Children's nurses' post-operative pain management practices: an observational study

BACKGROUND: Children continue to experience unrelieved moderate to severe pain post-operatively despite the evidence to guide practice being readily available. Previous studies have relied on self-report measures; there is a need to establish exactly how nurses manage children's pain in practice. OBJECTIVES: To ascertain how nurses actually manage post-operative pain in children and whether pain management practices adhere to current best practice guidelines. DESIGN: An observational study was carried out. Structured and unstructured data were collected. SETTING: A children's surgical ward in the English Midlands caring for children from birth to 16 years. PARTICIPANTS: Registered nurses (n=13) took part in the study. METHODS: Each participant was observed continuously for a period of 5 hours per shift for two to four shifts each. The role of the observer as participant was adopted whereby the researcher could shadow the nurse and act primarily as an observer. Data were collected for 36 shifts (185 hours). RESULTS: While nurses administered analgesic drugs when a child complained of pain, in most other areas practices did not conform to current recommendations and are in need of improvement. Nurses did not, for example, routinely assess a child's pain, nor use non-drug methods of pain relief on a regular basis. CONCLUSIONS: The sub-optimal pain management practices may be attributable to several factors. The professional culture of nursing and/or ward culture may result in poor pain management practices being perpetuated. Nurses may not have the requisite theoretical knowledge to manage pain effectively. A lack of priority may also be attributed to pain management. These areas need exploring further.     

The development of national guidelines for pain control: synopsis and commentary

This synopsis outlines factors that prompted development of national clinical practice guidelines for the management of pain and presents the essential content of major pain control guidelines. Also described is the concurrent growth of the evidence-based pain management movement worldwide in the decade since initial US federal guidelines on acute and cancer pain were developed, and products of this global movement. The latter include systematic reviews and meta-analyses about treatments for pain, their assemblage in resources such as the Cochrane Collaboration, and (in the US) the embedding of pain assessment and management within quality assurance requirements for hospital accreditation. This survey will highlight recent research that evidence-based guidelines alone are insufficient to overcome established attitudes, practices and myths that hinder pain assessment and management. Hypotheses for the inadequacy of scientific evidence per se to overcome clinicians' attitudes and practices will be advanced, along with suggestions as to how those in the ‘pain treatment community’ may help to tip the balance.     

Managing Children's Cancer Pain in Morocco

Purpose: To identify issues in managing pain of children with cancer in the two pediatric oncology centers in Morocco.
Methods: Focus groups were conducted with pediatric oncology nurses and physicians.
Findings: Four themes were identified: (a) children's cancer pain is an overwhelming concern to the Moroccan nurses and physicians who participated in this study; (b) training and resources for children's cancer pain management are lacking in Morocco; (c) some impediments to pain relief were verbalized, such as a stoic approach to suffering and limited use of some drugs; and (d) a critical need exists for a comprehensive pain management approach for children with cancer in Morocco.
Conclusions: This study elucidated issues in managing children's cancer pain in Morocco and increased knowledge of current practice issues. A program of policy research has been initiated with the aim of establishing guidelines for practice policies for managing children's cancer pain in Morocco.     

Identification of perceived barriers of pain management in Iranian children: a qualitative study

Hospitalized children are often inadequately treated for their pain. Paediatric nurses experience these inadequacies more than other health-care team members. This research was an attempt in the form of a phenomenological study to reveal some major barriers in children pain management as the nurses had perceived. Sixteen nurses were interviewed in the medical, surgical and infectious paediatric wards of a hospital in Iran. Data analysis were based on Colaizzi method that surfaced three main themes in different areas namely: organizational barriers, limitations relating to child's characteristics and barriers relating to the nature of disease and its treatments. The study results have shown organizational limitations added to the lack of authority for administering some medical intervention, inadequate equipment and utilities and unavailability of opioids as the main pain controlling and restricting factors. Additional factors that relate to the child specifications like age, temperament, behaviour, expression and gender affect the assessment and treatment of pain. The results revealed identified barriers in real context. It seems that some guidelines are needed to achieve optimal pain management.     

Pain management in Australian emergency departments: Current practice,enablers, barriers and future directions

Objective: To explore current pain management practice in Australian EDs and identify enablers and barriers for best‐practice pain management. Methods: Five focus groups and two in‐depth interviews were held with ED clinical staff (n= 47) from six hospitals in three states. Participants were asked open‐ended questions to determine current pain management practices, enablers and barriers to implementing best‐practice pain management, and understand change in practice within the ED setting. Results: Emergency department staff identified a gap between evidence‐based pain management recommendations and everyday practice. Perceived barriers to improving pain management included a lack of time and resources, a greater number of urgent and serious presentations that place pain management as a lower priority, organizational protocols and legislative issues. All groups noted difficulty in applying pain management guidelines in the context of competing priorities in the challenging ED environment. A culture of learning clinical practice from respected senior staff and peers was perceived to be a key enabler. Participants consistently expressed the view that evidence‐based practice improvement should be championed by senior clinical staff, and that evidence to demonstrate the benefits of change must be presented to support the need for change. Conclusions: Effective and sustainable system change requires a strategy that is initiated within the ED, targets opinion leaders, is supported by evidence, and engages all levels of ED staff.     

How Well Is Acute Pain in Children Managed? A Snapshot in One English Hospital

This study set out to obtain a picture of pediatric pain management practices in one English hospital. Data were collected on two wards. Nonparticipant observation combined with a chart audit was used to collect data about actual practices. Questionnaires were used to collect information from parents and young people. Observational data showed that practices conformed to current guidelines in some but not all areas. When prescribed, the dosage of analgesic drugs complied with the hospital's guidelines, and drugs were usually administered as prescribed. There was some involvement of parents in decision making but this was usually initiated by them rather than the nurses. Pain assessment tools were not always used nor was a pain history routinely taken. Documentation about pain management was limited and there was little evidence of nonpharmacologic methods of pain relief being used. Parents and young people felt that their pain management was of an acceptable level or very good. This was despite the fact that 58% of children experienced severe pain and 24% moderate pain. The results provide a snapshot of pain management in one English hospital. As in other studies, pain management practices do not adhere to current guidelines in all areas, and children appear to be experiencing moderate to severe pain. Despite this, parents and children indicated that they were happy with the quality of pain management. There is a need to explore this further and to identify strategies that support the implementation of guidelines in practice.     

Parent-nurse interactions: care of hospitalized children

BACKGROUND: An essential component of quality nursing care is nurses' ability to work with parents in the hospital care of their children. However, changes in the health care environment have presented nurses with many new challenges, including meeting family-centred care expectations. AIM OF THE PAPER: To report a research study examining the experiences of parents who interacted with nurses in a hospital setting regarding the care of their children. METHODS: A qualitative approach was employed for this study. In-depth audiotaped interviews were conducted with eight parents representing seven families. Data collection was completed over a 7-month period in 2001. FINDINGS: Parents characterized their experiences with nurses caring for their children as interactions, and identified the elements of establishing rapport and sharing children's care as key to a positive perception of the interactions. These elements were influenced by parental expectations of nurses. Changes in nurses' approach were reported by parents as the children's conditions changed. CONCLUSION: Nurses were able to work with families in the hospital care of their children in ways that parents perceived as positive. However, in parents' views, their interactions with nurses did not constitute collaborative relationships. A deeper understanding of these interactions may provoke new thinking about how to promote an agency's philosophy, and how nurses enact this philosophy in practice.     

Pain Management in Patients with Heart Failure: A Survey of Nurses’ Perception

BackgroundOver 50% of patients with heart failure (HF) report suffering from pain and pain-related burdens; however, pain in HF patients has not been recognized or well treated. Few studies have comprehensively examined pain management in patients with HF from nurses’ perception.AimsTo investigate nurses’ perception of pain management in HF patients.MethodsMembers of American Association of Heart Failure Nurses (AAHFN) were invited to participate in a cross-sectional online survey.ResultsA total of 147 nurses responded and completed the survey. The majority agreed that pain in HF patients was related to anxiety, depression, fatigue, and unplanned hospitalization, and that pain should be individually assessed and managed. More than 80% thought pain management practice in HF patients should be improved, and 78.1% were interested in getting more information and believed an online education module was the most preferable approach. Lack of pain assessment tools, drug addiction, side effect, overuse, underuse, and contraindication with other medications were the main concerns regarding opioid use in pain management in HF. The gaps in pain management in HF patients included lack of knowledge of opioid use, lack of consideration and awareness of pain, no clinical guidelines for pain assessment and treatment, and complicated pain management with multiple chronic conditions.ConclusionsThe impact of pain and need for individual assessment and management of pain in HF patients were perceived by nurses; improvement in pain management practice in HF patients is needed. Concerns regarding opioid use and gaps in pain management of HF patients should be addressed.     

Consensus statements, positions, standards, and guidelines for pain and care at the end of life

Standards, guidelines, and position and consensus statements by themselves do not change practice or improve pain management and care at the end of life. However, if they are used effectively, they support best practices, provide a forum for discussion of current recommendations, and provide nurses with the latest science and information to advocate for effective pain and symptom management.     

Unplanned hospital admission: supporting children, young people and their families

This article discusses issues relating to unplanned hospital admission which can be particularly distressing for children, families and carers. Good initial assessment can establish appropriate support from children's nurses throughout the hospital stay. Ongoing mutual understanding and clear explanations are essential, and prompt, effective pain management reduces stress. The article highlights that family-centred care, with as much family or carer involvement as possible, leads to the best outcomes.     

Use of Three Evidence-Based Postoperative Pain Assessment Practices by Registered Nurses

To provide optimal postoperative pain relief, nursing practice should be based on the best evidence available. For over 20 years, results of studies regarding nurses' use of evidence-based practices, including postoperative pain assessment practices, have shown that nurses use the practices inconsistently. The present cross-sectional survey study was conducted to: 1) determine the extent to which registered nurses caring for postoperative patients experiencing pain used three evidence-based postoperative pain assessment practices; and 2) identify relationships among the level of adoption of evidence-based postoperative pain assessment practices and selected characteristics of registered nurses. Data were collected from a convenience sample of all nurses caring for adult postoperative patients in two Midwestern hospitals where 443 surveys (46.9%) were returned. Respondents were aware of, but not using, three evidence-based postoperative pain assessment practices consistently. Registered nurses who used multiple sources to identify solutions to clinical practice problems or read one or two professional journals regularly were more likely to have adopted the three evidence-based postoperative pain assessment practices. Registered nurses need to be encouraged to use multiple sources to identify solutions to clinical practice problems, including professional nursing journals. Innovative approaches to promote the application of research to education and practice settings are needed. It is important to identify opinion leaders, because opinion leaders are an important resource in overcoming the barriers so that adoption of pain of evidence-based postoperative pain assessment practices can proceed. Additional research is needed to identify what variables effect the adoption of evidence-based practices and identify interventions to improve the level of adoption.     

Unresolved pain in children: a relational ethics perspective

It is considered the right of children to have their pain managed effectively. Yet, despite extensive research findings, policy guidelines and practice standard recommendations for the optimal management of paediatric pain, clinical practices remain inadequate. Empirical evidence definitively shows that unrelieved pain in children has only harmful consequences, with no benefits. Contributing factors identified in this undermanaged pain include the significant role of nurses. Nursing attitudes and beliefs about children's pain experiences, the relationships nurses share with children who are suffering, and knowledge deficits in pain management practices are all shown to impact unresolved pain in children. In this article, a relational ethics perspective is used to explore the need for nurses to engage in authentic relationships with children who are experiencing pain, and to use evidence-based practices to manage that pain in order for this indefensible suffering of children to end.     

Acute pain relief in children: use of rating scales and analgesia

Evidence suggests that children who are in pain and who present to emergency departments receive sub-optimal pain assessment and relief. Many factors contribute to this unacceptable quality of care, including emergency nurses' lack of knowledge about the appropriate pain assessment tools. This article refers to a literature review and case study to discuss children's pain assessment tools. It concludes that an education programme for emergency nurses could be provided to augment their awareness of best practice pain assessment and management guidelines.     

Pain Management Practice and Guidelines in Jordanian Pediatric Intensive Care Units

Limited knowledge exists of current pain management practices and supporting guidelines in Jordanian pediatric intensive care units. To determine the current pain management practices and the availability and content of practice guidelines in Jordanian pediatric intensive care units, we conducted a cross-sectional and multisite survey of four pediatric intensive care units in Jordan. A questionnaire was developed and orally administered over the phone or in person to head nurses or their nominees to capture pain management practices and the existence and content of guidelines. All units had written pain management guidelines that included pain assessment, documentation, and management. All four units used one or more pain assessment tools. In three units, pain management was considered multidisciplinary and routinely discussed on unit rounds. In two units, continuous infusion of intravenous opioids was used as well as sedatives and neuromuscular blockers for most ventilated patients. In the two other units, continuous intravenous infusion of opioids was not used and only sedatives were administered for patients on mechanical ventilation. In two units, there were no specific guidelines on the use of nonopioid analgesics, patient-controlled anesthesia, or the management of postoperative pain. No unit used an opioid or sedative withdrawal assessment tool or had pain management guidelines on the use of topical anesthetic agents or sucrose. Pain management practices and guidelines varied across the four units, suggesting that there is an opportunity for improvement in pain management in pediatric intensive care units in Jordan.