Does the perceived importance of a pain management task affect the quality of children’s nurses’ post-operative pain management practices?

Nurses' management of children's acute postoperative pain: A theory of bureaucratic caring deductive study

BACKGROUND

Few studies have examined the translation of nurses' knowledge of pain management into clinical practice or how nurses negotiated the bureaucracy of caring to treat patients' acute pain.

PURPOSE

This study describes factors that influence pediatric nurses' actions in caring for hospitalized children's acute post-surgical pain.

METHOD

Ray's Theory of Bureaucratic Caring provided the theoretical framework for this mixed methods study of ethnography and human factors engineering. Fourteen nurses were observed throughout their shifts (175.5 h) to elucidate humanistic and bureaucratic influences.

FINDINGS

Of 105 pain assessments, nurses intervened with pharmacologic (n = 45) and biobehavioral (n = 13) interventions for pediatric patients' post-surgical pain in less than 11 min; and 25 assessments revealed patients did not have pain. Pain was assessed and no intervention was provided to 4 patients who were asleep, 5 patients who refused, 2 patients who had no ordered analgesics and 10 patients who were assessed prior to peak effectiveness of their prior analgesic. Overall pain was well-controlled. Of the 28 themes identified, the interplay of 6 categorized to the social/cultural humanistic, 7 political, and 6 technologic/physiological bureaucratic dimensions most strongly influenced pain care.

DISCUSSION

To achieve optimal pain care outcomes, nurses' and parents' pain management knowledge was less influential for clinical practice translation than nurses' negotiation of other dimensions of bureaucratic caring.

A Proposed Model of the Effective Management of Children's Pain

The aim of this study was to understand the various factors that contribute to the delivery of effective pain management. The current picture of pain management is complex and contradictory, with children in the hospital still experiencing unnecessary pain, nurses reporting better pain care than is evidenced, and parents who are reluctant to report their child's pain. There is a real need to focus on areas of excellence where pain management innovations have been successfully implemented. Five hospitals were visited in three countries: the United Kingdom, Sweden, and Australia, spending a week in each country. In all, 28 health care professionals were interviewed exploring innovations in pain management; the effect of improvements on children, parents, and nurses; and what helped and hindered the delivery of effective pain management. Better pain management provides nurses with confidence, which in turn gives children and parents confidence in their care and reduces anxiety for nurses. Resources, on the other hand, were a common issue in relation to obstacles to innovation. A recurring theme in all areas visited was the issue of culture and how it affected both negatively and positively on the management of children's pain. Strong leadership was integral to moving practice forward and to introducing the innovations that led to effective pain management. The key findings identified that underpin the effective management of children's pain are effective leadership, resources, and confidence; the consequences are less stress for children and nurses, more trusting relationships, and greater job satisfaction. A model of effective pain management is proposed.

Do barriers to pediatric pain management as perceived by nurses change over time?

For decades, nurses (RNs) have identified barriers to providing the optimal pain management that children deserve; yet no studies were found in the literature that assessed these barriers over time or across multiple pediatric hospitals. The purpose of this study was to reassess barriers that pediatric RNs perceive, and how they describe optimal pain management, 3 years after our initial assessment, collect quantitative data regarding barriers identified through comments during our initial assessment, and describe any changes over time. The Modified Barriers to Optimal Pain Management survey was used to measure barriers in both studies. RNs were invited via e-mail to complete an electronic survey. Descriptive and inferential statistics were used to compare results over time. Four hundred forty-two RNs responded, representing a 38% response rate. RNs continue to describe optimal pain management most often in terms of patient comfort and level of functioning. While small changes were seen for several of the barriers, the most significant barriers continued to involve delays in the availability of medications, insufficient physician medication orders, and insufficient orders and time allowed to pre-medicate patients before procedures. To our knowledge, this is the first study to reassess RNs' perceptions of barriers to pediatric pain management over time. While little change was seen in RNs' descriptions of optimal pain management or in RNs' perceptions of barriers, no single item was rated as more than a moderate barrier to pain management. The implications of these findings are discussed in the context of improvement strategies.

Post-discharge experiences of children and their families following children's surgery

Increasing rates of day surgery and decreasing length of hospital stay mean children's recovery from surgery extends beyond hospital and into the home. The objective of this study is to improve the understanding of experiences of children and their families during recovery at home post surgery. This is an exploratory, interpretive study using diaries and semi-structured interviews with children and parents. Results from this research show that children recovering at home after surgery have increased dependency and are likely to become the centre of family life; re-establishing independence is a marker of recovery. When present, pain dominates the experience. The families that go home ill-prepared experience high levels of worry. In conclusion, recovery from surgery is influenced by multiple factors; overall, families and children are resilient. There is a role for health professionals to tailor and improve information provision to parents and children about post-operative recovery, including assessment and management of pain. Information should be made available that describes the experience of other families who have undergone a similar surgery, and families should be made aware of what information they need and how to access it before and after discharge.

Nurses' views about the barriers and facilitators to effective management of pediatric pain

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.

'I didn't really like it, but it sounded exciting': admission to hospital for surgery from the perspectives of children

It is a mark of respect for children that their views around their healthcare are listened to and considered. To date, too little attention has been paid to children's views and experiences of admission to hospital for surgery. This paper presents findings from a constructivist grounded theory study of children's experiences of admission to hospital for surgery (from their perspectives). Age appropriate data collection techniques were used and included interviews with children and their drawings and stories. Ten children, aged 6-12 years, who were admitted to hospital for surgery participated in the research. The children were able to clearly articulate aspects of their experience, including their fears and anxieties, the things they enjoyed and the things that assisted them to cope with their experience. The substantive theory developed was 'children's reframing of their sense of selves to incorporate the experiences of hospitalization and surgery'. Children require information and support to alleviate their anxieties around the time of their surgery. With pressures on children's services, increased day surgery rates and shorter admissions, nurses who care for children around this time are challenged to find ways of knowing each child's story and the fears that they have.

[Pediatric pain management: what do German nurses know?]

BACKGROUND

In order to provide efficient pain treatment clinicians need to know the latest developments in pain management and to implement this knowledge into clinical practice. The knowledge of pediatric nursing staff with regards to pediatric pain management has not yet been investigated. In this study we therefore investigated nurses' knowledge of pediatric pain management strategies.

METHODS

Nursing staff knowledge was analyzed using the German version of the PNKAS-Sr2002. This questionnaire was distributed to 310 pediatric nurses and the response rate was 51.3% (n=159). Analyses of variance (ANOVA) were conducted to examine whether educational level and work experience had an influence on knowledge. Independent from work experience the educational level of nurses is important for their knowledge in pediatric pain management.

RESULTS

On average nurses obtained a mean individual test score of 69.3%. Nurses with advanced qualification and nurses with 6-10 years work experience obtained the highest scores.

CONCLUSION

Pediatric nurses must be trained more efficiently in pediatric pain management so that an adequate pain management is available for children and adolescents.