help in comparing research studies using a VAS and for practice to have a comparable common tool for paediatric pain measurement (Hicks et al. 2001). McGrath et al. (1995), Field (1996), Twycross et al. (1998) and Hicks et al. (2001) advocate the use of a visual analogue scale for children with a 10 cm ruler line where 0 at one end represents ‘no pain’ and 10 at the other end represents the ‘worst possible pain’. This is a commonly used throughout the world because it is reliable and valid (Field 1996, Hicks et al. 2001, McGrath et al. 1995, Twycross et al. 1998). Hicks et al. (2001) found that a combination of the child friendly, linear interval Wong-Baker faces scale with a widely used numerical scoring system (0–10 scale) was straightforward and simple to use. This version is appropriate for
Orthopaedic paediatric practice 135
children of four or five years who are in acute pain. Wong and Baker (1988) compared six pain assessment scales for their validly and reliability on a convenience sample of 150 children aged three to eighteen years. Subjects reported 116 painful events (77 procedures and 39 bodily symptoms). The average number of total painful events was three per child. Orthopaedic conditions were associated with a higher average number of painful events (3.8); this correlates with Goodarzi et al.’s (1993) suggestion of orthopaedic pain being severe. The validity of each tool was determined by comparing the consistency between the rankings of the listed procedures with the pain rating. The most preferred scale for all children was the face rating scale followed by colours, chips, numeric and simple descriptive scales. With the colour coded scales, orange represented no pain, while black signified severe pain. The results showed no gender differences. The reliability for all scales increased in the three to twelve year age bracket. The decrease in reported pain with age correlates with Taylor (2000) who suggests that children are different from adults but contradicts Lloyd-Thomas (1999) who suggests age is an irrelevant factor with pain. This suggests that all children experience pain but their age may be a variable relating to how they vocalise, describe and report their pain, factors of particular relevance in the care of young or neurologically impaired children.
Vocalisation of pain Research by Hamers et al. (1996) reviewed the influence of vocalisation in children. Hamers et al. completed a randomised controlled trial the preferred scientific method for equalising groups and avoiding systematic bias. Polit and Hungler (1999) however, state that this design is not absolute, as there is no guarantee that the groups will be equal. The trial involved giving a sample of paediatric nurses four vignettes, their pain assessments and decisions regarding interventions were then analysed. The findings suggest nurses attribute more pain to children who are vocally expressive as they considered vocal expression to be a reliable and valid cue for the diagnosis of pain. The nurses were more ready to carry out pain assessments on a vocal child, compared to a non-vocal child in equal pain, which supports earlier studies by Wallace (1989) and Hamers et al. (1994). The child’s age did not have an effect on the nurses’ decision-making or their accessing information from parents. As vocalisation appears to be a variable in pain assessment, it must be considered in future comparative pain studies. Any new data on vocalisation would add to the body of knowledge.
CONCLUSION AND RECOMMENDATIONS The reviewed literature identified a number of relevant studies, using various methods, sample groups, clinical areas and pain scales. The literature though is inconclusive in relation to several areas of pain assessment practice, which correlates with Chambers et al.’s (1998) review of child and parent reports of pain, which produced conflicting results. The literature on pain assessment proved inconclusive and that there is a lack of specific data on pain assessment in paediatric orthopaedics. Evidence by Klopfenstein et al. (2000) exposes nurses’ deficits in accurately assessing pain, raising the concern that pain assessment by parents and children following orthopaedic surgery may well not be effective in practice. This indicates the need for further research to clearly identify and address the issues raised, particularly in determining if parents and nurses correctly estimate a child’s pain following orthopaedic surgery and the impact of children’s vocalisation of their pain on the assessment process. The literature pertaining to pain assessment tools demonstrates evidence of their validity and reliability to practice. Additional evidence of their quality and patient outcomes needs addressing in relation to parent and nurse comparisons of assessment and the child’s vocalisation of pain. This would add to current knowledge by providing appropriate evidence on which to base practice. REFERENCES Bijur PE, Silver W, Gallergaher EJ (2001) Reliability of the visual analogue scale for measurement of acute pain. Academic Emergency Medicine 8(12): 1153–1157 Boonstra LC, Teule JA, Kastermans M, Dassen TH (1992) Pain assessment in children, an investigation of children in pain caused by medical illness and pain. Verpleegkunde 7: 147–151. Cited in: Hamers JPH, Adu-Saad HH, Van den Hout MA, Halfens RJG, Kester ADM (1996) The influence of children’s vocal expressions, age, medical diagnosis and information obtained from parents on nurses’ pain assessments and decisions regarding interventions. Pain 65: 53–61 Bulloch B, Tenenbein M (2002) Assessment of clinically significant changes in acute pain in children. Academic Emergency Medicine: Official Journal of the Society for Emergency Medicine 9(3): 199–202 Carter B (1994) Pain in infants and children. Chapman and Hall, London Chambers CT, Reid GJ, Craig KD, McGrath PJ, Finley GA (1998) Agreement between child and parent reports of pain. Clinical Journal of Pain 14(4): 336–342 Chambers CT, Giesbrecht K, Craig KD, Bennett SM, Hunysman E (1999) A comparison of faces scales for the measurement of paediatric pain: children’s and parents’ ratings. Pain 83(1): 25–35
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Colwell C, Clark L, Perkins R (1996) Postoperative use of paediatric pain scales: children self-report versus nurse’s assessment of pain intensity and affect. Journal of Paediatric Nursing 11(6): 375–382 Craig KD, Lilley CM, Gilbert CA (1996) Social barriers to optimal pain management in infants and children. The Clinical Journal of Pain 12: 232–740 Cummings E, Reid GJ, Finley A (1996) Prevalence and source of pain in paediatric inpatient. Pain 68: 25–31 Department of Health (1991) The children’s Charter. H.M.S.O., London Department of Health (1996a) Children Order (N.I.). H.M.S.O., Belfast Department of Health (1996b) The Clothier Report. H.M.S.O., London Doorbar P, McClarey M (1999) Ouch! Sort it out. Children’s experiences of pain: report of a qualitative study of children’s experiences of pain. Royal College of Nursing Institute and Action for Sick Children. H.M.S.O., London Eland J, Coy J (1990) Assessing pain in the critically ill child. Focus on Critical Care 17(6): 469–475 Field L (1996) Are nurses still underestimating patients’ pain postoperatively? British Journal of Nursing 5(3): 778–784 Finley GA, McGrath PJ, Forward SP (1996) Parents’ management of children’s pain following minor surgery. Pain 64: 83–87 Finley GA, McGrath PJ (1998) Measurement of pain in infants and children. IASP Press, Seattle Goodarzi M, Shier N, Ogden JA (1993) Epidural versus patient-controlled analgesia with morphine for postoperative pain after orthopaedic procedures in children. Journal of Paediatric Orthopaedics 13(5): 663–667 Guy I (2001) Relationship-centred care: what’s in a name? British Journal of Nursing 10(16): 1026 Hamers JPH, Abu-Saad HH, Van den Hout MA, Halfens RJG, Kester ADM (1996) The influence of children’s vocal expressions, age, medical diagnosis and information obtained from parents on nurses’ pain assessments and decisions regarding interventions. Pain 65: 53–61 Hamers JPH, Huijer Abu-Saad H, Halfens RJG, Schumacher JNM (1994) Factors influencing nurses’ pain assessment and interventions. Journal of Advanced Nursing 6: 853–860 Harp S (2002) Paediatric pain assessment. Arkansas Children’s Hospital. Division of paediatric Anaesthesia pain management 1-3 Available from: http://www.uams.edu/anaesthesiology/painslide/ sld001.htm Hicks CL, Von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B (2001) The faces pain scale-revised: toward a common metric in paediatric pain measurement. Pain 93(2): 173–183 Hunter M, McDowell L, Hennessy R, Cassey J (2000) An evaluation of the Faces Scale with young children. Journal of Pain and Symptom Management 20(2): 122–129 Jylli L, Ollson GL (1995) Procedural pain in a paediatric surgical emergency unit. Acta Paediatrica 84: 1403–1408
Juhl LH, Christensen BV, Bulow HH (1993) Postoperative pain relief, from the patients and nurses point of view. Acta Anaesthesiology Scandinavicia 37: 404–409 Klopfenstein CE, Herrmann FR, Marinie C, Gessel EV, Forster A (2000) Pain intensity and pain relief after surgery: a comparison between patients’ reported assessments and nurses’ and physicians’. Acta Anaesthesia Scandinavica 44: 58–62 LLyod-Thomas AR (1999) Modern concepts of paediatric analgesia. Pharmacology and Therapeutics 83: 1–20 McGrath PJ, Unruh AM, Finley AG (1995) Pain measurement in children. Pain Clinical Updates: International Association for the Study of Pain 3(2): 23–25 Mackrodt K, White M (2001) Nurses’ knowledge within the context of pain management. Journal of Orthopaedic Nursing 5(1): 15–21 Manne SL, Jacobsen PB, Redd WH (1992) Assessment of acute paediatric pain: do child self report, parent ratings and nurse ratings measure the same phenomenon. Pain 48: 45–52 Morgan J, Peden V, Bhaskar K, Vater M, Choonara I (2001) Assessment of pain by parents in young children following surgery. Paediatric Anaesthesia 11(4): 449–452 Paul-Dauphin A, Guillemin F, Viron JM, Briancon S (1999) Bias and precision in visual analogue scales: a randomised controlled trial. American Journal of Epidemiology 150(10): 1117–1127 Polit DF, Hungler BP (1999) Nursing research principles and methods. Lippincott Williams and Wilkins, Philadelphia Rundshagen I, Schnabel K, Stand T, Schulte AM, Esche J (1999) Patients’ vs. nurses’ assessments of postoperative pain and anxiety during patient-ornurse controlled analgesia. British Journal of Anaesthesia 82(3): 374–378 Rush SL, Harr J (2001) Evidence-based paediatric nursing: does it have to hurt? AACN Clinical Issues 12(4): 597–605 Schuyler W (2000) The unnatural nature of pain. Journal of the American Medical Association (JAMA) 283(1): 117, Available from: http://biomed.niss.ac.uk/ ovidweb/ovidweb.cgi Simons J, Frank L, Robertson E (2001) Parent involvement children’s pain care: views of parents and nurses. Journal of Advanced Nursing 36(4): 591–599 Smith G (1989) Management of Postoperative pain. Canadian Journal Anaesthesia 36: S1–S4 Taylor R (2000) The challenges of regional anaesthesia. Unpublished document, Royal Belfast for Sick Children, Belfast Twycross A, Mortiarty A, Betts T (1998) Paediatric pain management: a multidisciplinary approach. Radcliffe Medical Press Ltd, Oxford Wallace MR (1989) Temperament: a variable in children’s pain management. Paediatric Nursing 15: 118–121 Wolfe G (2002) Pain: obtaining and using pain assessment tools. Mason Medical Communications Available from: http://www.jcaremanagement.com/html/pain Wong D, Baker C (1988) Pain in children: comparison of pain assessment scales. Paediatric Nursing 14(1): 9–17
A R T I C L E
Orthopaedic paediatric practice: An impression of pain assessment Sonya Clarke Innovations within pain management should ensure that pain from orthopaedic surgery is minimal but ineffective pain assessment leads to unnecessary pain for children. This article identifies issues raised by the literature that affect the pain assessment process: the nurse and parent’s ability to assess pain accurately, the pain tool used and the child’s vocalisation of their pain. The review has identified gaps in the available literature, makes recommendations for future research that will build on the current results and thereby influence future practice. c 2003 Elsevier Science Ltd. All rights reserved.
Editor’s comment This article looks specifically at the literature related to paediatric pain assessment, identifying issues that need considering to ensure an evidence-based approach to assessment is used. There are lessons here for all involved in pain assessment and many of the issues raised, including the reliability of assessment tools and patient’s vocalisation of pain, are as relevant in adult as paediatric care. PD
KEY WORDS: paediatrics, orthopaedics, pain assessment, evidence-based care
INTRODUCTION
Sonya Clarke RGN, RN(child branch), BSc(Hons), PGCert Lecturer Practitioner, Orthopaedic Nursing, Queens University Belfast, Belfast, UK. Correspondence to: Sonya Clarke Lecturer Practitioner, Orthopaedic Nursing, School of Nursing and Midwifery, Queens University Belfast, 50 Elmwood Avenue, Belfast BT9 6AX, UK. Tel.: +44-2890-272048; E-mail: [email protected]
Every child admitted for orthopaedic surgery has the right to a pain free post-operative recovery period. The assessment of the child’s pain is essential to ensure the correct analgesia are prescribed and administered as ineffective pain assessment will cause unrelieved pain following orthopaedic surgery. The validity and reliability of an assessment tool are vital for ensuring that the tool will enable effective and consistently accurate measurement of pain. Questions have been raised about the validity and reliability of a nurse’s ability to accurately assess a patient’s pain following orthopaedic surgery (Field 1996, Rundshagen et al. 1999). Aspects of validity within pain assessment are the clinician’s ability to measure the intensity of a child’s pain, while reliability refers to a consistent measurement of pain intensity. Such reliability would also involve the nurse’s ability to achieve a consistent measurement of pain intensity from one pain assessment occasion to the next. These are tested through
Journal of Orthopaedic Nursing (2003) 7, 132–136 doi:10.1016/S1361-3111(03)00055-4
C
2003 Elsevier Science Ltd. All rights reserved.
repeated evaluation using the assessment tools (Chambers et al. 1999, Finley & McGrath 1998, Wong & Baker 1988). However, most of the research following orthopaedic surgery is carried out using adult patients rather than children. This article discusses how effective nurses are in carrying out pain assessment, the implications of parents’ assessment of their child’s pain, the influence of child orientated pain assessment tools and the involvement of children in the pain assessment.
PAIN ASSESSMENT Orthopaedic surgery is a known cause of severe pain (Goodarzi et al. 1993). Despite medical research providing an understanding of the mechanisms of pain, the anatomy of dermatones and the physiology of nerves, the actual experience of pain cannot be described (Schuyler 2000). An accurate assessment of pain in adults following orthopaedic surgery is “difficult, as pain is a highly subjective and personal experience”
Orthopaedic paediatric practice 133
(Rundshagen et al. 1999 p374). The same can be said of children’s pain assessment. Taylor (2000) suggests that as children differ from adults anatomically and physiologically age is a relevant factor in assessment, consequently children must not be categorised as small adults. Hamers et al. (1996) supports this by stating that assessing a child’s pain is complex, especially in young or cognitively impaired children. The assessment of pain is therefore a difficult but vital part of paediatric practice (Bulloch & Tenenbein 2002) as it provides an information base from which to provide effective pain management (Carter 1994, McGrath et al. 1995, Simons et al. 2001).
ASSESSING CHILDREN’S PAIN The Department of Health reports relating to paediatric care (DOH 1991, DOH 1996a,b) recognise the complexity of nursing children and acknowledge the need for specialist knowledge and skills. Additionally the Royal College of Nursing (Doorbar & McClarey 1999) guidelines enable paediatric nurses to better recognise and assess pain in children. Despite these documents several studies (Juhl et al. 1993, Klopenstein et al. 2000) suggest that health care professionals’ knowledge of pain assessment is inadequate with the under assessment of pain being a major contributory factor in ineffective pain management. Ideally, parents and nurses should be able to give an impartial and objective assessment of a child’s pain; however, aspects of a subjective assessment can counteract their objectivity. Twycross et al. (1998) suggests certain indicators impact on a subjective pain assessment. The negative influences include previous experiences of hospitalisation and surgery, the level of pain tolerance, the patient’s anxiety level, and the preparation for surgery. In addition, the nurse’s experience of pain management, their values and beliefs are factors that affect their impartiality in pain assessment. Current literature implies that nurses do not accurately assess patient’s pain following surgery. Rundshagen et al. (1999), Julh et al. (1993) and Smith (1989) all report adult patients continually score their pain higher in comparison to nurses’ scores for their pain. These findings correlate with Twycross et al. (1998) and Cummings et al. (1996) who compared children’s pain scores to nurses’ assessments of their pain, again the nurses underestimated the levels of the children’s pain. There appears to be no research comparing the pain assessment scores of children with assessments done by their parents and nurses
following orthopaedic surgery specifically. Such a study would provide evidence of the effectiveness of nurses and parents roles in pain assessment. By evaluating such research and the available literature (Rush & Harr 2001), an evidence-based approach to practice should be achievable.
IMPRESSIONS FROM THE LITERATURE To gain an impression of the literature on paediatric pain assessment, a search for research articles was carried out using the terms paediatric, orthopaedic, pain and nurse on the Medline (1966-present), Cinahl (1982-July 1999), Cochrane database of systematic reviews and the British Nursing Index databases, this elicited 46 relevant English language publications. In addition, the reference lists of these articles and relevant reports were searched. From these the following themes were highlighted for discussion: pain assessment, paediatric pain assessment, assessment tools and the impact of children’s vocalisation of their pain.
Pain assessment Field (1996) reported that nurses underestimated the severity of adult patient’s pain, leading to ineffective pain management. This empirical study demonstrated the inadequacy of pain assessment tools and their under use by practitioners as the main factors in poor pain management. More recently Klopenstein et al.’s (2000) survey of adult patients (n ¼ 42) and nurses (n ¼ 8) found nurses inadequately assessed pain, citing inadequate pain management training as a contributory issue. Rundshagen et al. (1999) carried out a comparative study and reported lower scores by the nurses in comparison to the adult patients. As these studies used adult patients the results need to be considered in relation to whether the same effects will be found in paediatric care. The reviewed studies show limitations in research focus, the sample groups and sizes, study methodology and the ability for the results to be generalised. Available studies report an improvement in pain assessment and management, when nurse education in this area is increased (Boonstra et al. 1992 cited in Hamers et al. 1996). Mackrodt and White (2001) suggest that nurses’ knowledge of pain was derisory, although the study on which this comment is based was limited by a small sample size. The above studies demonstrate the need for appropriate pain assessment tools to be used, particularly in orthopaedic nursing (Colwell
134
Journal of Orthopaedic Nursing
et al. 1996). As pain assessment is inadequate for adults, the additional vulnerability of children (Hamers et al. 1996) will make their pain assessment even more important to get right.
Paediatric pain assessment Harp (2002) reports a desirable correlation between the assessment of pain by the nurse and parent compared to the child. In contrast, Boonstra et al. (1992), (cited by Hamers et al. 1996) and Juhl et al. (1993) imply both nurses and parents are unable to consistently and correctly, assess a child’s pain in comparison to the child’s ‘self-report’ of their pain. Finlay et al. (1996) found that when parents were assessing their child’s pain, it led to the child receiving inadequate analgesia. Subsequently Chambers et al. (1998) found that parent’s underestimation of their child’s pain leads to inadequate pain control. Simons et al.’s (2001) results found that the level of parental involvement was superficial, passive and limited in the management of their child’s pain. This is a contributing factor in the underestimation of the child’s pain and analgesia needs. Manne et al. (1992) adds to the proposition by suggesting parents are influenced by subjective factors in the assessment of their child’s pain, while nurses are more objective than the parents in a child’s pain assessment. Alternative views on parental involvement in pain assessment demonstrate that parents’ ratings are more accurate than those given by a nurse leading to improved effectiveness of pain management when parents are involved (Craig et al. 1996, Jylli & Olsson 1995). Morgan et al. (2001) found parents were able to assess pain more objectively in younger children (aged 1–5 years) following surgery despite Hamers et al.’s (1996) view that pain assessment in this age group is more complex. Simons et al. (2001) and Morgan et al. (2001) identified a clear need for nurses to discuss parental involvement and negotiate roles in relation to pain assessment. Simons et al. (2001) advocated taking a family centred approach to pain assessment, which supports the benefits seen in other aspects of paediatric care (Guy 2001). The literature consistently agrees that nurses underestimate children’s pain, but there are different views on the ability of parents to assess their child’s pain accurately.
Pain assessment tools Optimal and accurate pain assessment is in part dependent on the use of standardised pain assessment tools of which there are a diversity of scales available for use with children in acute pain. The ideal or gold standard tool should in-
clude a self-report of pain by the child. McGrath et al. (1995), Twycross et al. (1998), Chambers et al. (1998) and Wolfe (2002) have researched the use of self-reporting in pain assessment. Finley & McGrath (1998) report there to be more than 40 published pain assessment tools available for use with children. A high rate of reliability and validity is essential for any assessment tool that is going to be effective. The tool should be simple and easy to use for the nurse, parent and child. Any scoring system should be quick, not be labour intensive and demonstrate elements of simplicity and clarity (Wolfe 2002) for patient understanding no matter what their age or level of formal education. Eland and Coy (1990) and McGrath et al. (1995) suggest children from the age of two are able to report pain, however, it is not until they are four to five years of age that they can use a standardised measurement tool effectively. Wong and Baker’s (1988) face rating scale is established as valid and reliable (Hicks et al. 2001, Hunter et al. 2000). However, Chambers et al. (1999) surmised that variations in the faces used could influence a child and parent’s ratings of pain thus affecting the reliability and validity of a face rating scale. Chambers et al. found evidence of bias when smiling faces were used rather than the neutral ‘no pain’ face. Although Wong and Baker’s study provides evidence to support the use of an appropriate pain scale within paediatric practice, the faces used need to be considered in relation to any potential bias that may appear. The smiling faces scale is widely used in practice within Northern Ireland, as children appear to assess their pain more reliably as they associate a smiling face with having no pain. Bijur et al. (2001) suggests a visual analogue scale (VAS) is sufficiently reliable for the assessment of orthopaedic pain. Paul-Dauphin et al. (1999) suggest that researchers should attempt to reach a consensus on what type of VAS to use, this would help in comparing research studies using a VAS and for practice to have a comparable common tool for paediatric pain measurement (Hicks et al. 2001). McGrath et al. (1995), Field (1996), Twycross et al. (1998) and Hicks et al. (2001) advocate the use of a visual analogue scale for children with a 10 cm ruler line where 0 at one end represents ‘no pain’ and 10 at the other end represents the ‘worst possible pain’. This is a commonly used throughout the world because it is reliable and valid (Field 1996, Hicks et al. 2001, McGrath et al. 1995, Twycross et al. 1998). Hicks et al. (2001) found that a combination of the child friendly, linear interval Wong-Baker faces scale with a widely used numerical scoring system (0–10 scale) was straightforward and simple to use. This version is appropriate for
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children of four or five years who are in acute pain. Wong and Baker (1988) compared six pain assessment scales for their validly and reliability on a convenience sample of 150 children aged three to eighteen years. Subjects reported 116 painful events (77 procedures and 39 bodily symptoms). The average number of total painful events was three per child. Orthopaedic conditions were associated with a higher average number of painful events (3.8); this correlates with Goodarzi et al.’s (1993) suggestion of orthopaedic pain being severe. The validity of each tool was determined by comparing the consistency between the rankings of the listed procedures with the pain rating. The most preferred scale for all children was the face rating scale followed by colours, chips, numeric and simple descriptive scales. With the colour coded scales, orange represented no pain, while black signified severe pain. The results showed no gender differences. The reliability for all scales increased in the three to twelve year age bracket. The decrease in reported pain with age correlates with Taylor (2000) who suggests that children are different from adults but contradicts Lloyd-Thomas (1999) who suggests age is an irrelevant factor with pain. This suggests that all children experience pain but their age may be a variable relating to how they vocalise, describe and report their pain, factors of particular relevance in the care of young or neurologically impaired children.
Vocalisation of pain Research by Hamers et al. (1996) reviewed the influence of vocalisation in children. Hamers et al. completed a randomised controlled trial the preferred scientific method for equalising groups and avoiding systematic bias. Polit and Hungler (1999) however, state that this design is not absolute, as there is no guarantee that the groups will be equal. The trial involved giving a sample of paediatric nurses four vignettes, their pain assessments and decisions regarding interventions were then analysed. The findings suggest nurses attribute more pain to children who are vocally expressive as they considered vocal expression to be a reliable and valid cue for the diagnosis of pain. The nurses were more ready to carry out pain assessments on a vocal child, compared to a non-vocal child in equal pain, which supports earlier studies by Wallace (1989) and Hamers et al. (1994). The child’s age did not have an effect on the nurses’ decision-making or their accessing information from parents. As vocalisation appears to be a variable in pain assessment, it must be considered in future comparative pain studies. Any new data on vocalisation would add to the body of knowledge.
CONCLUSION AND RECOMMENDATIONS The reviewed literature identified a number of relevant studies, using various methods, sample groups, clinical areas and pain scales. The literature though is inconclusive in relation to several areas of pain assessment practice, which correlates with Chambers et al.’s (1998) review of child and parent reports of pain, which produced conflicting results. The literature on pain assessment proved inconclusive and that there is a lack of specific data on pain assessment in paediatric orthopaedics. Evidence by Klopfenstein et al. (2000) exposes nurses’ deficits in accurately assessing pain, raising the concern that pain assessment by parents and children following orthopaedic surgery may well not be effective in practice. This indicates the need for further research to clearly identify and address the issues raised, particularly in determining if parents and nurses correctly estimate a child’s pain following orthopaedic surgery and the impact of children’s vocalisation of their pain on the assessment process. The literature pertaining to pain assessment tools demonstrates evidence of their validity and reliability to practice. Additional evidence of their quality and patient outcomes needs addressing in relation to parent and nurse comparisons of assessment and the child’s vocalisation of pain. This would add to current knowledge by providing appropriate evidence on which to base practice. REFERENCES Bijur PE, Silver W, Gallergaher EJ (2001) Reliability of the visual analogue scale for measurement of acute pain. Academic Emergency Medicine 8(12): 1153–1157 Boonstra LC, Teule JA, Kastermans M, Dassen TH (1992) Pain assessment in children, an investigation of children in pain caused by medical illness and pain. Verpleegkunde 7: 147–151. Cited in: Hamers JPH, Adu-Saad HH, Van den Hout MA, Halfens RJG, Kester ADM (1996) The influence of children’s vocal expressions, age, medical diagnosis and information obtained from parents on nurses’ pain assessments and decisions regarding interventions. Pain 65: 53–61 Bulloch B, Tenenbein M (2002) Assessment of clinically significant changes in acute pain in children. Academic Emergency Medicine: Official Journal of the Society for Emergency Medicine 9(3): 199–202 Carter B (1994) Pain in infants and children. Chapman and Hall, London Chambers CT, Reid GJ, Craig KD, McGrath PJ, Finley GA (1998) Agreement between child and parent reports of pain. Clinical Journal of Pain 14(4): 336–342 Chambers CT, Giesbrecht K, Craig KD, Bennett SM, Hunysman E (1999) A comparison of faces scales for the measurement of paediatric pain: children’s and parents’ ratings. Pain 83(1): 25–35
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