Pediatric nurses' postoperative pain management practices: an observational study

"Their Bodies Just Give It Away": A Qualitative Study of Pain Assessment in the Context of Pediatric Hematopoietic Stem Cell Transplantation Therapy

BACKGROUND

Children undergoing hematopoietic stem cell transplantation (HSCT) are vulnerable to pain.

OBJECTIVE

This study aimed to examine how healthcare providers and parents assessed pain and what contextual factors influenced their pain assessment practices for children hospitalized after allogeneic HSCT therapy.

METHODS

A qualitative case study was conducted in a tertiary level pediatric HSCT unit in 2 phases. Semistructured interviews with parents were conducted at 30 and 90 days after HSCT therapy. Healthcare providers participated in naturalistic observations of pain-related care provided to children during their hospitalization for HSCT therapy and a semistructured interview.

RESULTS

The assessment of pain after transplantation by healthcare providers and parents was predominantly reliant on the observation of children for behaviors indicative of pain, rather than the application of validated pain assessment tools. Without formal measures of the pain experience, judgments regarding the severity of children's pain were influenced by the context of high acuity of care posttransplantation and the emotional responses of healthcare providers and parents from bearing witness to children's pain.

CONCLUSION

Pain assessments mostly reflected children's ability to tolerate pain, rather than a genuine measurement of how significantly pain impacted the child.

IMPLICATION FOR PRACTICE

This study has emphasized how the assessment of pain for children hospitalized during HSCT therapy is limited by the complexity of the clinical environment. It is recommended that validated methods of assessing pain by healthcare providers and parents be implemented into clinical practice to ensure children's pain is visible.

Communication, information, involvement and decision making: A systematic scoping review of child-parent-nurse relationships during postoperative pain management

AIMS

To examine the existing literature on child-parent-nurse relationships (in relation to communication, information, and involvement and decision-making) during postoperative pain management.

BACKGROUND

Pain in children is under-reported and under-treated in hospitals and research has continued to report high rates of pain among hospitalised children worldwide. The role of child-parent-nurse relationships may be a factor and to date, no review has been identified that focus on these relationships during postoperative pain management.

DESIGN

A systematic scoping review following Arksey and O'Malley with further adaptations based on JBI.

METHODS

A systematic search for published primary studies was conducted using the Medline, CINAHL, British Nursing Index, ASSIA, PsycINFO, Science Direct and Web of Science in English from 2000 to 2022. Two reviewers independently carried out data screening and extraction and any differences were resolved with the assistance of a third reviewer. The data were analysed using thematic analysis and presented descriptively. This study followed the PRISMA-ScR Checklist.

RESULTS

A total of 37 studies met the inclusion criteria. The findings mainly demonstrated a focus on the perspectives of parents and nurses with less on children's perspectives and none of the studies explored child-nurse relationships. The findings were categorised under three themes: communication, information, and involvement and decision making.

CONCLUSION

A prevailing deficiency in child-parent-nurse relationships significantly contributed to suboptimal postoperative pain care, causing prolonged and untreated postoperative pain in children. Children's hesitation in communicating with nurses, the limited communication skills of nurses, and the weak communication position of parents in a hospital setting all hindered the development of strong relationships between children, parents, and nurses. The unclear definition of the roles of children and parents in postoperative pain management resulted in confusion for both parents and nurses. This was exacerbated by parents' lack of knowledge and inadequate guidance from nurses, ultimately leading to a decreased level of parental involvement in their child's postoperative pain management while in the hospital. Unattended requests for pain management caused children to experience prolonged pain and led to a deterioration in the relationship between parents and nurses, as well as a reduction in the parents' ability to provide pain care to their child.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the reasons behind the suboptimal management of postoperative pain in children. The importance of the relationship between children, parents, and nurses in pain management must be acknowledged, and the results of this study may be used to inform improvements in nursing pain management practices.

NO PATIENT OR PUBLIC CONTRIBUTION

Patient or public contribution is not a necessary stage in a systematic scoping review following Arksey and O'Malley's framework.

Interactions between children, parents and nurses during postoperative pain management: A grounded theory study

AIM

To explore the interactions between children, parents and nurses during postoperative pain management.

BACKGROUND

Despite the growing evidence relating to postoperative pain management in children and relevant practice guidelines, children still experience moderate to severe pain after surgery. One factor could be related to the relatively unexplored child-parent-nurse interaction.

DESIGN

A qualitative constructivist grounded theory methodology.

METHODS

Data were collected from a paediatric hospital in the United Kingdom. Ten children aged between 6 and 11 years old who had undergone surgery, 11 parents and 10 nurses participated. Methods included face-to-face semi-structured interviews. Data were analysed using constant comparison technique, memos and constructivist grounded theory coding levels. The COREQ guidelines were followed for reporting.

FINDINGS

Three concepts emerged from data, "Parents as a communicator for child-nurse interaction", "Parents' emotional turmoil in child-nurse interaction", and "Parents' actions in child-nurse interaction" which constructed the substantive theory of child-parent-nurse interaction during postoperative pain management: "Facilitating or Inhibiting Interactions: Parental Influence on Postoperative Pain Management". The findings highlight an absence of a three-way interaction between children, parents and nurses and a dyadic interaction process between children and nurses was not apparent. Instead, child-parent-nurse interactions were constructed around two dyads of child-parent and parent-nurse interactions with child-nurse interaction constructed via parents. Parents, as a communicator, influenced the entire postoperative pain management processes between children, parents and nurses by facilitating or inhibiting the interaction processes.

CONCLUSIONS

This study identifies potentially important evidence about the unique position parents hold between their child and nurses as a central pivotal communicator during children's postoperative pain management.

RELEVANCE TO CLINICAL PRACTICES

This study may help to explain how and why postoperative pain management remains suboptimal. The substantive theory could support improvements in the management of postoperative pain through a much wider recognition of parents' central pivotal communicator role and the complexity of these child-nurse interactions.

Mothers' Involvement in Pediatric Postoperative Pain Care in a Tertiary Healthcare Setting in Saudi Arabia

Background Many children feel moderate to intense pain in the hospital following surgery. Untreated pain can have deleterious physical and psychological effects. Mothers' involvement in child pain care and management postoperatively has been shown to be important in improving the outcomes and experiences of children, mothers, and health professionals. Aims To explore mothers' involvement in postoperative pain care and management of their children during hospitalization and following discharge and identify approaches to improve management and participation activities. Methods We used a qualitative single case study design with thematic analysis. The analysis included 20 mother-child dyads and 21 nurses, involving observation of participants and semi-structured interviews of mothers and nurses. The analysis also incorporated a review of documents from the pediatric surgical department (hospital policies and forms).  Findings The following main themes and sub-themes were generated from the data: (i) provision of pain information (expected type, frequency, and duration of pain after surgery, pain intensity score, pain relief medication, and pain management methods), (ii) communication deficiency (language barrier and breakdown in communication between health professionals), (iii) emotional and physical support (family support, environmental comfort, and sleep and meal requirements), (iv) social and cultural influences (patriarchal society, cultural and religious beliefs, and work status), and (v) hospital facilities, provisions, and services (entertainment, follow-up programs, education courses on pain management for nurses, and materials and services). Conclusions The study examined mothers' participation in postoperative pain care and management in a cohort of children admitted to a tertiary care setting in Saudi Arabia, highlighting key factors that influence involvement and suggesting approaches for improving participation.

The influence of contextual factors on children's communication of pain during pediatric Haematopoietic Stem Cell Transplantation: A qualitative case study

PURPOSE

The aim of this study was to describe how contextual factors related to the clinical setting of a pediatric HSCT unit influenced children's communication of pain to their health-care providers and parents during hospitalization.

DESIGN AND METHODS

A qualitative case study design was conducted in two-phases in a tertiary level pediatric HSCT unit. The Social Communication Model of Pain provided the conceptual framework for the study. In phase one participants were parents and phase two participants were health-care providers and children in a pediatric HSCT unit. Parents participated in semi-structured interviews at 30- and 90-days post-transplantation regarding their child's communication of pain. Naturalistic observations of children receiving clinical care were conducted and health-care providers participated in semi-structured interviews.

RESULTS

Children extensively denied pain to their parents and health-care providers. When children did communicate pain, they were motivated by a need to seek interventions for their pain. Children's willingness to communicate pain was influenced by the physiological impact of HSCT therapy, their previous experiences of pain, their relationship with parents and health-care providers and parents and an environment of fear and uncertainty.

CONCLUSIONS

There is a pressing need for child-centric approaches to support children to communicate their pain experiences to overcome the limitations imposed by the complexity of their medical treatment and the clinical environment in which they receive healthcare.

PRACTICE IMPLICATIONS

In the context of HSCT therapy children may not communicate pain until pain is severe, and no longer bearable, or outright deny the presence of pain.

Educational Intervention to Strengthen Pediatric Postoperative Pain Management: A Cluster Randomized Trial

BACKGROUND

Pediatric postoperative pain is still undertreated.

AIMS

To assess whether educational intervention increases nurses' knowledge and improves pediatric postoperative pain management.

DESIGN

Cluster randomized controlled trial with three measurement points (baseline T1, 1 month after intervention T2, and 6 months after intervention T3).

PARTICIPANTS/SUBJECTS

The study was conducted in postanesthesia care units at six hospitals in Norway. Nurses working with children in the included units and children who were undergoing surgery were invited to participate in this study.

METHODS

Nurses were cluster randomized by units to an intervention (n = 129) or a control group (n = 129). This allocation was blinded for participants at baseline. Data were collected using "The Pediatric Nurses' Knowledge and Attitudes Survey Regarding Pain: Norwegian Version" (primary outcome), observations of nurses' clinical practice, and interviews with children. The intervention included an educational day, clinical supervision, and reminders.

RESULTS

At baseline 193 nurses completed the survey (75% response rate), 143 responded at T2, and 107 at T3. Observations of nurses' (n = 138) clinical practice included 588 children, and 38 children were interviewed. The knowledge level increased from T1 to T3 in both groups, but there was no statistically significant difference between the groups. In the intervention group, there was an improvement between T1 and T2 in the total PNKAS-N score (70% vs. 83%), observed increase use of pain assessment tools (17% vs. 39%), and children experienced less moderate-to-severe pain.

CONCLUSIONS

No significant difference was observed between the groups after intervention, but a positive change in knowledge and practice was revealed in both groups. Additional studies are needed to explore the most potent variables to strengthen pediatric postoperative pain management.

Observation of Emergency Room Nurses Managing Pediatric Pain: Care to Be Given… Care Given…

BACKGROUND

Although pain undeniably has negative consequences, pain management often remains suboptimal, particularly in the pediatric population in the emergency room (ER).

AIM

In this observational study using qualitative and quantitative methods, we investigated everyday adherence to current nursing best-practice pediatric guidelines in the ER paying particular attention to the interaction between children, parents, and nurses.

METHODS

An adapted version of the nursing observation tool for pain management was used to describe pediatric pain management provided by nurses caring for children (0-14 years old) admitted to the ER. We also assessed child-parent-nurse interactions. (The aim of the study was presented to the nurses as part of the survey on interactions without specifying the focus on pain management.) RESULTS: Forty-seven children were included (91 painful episodes) during the observation period (112 hours). There was a screening for pain in 55% of cases, and pain scales were used in 10% of cases. Analgesic treatments were administered in 75% of cases (procedural or disease-related pain). Follow-up evaluations were performed in 19% of cases. Nonpharmacologic approaches were scarcely used. The use of both helpful and nonhelpful languages were noted during interactions with children and parents. Parents' collaboration was rarely requested to help relieve their child's pain.

CONCLUSIONS

Our results show that pediatric pain management in the ER could be optimized. Parents are still not considerably involved in their child's pain management. Parents' involvement could contribute to improving pediatric pain management.

Pediatric Nurse Practitioners' Knowledge and Attitudes Regarding Pain Management Study in Central China

BACKGROUND

Nurses' level of knowledge about pain management directly determines the steps of implementation of clinical pain policies.

METHOD

This study surveyed 2,882 pediatric nurse practitioners from six children's hospitals using demographics and pain management questionnaires, as well as the Chinese version questionnaire of the Pediatric Nurse Practitioners' Knowledge and Attitudes Survey Regarding Pain (PNKAS) via the WeChat application.

RESULTS

The total score on the PNKAS was 14.88 ± 3.58 for the pediatric nurse practitioners. Multiple regression results showed the main factors influencing the PNKAS score related to position, the frequency of receiving training pain-related knowledge, and working department, which could account for 35.1% of the total variance.

CONCLUSION

Pediatric nurse practitioners from pediatric hospitals were not found to have sufficient knowledge or an appropriate attitude regarding pain management. A new standardized training project of pain management that is closely related to clinical practice for children should be conducted in the future. [J Contin Educ Nurs. 2019;50(6):275-281.].

Exploring distraction and the impact of a child life specialist: Perceptions from nurses in a pediatric setting

PURPOSE

The purpose of this study is to explore perceptions held by nurses on the use of distraction and the role of a child life specialist in caring for children undergoing painful procedures.

DESIGN AND METHODS

A qualitative focus-group design was conducted with 18 nurses from a 24-bed pediatric unit in New South Wales, Australia; this represented 51% of the staff from the unit. Three focus groups were conducted and transcribed verbatim followed by thematic analysis.

RESULTS

Findings revealed five main themes that reflected the perceptions of the nurses' use of distraction and the impact of the child life specialist. The theme "Distraction as part of everyday nursing practice" was viewed by nurses as an integral component of nursing practice. The theme "Influence of child life specialist" revealed that the child life specialist created a feeling of ease during procedures. Differences were acknowledged between the two roles, "Contrast of roles" the child life specialist was seen as positive for children and families, whereas nurses viewed themselves as mean and unkind due to the nature of their work. The theme "The value of collaboration for positive healthcare experiences" acknowledged distraction as a contributing factor in ensuring the child and their family had a positive healthcare experience. The types of "nurses perception of the child's experience with distraction" shared in each of the focus groups identified nurses felt their techniques for distraction were much more simplified than the child life specialist; nurses felt disadvantaged at times in not having access to the same tools.

PRACTICE IMPLICATIONS

The findings indicate the positive impact that a child life specialist has on a nurse's role while caring for children undergoing painful procedures. Nurses felt they were able to focus on the procedure, therefore ensuring the physician received the right amount of assistance. This reassured the nurses in knowing the child and their families emotional needs were being taken care of. The child life specialist was viewed as being able to provide a positive healthcare experience for the child and families, nurses felt this added to the value of care provided in the pediatric unit. Recommendations include further exploration of the child life specialist role in the pediatric inpatient setting.

Improving paediatric pain management in the emergency department: An integrative literature review

BACKGROUND

Children presenting to the emergency department continue to experience suboptimal pain management. While evidence-based pain management interventions are available to clinicians, effective and sustainable practice change is yet to be achieved. This practice gap requires a collaborative approach to knowledge translation targeting systems of care.

OBJECTIVES

The purpose of this review was to explore systems level change in the emergency department for improved paediatric pain management.

DESIGN

Integrative review.

DATA SOURCES

CINAHL, Embase, PubMed/Medline, Dynamed, Cochrane, Scopus, Prospero and Joanna Briggs Institute were systematically searched, and clinical guidelines and reference lists scanned.

REVIEW METHODS

Studies were screened and selected according to the inclusion criteria, and independently appraised for risk of bias. Integrative review methodology informed data extraction and synthesis, focused on organisational context and engagement, facilitation and implementation of practice change, key components of the pain management interventions, and evaluation.

RESULTS

Twenty studies met the inclusion criteria: 18 uncontrolled pretest-posttest and two pseudo-randomised design. Study populations ranged from children with a specific presentation, to all presenting children. All studies adopted a multifaceted approach to organisational change, bundling various interventions including pain assessment tools and management protocols, clinician education, nurse-initiated analgesia, feedback and family engagement. Four studies used local systems analysis to inform interventions and two studies applied an implementation framework. Time to analgesia was the most commonly improved primary outcome. Parent and child sensitive outcomes were assessed in five studies. Interventions that hold the most promise for optimised pain management if embedded in the workplace include nurse-initiated analgesia and family involvement at each stage of pain management in the emergency department.

CONCLUSION

The way forward is to respectfully engage all stakeholders-children, parents and clinicians-to collaboratively develop evidence-based, sustainable solutions aligned with the emergency department context. Guided by an implementation framework, future research designed to creatively translate evidence into practice and facilitate change at a systems level is a priority. Key to this solution is the integration of family involvement in pain management, considering child and family sensitive outcome measures. Effectiveness of new interventions should be evaluated in the short and long term to embed sustainable practice change. Frontline nurses are well placed to lead this transformation in paediatric pain management in the emergency department.

Surgeons' aims and pain assessment strategies when managing paediatric post-operative pain: A qualitative study

Children experience moderate to severe pain post-operatively. Nurses have been found to have a variety of aims in this context. Surgeons' aims when managing post-operative pain have not been explored. This qualitative study set out to explore paediatric surgeons' aims when managing post-operative pain in one paediatric hospital in Canada. Consultant surgeons (n = 8) across various specialities took part in semi-structured interviews. Surgeons' overarching aim was to keep the child comfortable. Various definitions of comfortable were given, relating to the child's experience of pain itself and their ability to undertake activities of daily living. Children's behavioural pain cues seem to be a primary consideration when making treatment decisions. Parents' views regarding their child's pain were also seen as important, suggesting children may not be seen as competent to make decisions on their own behalf. The need to maintain a realistic approach was emphasised and pain management described as a balancing act. Surgeons may draw on both tacit and explicit knowledge when assessing children's pain. There appears to be an expectation among surgeons that some pain is to be expected post-operatively and that the diagnostic value of pain may, in some cases, supersede concerns for the child's pain experience.

Parental attitudes to children's pain and analgesic drugs in the United Kingdom

Many children experience treatable moderate to severe pain following surgery. Increasingly, children undergo surgery as day cases, and, as such, parents are more likely to be responsible for managing pain post-operatively. Research in the United States and Finland has found parents fear the side effects of analgesics; think they are addictive; and that children should receive as little analgesia as possible. Little is known about parental attitudes in this context in the United Kingdom. This study set out to explore parental attitudes towards children's pain and analgesic drugs to contribute to existing knowledge about parental attitudes elsewhere so that the information provided to parents can be tailored effectively. A convenience sample of parents (n = 108) at one hospital in South West London completed the Parental Pain Expression Perceptions and the Medication Attitudes Questionnaires. Although many parents have a good understanding of the ways in which children express pain, a substantial proportion of parents hold misconceptions regarding how children express pain and concerns in relation to analgesic drugs. This may impact on the quality of the pain management provided to children post-operatively and needs taking into account when preparing parents in this context.

Nurses' provision of parental guidance regarding school-aged children's postoperative pain management: a descriptive correlational study

Involving parents in children's pain management is essential to achieve optimal outcomes. Parents need to be equipped with sufficient knowledge and information. Only a limited number of studies have explored nurses' provision of parental guidance regarding the use of nonpharmacologic methods in children's pain management. This study aimed to examine nurses' perceptions of providing preparatory information and nonpharmacologic methods to parents, and how their demographics and perceived knowledge adequacy of these methods influence this guidance. A descriptive correlational study using questionnaire surveys was conducted to collect data from a convenience sample of 134 registered nurses working in seven pediatric wards of two public hospitals in Singapore. Descriptive statistics, independent-samples t test, and multiple linear regression were used to analyze the data. Most nurses provided various types of cognitive information to parents related to their children's surgery, whereas information about children's feelings was less often provided. Most nurses provided guidance to parents on positioning, breathing technique, comforting/reassurance, helping with activities of daily living, relaxation, and creating a comfortable environment. Nurses' provision of parental guidance on preparatory information and nonpharmacologic methods was significantly different between subgroups of age, education, parent or not, and perceived knowledge adequacy of nonpharmacologic methods. Nurses' perceived knowledge adequacy was the main factor influencing their provision of parental guidance. More attention should be paid to nurses who are younger, have less working experience, and are not parents. There is a need to educate nurses about nonpharmacologic pain relief methods to optimize their provision of parental guidance.

Influences shaping nurses' use of distraction for children's procedural pain

PURPOSE

This study explored pediatric nurses' choices to use distraction for managing painful procedures.

DESIGN AND METHODS

Using interpretive description approaches, interviews with pediatric nurses provided descriptions of choices to manage procedural pain.

RESULTS

Nurses' distress influenced distraction use to mitigate the suffering of children and themselves. Newer nurses described task mastery as influencing distraction choices. Nurses' accounts of performing painful procedures on children mirrored children's descriptions of pain from the literature.

PRACTICE IMPLICATIONS

Nurses' distress and competency performing painful procedures on children influenced practice. Future qualitative studies could extend understanding of pain management choices by pediatric nurses and the impact on undermanaged pain.

Nurses' aims when managing pediatric postoperative pain: is what they say the same as what they do?

PURPOSE

The purpose of this study was to explore nurses' aims when managing postoperative pain and whether reported aims reflect actual practices.

DESIGN AND METHODS

Participant observation was used to collect data regarding nurses' (n = 17) pain management practices. Nurses (n = 19) were asked: When managing postoperative pain, what is your overall aim?

RESULTS

Around half the participants (n = 10) aimed for patients to be comfortable while others aimed for a pain score of 2-3 (n = 7), or below 5 (n = 2). Observed practices matched aims for just more than half the participants (n = 9).

PRACTICE IMPLICATIONS

There is evidence of individual variation in practices. This may impact on the care provided.