How do nurses intervene to support children experiencing pain?
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other health professionals, nurses have a responsibility to provide adequate care for pediatric patients in pain Brunier, Carson Harrison 1995. However, I noticed that
many Indonesian nurses seemed to lack attention in caring for children experiencing pain. They tended to be more focused on routine activities such as wound care and
giving injections than assessing children’s pain. Aims of this study
This study aimed to explore some of the issues discussed above. The aims of the study were to answer the following research questions:
1. What are nurses’ beliefs regarding assessment and management of pain in
children?
2. How do nurses intervene to support children experiencing pain?
Literature review Definition of pain
Pain is a common human experience. However, pain is a concept that is difficult to understand. It may be that because pain is not a simple stimulus and is a subjective
experience. Among the most popular definitions of pain are those of the International Association for the Study of Pain 1979 and McCaffery Beebe 1994. The
International Association for the Study of Pain subcommittee on taxonomy 1979 cited in McGrath Unruh 1987, p. 45, asserted that ‘pain is an unpleasant sensory
and emotional experience associated with actual or potential tissue damage or described in term of such damage’. McCaffery Beebe 1994, p. 15 offered a more
personal explanation of pain, which states that pain is whatever the experiencing person says it is and exists whenever he says it does’. Basic to this definition is the
notion that nurses should believe children who say they are experiencing pain.
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The role of nurses in dealing with children’s pain
Most literature asserts that nurses have an important role in dealing with children’s pain McCaffery Beebe 1989; Price 1992: Hunt 1995; Jacob Puntillo
1999; Salantera et al 1999; Carlson, Broome Vessey 2000. Nurses are central to pain management because they provide twenty-four hour care to pediatric patients in
acute and chronic pain care, and have more frequent contact with patients than any other health professionals. According to Price 1992 nurses have a professional
responsibility to the community to provide the highest standard of nursing care. This means that nurses have a professional responsibility to provide adequate assessment
and appropriate nursing interventions for pediatric patients experiencing pain. Nurses also are ethically responsible to manage pain and relieve suffering Potter Perry
1995.
Assessment of pain in children
Assessment is a fundamental part of taking care of children in pain. However, many researchers have investigated the difficulty of pain assessment in children
Salantera et al 1999; Jacob Puntillo 1999; Allcock 1996; Brunier et al 1995. The main problem faced in assessment of children’s pain is because children have limited
ability to express their pain to those who take care of them such as health
professionals and parents, especially in neonates and young children Salantera et al 1999; Soetenga, Frank Pellino 1999; The Royal College of Nursing Institute 1999;
Twycross 2001. The problem may relate to inability to understand the instruction of pain measurement McGrath Unruh 1987; Bradshaw Zeanah 1986. Thus the
assessment of children’s pain continues to be an important challenge for health care providers in clinical practice McCaffery Pasero 1999; LaFleur Raway 1999;
Stone et al 1998.
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A number of studies have identified that nurses do not always assess pain effectively Caty et al 1995; Zalon 1995; Vessey Carlson 1996; Woodgate
Kristjanson 1996; Carr 1997; Jacob Puntillo 1999. A possible reason is that the subjective and multidimensional nature of pain experience and lack of knowledge
about pain may influence accurate assessment of pain in children LaFleur Raway 1999; Thomas 1997; McCaffery Beebe 1999; Caty et al 1995.
Reviews of pain assessment in children McGrath Unruh 1987; Atkinson 1996 have argued that because pain assessment in children is a complex procedure, it
should be based on a variety of approaches, as no single approach provides all the required information. Multi dimensional pain assessment typically includes indicators
such as verbal complaints of pain, behaviors such as facial expression and body movement and physiological arousal such as vital signs Bradshaw Zeanah 1986;
Caty et al 1995; Rheiner et al 1999; Salantera et al 1999.
The tools for measuring pain in children
There is a wide range of qualitative and quantitative instruments for measuring the sensory and emotional aspects of children’s pain Finley McGrath 1998;
Thomas, 1997; McGrath Unruh 1987. These include projective methods, in which children’s attitudes or perceptions of pain are inferred from a selection of colors, their
drawing, or their interpretation of cartoons and stories, and self-report measures, which directly describe their pain and rate pain intensity.
Thomas 1997 and Champion et al 1998 suggested that there are number of rating scales generally used to measure pain in clinical practice. Self-report scales
which are published and commonly used for measuring pain in children include: Facial Affective Scales Whaley Wong 1999; the Oucher scale Beyer 1984;
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Faces Pain Scales Bieri et al 1990; Visual Analog Scale VAS, Visual Numeric Scale Champion et al 1998. Visual Analog Scales VAS are reliable and valid
measures of pain McGrath Unruh.1994.
Pain management
With regard to pain management approaches, there are two common strategies used to manage pain in children and these can be divided into non-pharmacological
and pharmacological interventions Atkinson 1995; Llwellyn 1997.
Pharmacological interventions
The commonly used analgesia for treating pain in children includes opioids narcotics and non-steroidal anti-inflammatory drugs NSAIDs. Narcotics such as
morphine, codeine, meperidine can be administered by intravenous, intramuscular, subcutaneous and oral route Ball Bindler 1999. Non-steroidal anti-inflammatory
drugs NSAIDs such as aspirin and acetaminophen are effective for the treatment of mild to moderate pain and chronic pain, and they are primarily given orally 10-5
mgkg q 4h Ball Bindler 1999. The literature suggests that nurses often undermedicate children’s pain. For
example, Jacob Puntillo 1999 ; Gadish et al 1988; Schecter et al 1986; Asprey 1994 found that nurses administered prescribed morphine to children less frequently
than prescribed acetaminophen and that both were administered only once or twice in a 24 hour period. Some prescribed medications were not administered in the 24 hours.
The study showed that nurses administered analgesics to pediatric patients infrequently.
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Some researchers have indicated there are two major factors that may contribute to under medicating children for pain including lack knowledge about analgesia and
attitudes to pharmacological pain management policies Twycross 2001; Hamers et al 1994; Gadish et al; Clarke et al 1996; Abu-Saad Hamers 1997; Salantera 1999;
Caty et al 1995.
Non-pharmacological interventions
Non-pharmacological interventions are nursing authority in taking care of children’s pain. Non-pharmacological intervention is a broad construct encompassing
a variety of approaches designed to relieve pain which do not involve medications Vessey Carlson 1996.
Number of studies suggested evidence for effectiveness of non-pharmacological interventions in managing acute pain Good et al 2001; Mediani et al 1997; Vessey
Carlson 1996; Vessey et al 1994. Good et al 2001 conducted a randomised controlled trial to investigate the effects of relaxation, music and the combination of
relaxation and music on postoperative pain, across and between two days and two activities rest and ambulation and showed that music, relaxation and their
combination reduced pain on day one and two and during ambulation and rest. Furthermore, longitudinal effects were found over two days and across both activities
on each day. These treatments were clearly effective and patients can ambulate with greater relief without increasing opioid intake and possible side effects. However,
non-pharmacological interventions are not always used by nurses when dealing with children’s pain in clinical practice.
Several studies Jacob Puntillo 1999, Coffman et al 1997; Clarke et al 1996 indicated that non-pharmacological management approaches have not been optimally
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used in clinical practice. Coffman et al 1997 found that non-pharmacological interventions were used less as pain relief modalities by nurses than pharmacological
methods because nurses believed that critically ill children’s pain cannot be managed by non-pharmacological methods. Interestingly, nurses tended to perform in intuitive
ways and they rarely documented what they did. Furthermore, nurses also assumed that these interventions were not a specific nursing intervention for pain relief.
Research design and method
An interpretive qualitative approach was chosen to explore and gain an understanding how nurses dealing with children’s pain. Through qualitative research,
the nurse researcher comes to know the perceptions of nurses and the people for whom they care Munhall Boyd 1993; Streubert Carpenter 1995.
Minichiello et al 1995 stated that the interpretive approach seeks to understand direct lived experience rather than make an abstract generalisation. Similarly, Taylor
1994 suggested that through the accounts of their lived experiences, people are able to reflect the meaning they find within themselves and things around them. For
instance, in this research, nurses’ practices in dealing children’s pain are explored through nurses’ personal accounts.
The general perspective of the interpretive approach suggests that reality is subjective and what an individual believes it to be Taylor 1994. Reality is built on
social and historical contexts Neuman 2000. This means that reality may change based on features of times, place, and circumstance Neuman 2000. Understanding
meaning and interpretation are crucial elements of knowledge. With an interpretive approach, the perspectives of the participants are taken into
account. Neuman 2000 points out that in the interpretive approach the researcher
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shares the feelings and interpretations of the people being studied through their eyes. Thus, both participants and interviewer may share their knowledge and experience. In
this study nurses were asked to discuss their perceptions about pain assessment and management of pain in children and how they cared for children experiencing pain.
According to Taylor 1994 the interpretive approach is based on the assumption that people are the interpreter of their own experience and that elements of context
and inter-subjectivity are important components of how they can make sense of their experiences. Thus, in this study I wished to learn what is meaningful to the nurses
being studied with regard to their experiences in dealing with children’s pain. It was my purpose to listen, record, understand and interpret nurses’ beliefs and perceptions
regarding pain in children and its assessment and management.
Methods of data collection Setting
I chose pediatric surgical ward in a general government teaching hospital in Bandung as the setting for this research. It is also a referral hospital for other hospitals. The
total number of nurses in the Pediatric surgical ward was 17. Most had a qualification from vocational school 70 . Meanwhile, 30 had a qualification at a diploma
level. None of nurses had a university degree.
Selection and recruitment of participants
To recruit participants I sent a letter of introduction to nurses on the Pediatric surgical ward at the hospital. Nurses were chosen and approached on an individual
basis by myself. The potential participants were nurses who were currently working
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on the Pediatric surgical ward. The final number of participants was five all female. This number allowed for adequate exploration of the question and related issues, and
data saturation to be reached. For the purpose of this study, a convenience sampling method was considered to be the most appropriate, as the population to be researched
was small and based on information needs Polit Hungler 1999. I selected nurses who had shown interest in the issue under investigation and had agreed to participate
in the study.
Inclusion criteria
In this study I chose nurses with different education backgrounds, years of nursing experience and ethnicities. Inclusion criteria for this study were that nurses
should be currently working on the Pediatric surgical ward, and that they should have more than one year’s working experience on this ward. Additional selection criteria
included having a minimum nursing qualification from vocational nursing school. Therefore, these nurses all had direct experience caring for children experiencing
pain. Another selection criterion was informed consent to be interviewed and recorded and to verify the transcript.
Data collection
The interview method was chosen to explore how Indonesian nurses’ practice in dealing children’s pain. Furthermore, the use of the interview in this study provided
me with an opportunity to understand the significant issues concerning nurses’ perceptions, knowledge and practices regarding pain in children, and to describe their
practices from their perspective, and to interpret their words Koch 1998. A semi-structured interview method, using open-ended questions was used to
facilitate in depth exploration of nurses’ practice regarding children’s pain. The use of
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a semi-structured guide kept the phenomenon of interest in focus Wimpenny Gass 2000 and facilitated in-depth exploration of nurses’ perceptions of children’s pain
and their practice in dealing with children’s pain. Moreover, the interviews allowed participants freedom in answering the questions, and allowed me to adjust the
interviews and explore emergent issues as they arose. In-depth interviews encourage participants to ‘recall, reveal and construct
aspects of subjective experiences and interpretations and to make discussion coherent and meaningful’ Minichiello et al 1999, p.397. Meanwhile, the use of open-ended
questions means that the questions are not structured or rigid, question order may be changed and extra questions may be added if necessary. By using open-ended
questions participants are encouraged to expand on their own experiences Appleton 1995, and consider their responses Cormack 1996.
Interview process
In this study each participant was interviewed separately. Letters of introduction were provided and consent forms were signed prior to the interview. The interviews
were conducted in a quiet, private room provided by the head nurse to avoid distraction, to enhance concentration and to maintain confidentiality. The duration of
each interview was approximately 30 to 60 minutes. A mutually convenient time, date and place of interviews was organized between my self and each participant.
Although participants were given the opportunity to select a place for the interview, all participants preferred to be interviewed in the Pediatric surgical ward at the
hospital. Interviews were conducted and guided by a list of 8 questions. These questions
provided a focus and guidance for the participants, as well as allowing me to collect data on other issues that were related to this study Appleton 1995.
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All interviews started with the same question about demographic information, then a personal view: “I believe that as a nurse you have had experience in caring for
children in pain, can you please describe to me what is pain?” This question allowed the nurses to feel comfortable and to freely express their opinions. During the
interview further questions were asked to elaborate on responses to earlier questions. If participants had difficulties in answering the questions, I provided them with
examples that might give them some ideas. I also took written notes. Note taking helped me to emphasize issues of key significance in the interview and to summarize
the content of the interview. The interviews were audio taped, and then transcribed and summarised by me. A
copy of transcripts was returned to each participant with a covering letter. The covering letter instructed participants to make sure of the accuracy of the transcript
and to add or change the content of the interview if necessary. I asked the participants if the transcripts were correct. These processes aimed to make sure I captured accurate
information as told by the participants. All participants agreed that the transcripts were accurate.
Data analysis and presentation of findings
Data were analysed by organizing the data into two columns. One column listed
key topics from the interview questions. The second column listed nurses’ responses to these topics. The interview data were transcribed in order to preserve the
participants’ meaning. Participants who gave the same answer to the questions were put together under the same question. In order to become familiar with the data, I
listened again and again to the interview tapes, and read and reread the transcripts to gain an overall picture of participants’ stories Browne Sullivan 1999. The data
were analysed and refined until themes could be formulated. In this process, each
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topic was analysed separately. To support my interpretation, direct quotations with false names of participants were used in the results Mariano 1993.
Establishing rigour
The general term of rigour is more specifically known as validity and reliability Roberts Taylor 1998. Some authors Guba Lincoln 1985; Sandelowsi 1986;
Koch Harrington 1998 have suggested that it is inappropriate to apply quantitative rigour validity and realibility to judge qualitative products because of the difference
in ontological and epistemological assumptions. Burns Grove 1993, p. 64 indicated that rigour in qualitative research is ‘associated with openness, scrupulous
adherence to a philosophical perspective, thoroughness in collecting data, and consideration of all the data in the subjective theory development phase’.
The criteria for rigour in this study were based on Sandelowski 1986, Guba Lincoln 1981 and Beck 1993 which involved credibility, fittingness, auditability.
Credibility
A research design is valid when the outcomes can be accepted as ‘true’. Guba Lincoln 1981 mentioned that the ‘truth value’ of a qualitative study should be
evaluated by its credibility rather than internal validity as in quantitative research methods. Research is credible when ‘participants and readers of the research
recognize the lived experiences described in the research as being similar to their own’ Robert Taylor 1998, p.399.
Credibility in this study was achieved by sending and showing the transcript to the participants to confirm the truth and accuracy of content and the transcript. Also
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frequent consultations with my research supervisors to ask question made sure that data analysis and discussion met adequate standards of research.
Fittingness
Fittingness refers to ‘the extent to which a project’s findings fit into other contexts outside the study setting’ Roberts Taylor 1998, p.400. For instance, this
study’s finding about nurses’ perceptions about pain relief on the Pediatric surgical ward would be expected to be similar to experiences of nurses from other wards or
countries. Furthermore, fittingness of a study is shown when the findings are grounded in the life experiences studied and reflect the typical elements of data
Sandelowski 1986. By using interviews to collect data, I ensured that interpretations of the nurses’ perceptions regarding pain assessment and management of pain in
children were grounded in the words of the nurses themselves and were not derived solely from my own point of view.
Auditability
Sandelowski 1986, p. 33 pointed out that ‘a study and its findings are auditable when another researcher can clearly follow the ‘decision trail’ used by the
investigator in the study’. In order to attain auditability in this study, I recorded decision making at every stage of the research process and consulted with my
supervisors to examine whether the study was relevant, comprehensive and well developed Koch Harrington 1998. In addition, to achieve auditability in this study
I kept a journal to record the research process. Thus, I wrote activities and experiences that occurred during the research.
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Ethical considerations
Participants were provided with plain language information sheets and gave informed consent. I provided each participant with an undertaking that all data
relating to them would remain confidential. The participants were assured that their names would not appear anywhere in the transcribed material. Pseudonyms were
used. Furthermore, the name of the hospital in which the study was set is not disclosed in this thesis.
I informed the nurses of their right to withdraw or refuse involvement in the research project without prejudice. In the event of any distress or other problems
arising from this research counseling would be offered by me or by the Head Nurse at the hospital.
Result of study
The participants’ demographic data are described first as these began the interview process. The interview results are presented using
examples the participants’ own words in the following sections: the meaning of pain; nurses’ views
on assessment of pain in children; nurses’ views on pain management in children and nurses’ role in dealing with children experiencing pain.
Participants’ demographic data
Five nurses participated in the study. All were female. The range of years of working experience was from 2 to 22 years. The average length of experience was 17.4 years.
Most of the nurse participants were up to 40 years of age or between 40 and 55 years
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of age. Most nurses had a qualification at diploma level. None of nurses had a university degree.
Assessing pain in children
The nurse participants were asked to describe whether they found assessing pain in children difficult. The opinion among participants was that assessing pain in
children is difficult especially in younger children, because crying is a common response to many unpleasant sensations such as hunger or being wet.
Bunga described her opinion by expressing: Children’s response to painful procedures usually is only crying. So that sometimes it is difficult to distinguish crying
caused by pain from crying caused by other feelings such as hunger especially for young children such as infants, so that we have to investigate further the crying
response. Similarly, Anyelir, Asri, Mayang and Tiara gave their view by saying that ‘infants cry if they are in pain or hungry, thus infants’ pain is difficult to define’
The tools for measuring pain
The nurse participants were asked whether they were familiar with pain scales and if so, if they used them or not. All of the nurses knew about pain scales such as
the Facial Analog Scale and Numeric Scale. Most of the participants had used the Facial Analog Scale when involved in previous research in the hospital, but they did
not use it anymore. Reasons included that it was too time consuming to use and the tools were not available on the ward.
Bunga knew about the tools for measuring children’s pain. But she seldom applied them when she assessed patients’ pain due to them being too time consuming.
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Interestingly, she gave the explanation: sometimes I used the facial analog scale for assessing children’s pain when I was teaching nursing students.
But, she revealed further that: I never use other pain scales such as numeric scales because I do not have much time. Moreover as far as I am aware nurses in this ward
never use the tools in assessing children’s pain. I suppose they may have used them when they were involved in a study of pain a few years ago, but after the study had
finished, they did not apply them anymore. In the same way, Anyelir explained that: I have used pain scales the facial
analog scale when I was involved in a study of pain few years ago. After the study had finished I never used it again because its taking time
Anyelir assumed that pain scales are never used on the ward because many nurses believed that a child’s facial expression is an important indicator of pain. She
revealed: Honestly it happened due to nurses’ habit, commonly nurses in this ward never use pain measurement in assessing children’s pain, they just observe children’s
facial expressions. So we do not know exactly how much pain children are feeling. Mayang gave an explanation why she did not use an assessment tool anymore by
saying ‘because the tools are not available on the ward and I do not how to use them exactly.
Only one participant had never used pain scales to determine children’s pain. Tiara stated: ‘I never use the pain scales, I just ask the patient’. Further she described
her reasoning by expressing: It is because the tool for measuring pain is not available in this ward. So I just assess pain based on my point of view. I observe the patient’s
activities, if I see that the patient really needs our assistance, it means that the
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patient’s pain is severe. If the pain does not disturb the patient’s activity it indicates that pain is mild.
How to assess pain
Nurse participants were then asked to describe how they went about assessing pain. In assessing children’s pain, all nurses considered children’s behavioral and
psychological responses to pain. Interestingly, most participants also asked parents or families about their child’s response to pain.
Bunga and Anyelir used facial expressions or behavioral reactions to assess pain in children. As Bunga asserted: Firstly, I observe the location of the pain, facial
expression, and how children express their pain, and how long the experience has lasted.
Meanwhile, Mayang mentioned: I observe facial expression, movement, and ask children whether they feel pain or not. Sometimes they told me that they were pain,
but actually they were not in pain. Tiara stated that children in pain should be monitored because their coping
ability was not good. She asserted: First, I observe the patient’s condition and if they are able to communicate, I ask whether they feel pain or not, where the location of
pain is and for how long; or we can observe their coping mechanism, because children’s coping skill is not good so we can ask their parent as well.
Meanwhile, Asri told that she usually observed the patient’s condition and asked how the experience felt. Whereas, Anyelir explained that in order to know information
about children’s pain besides asking patients or parents, she looked at the child’s facial expression.
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Nurses’ views on pain management in children How to relieve pain
The nurse participants were asked to explain how they managed children in pain. All participants believed that analgesic treatment pharmacological approach
and distraction techniques such as reading books, conversation, and sponging patients’ bodies were effective ways to reduce pain in children, particularly for acute
pain. However, activities such as music intervention were never used because of lack of facilities.
Bunga told how she used pharmacological pain relief after first trying a non- pharmacological approach. She stated: I usually use distraction techniques, such as
conversation with patients, if it does not work I use pharmacology intervention using analgesic treatment such as profenid.
Anyelir used both pharmacological and non-pharmacological approaches when dealing with children’s pain. She stated: Beside medication I usually ask patient to do
deep breathing or I sponge the patient’s body; keep talking with the patient or encourage the patient to read a book. I give analgesic treatment especially for post
operative patients. Interestingly, Tiara used another kind of distraction technique to minimize
children’ pain. She commented: I usually use distraction and relaxation techniques. For example, I ask patients to read a storybook, or play with children using their toys.
Meanwhile, for a little kid I encourage his mother to sponge her child; and give analgesic treatment.
In the same way, Asri and Mayang usually used pharmacological pain relief and non-pharmacological methods in alleviating children’s pain. Mayang revealed:
Usually children are given profenid pain- killer and also comforted by ways such as
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by holding the patient, making conversation and sponging his body in order for children to be able to forget their pain experience’.
Asri asserted: I usually gave analgesic and tried to change the patients’ attention of their pain by communication in order for children to be able to forget their pain
experience.
Non-pharmacological intervention approaches
The nurse participants were asked a question specifically about their views on non-pharmacological intervention approaches as a way of minimising children’s pain.
As mentioned above most participants knew some types of non-pharmacological intervention. Indeed, all participants had applied distraction and relaxation techniques
for decreasing patients’ pain, but other methods such as music intervention and play therapy were rarely used because they were not provided on the ward. Interestingly,
even though participants agreed that non-pharmacological approaches can minimise children’s pain, these methods were not always used by nurses on the ward because
they thought they were time consuming. Moreover, there is a belief that analgesic treatment pharmacological approach is a simple, effective and quick approach to
managing pain. Bunga argued: I know some of non-pharmacological approaches such as distraction
and music intervention. I usually use distraction technique. I have used music intervention when I was involved in a study of pain. However, I never use it anymore
due to unavailable facilities. Anyelir explained that she knew distraction, deep breathing technique and music
techniques as non-pharmacological pain relief methods. Moreover, she thought that these techniques were suitable for relieving children’s pain. Asri agreed that non-
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pharmacological intervention is a fitting approach in decreasing pain. But, she stated she never uses music intervention. I never use other methods such as music
intervention due to this facility in this hospital not being available and nursing’s workload is too heavy.
Similarly, Mayang
agreed that non-pharmacological approaches
were appropriate ways for reducing pain in children. However, she told that she often
forgot to use the relaxation technique. She asserted: I often forget to apply the relaxation technique. I never use other methods such as guided imagery because I do
not know about them. Music intervention is never used because it is not available on this ward. But, I did use it when I was involved in a study of pain a few years ago
Tiara said that she did not recognise the term ‘distraction technique’ even though in caring for children experiencing pain she used distraction methods such as
communication, and sponging. She knew about other non -pharmacological
approaches such as music intervention. Also, she thought that hypothetically this method helps children to forget about their pain. She stated: I suppose communication
with the patient and sponging the patient’s body will decrease children’s pain and children might forget their experience. I did not know exactly the term distraction
techniques and also other methods, but I know music intervention.
Pharmacological intervention approaches
The participants were asked to describe their views about pharmacological pain approaches to relief of pain in children. Moreover, they were asked how doctors
offered pain relief to patients. According to some participants analgesic treatments are generally offered by the doctor post operatively, but others said that sometimes it is
not given for minor procedures. Furthermore, some doctors did not write any
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instructions for giving the analgesic treatment. Interestingly, there were different beliefs regarding pain treatment among participants. Some participants assumed that
analgesic treatment would be administered if patients were really in pain, and they believed that pain medication might cause children to become addicted to analgesic
treatment. For instance, as Bunga and Anyelir stated, they did not always administer pain relief to children although doctors had ordered it. They administered pain
medication in accordance with their judgment of the child’s pain. Bunga revealed: Generally children are always offered analgesic treatment post-
operatively. But, after they come to the ward, it is not always administered as ordered by nurses. I usually observe the patient’s condition first and if I judge that they are
not in pain, I do not administer pain relief. Thus, pain relief is only given if really necessary, even if the medication is not used at all.
Anyelir’s reason for not administering pain relief was that for a minor operation such as a herniotomy or a hydrocelectomy, pain relief is not needed because the
anesthesia is still working. Interestingly, she described her belief by stating: if children are given analgesic treatment continuously, children will bear greater risk
for addiction to analgesic treatment, so that they need higher doses. Moreover, I assume that children tolerate pain better than adults. Thus analgesic treatment is
administered only if children are really in pain.
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Similarly Asri and Mayang described that she administers medication if she thinks that the patient really needs it and if the patient feels very painful. However, if
the patient’s pain can be tolerated by using other techniques such as by touching, holding, the pain relief is not given. Thus, the medication is administered if really
necessary. However, Mayang argued that some doctors sometimes do not offer analgesic
treatment to the patients post minor operation, they only gave antibiotics. She asserted: As far as I am concerned for minor operations some doctors seldom offered
pain relief but they only gave an antibiotic. However, if I know that the patient was in pain, I always report and ask the doctors whether the patient should take analgesic or
not. Meanwhile, Tiara argued that she always administer analgesic treatment as written up by doctors in the patients’ notes.
Barriers to managing pain effectively
All participants noticed that pain management in children on the ward was not
yet optimal due to some restrictions such as limited knowledge, in particular the theories of pain, pain assessment, and non-pharmacological approaches. Nurses
assumed that their knowledge about theories of pain, pain assessment, pain management and non-pharmacological approaches was lacking. They revealed that
although they have learnt about pain theory, it was very little, not in detail and it was never applied to the patients directly. Therefore, they realised that they still needed to
learn more about pain and non-pharmacological intervention. Bunga said : The nursing knowledge is an important point for nurses to care for
patients adequately .Dahlia expressed similar words: I suppose the nursing
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knowledge is a pivotal aspect for nurses in caring for paediatric patients effectively. Further, Dahlia argued that: Nurses on this ward have limited knowledge about theory
of pain, pain assessment and management. We have not known yet how to do assessment and pain management using a non-pharmacological approach to the
patients correctly. Similarly, Mayang agreed that generally nurses on the ward have a lack of
knowledge about pain assessment and management, especially non-pharmacological interventions.
Other barriers to giving pain relief were lack of resources and facilities. All participants agreed that facilities such as pain scales, toys and music intervention were
not available on the ward. Moreover, all nurses assumed that ineffective pain management happened because they have heavy workloads on the ward. For
instance, Bunga explained that: Nurses face some restrictions in dealing with children’s pain such as nurses’ workload being too high; nurses must do other
activities besides nursing activities, for instance, consult with laboratories, do administration tasks etc, so we do not have enough time to assess children’s pain
effectively. Interestingly, Asri thought that ineffective pain management was influenced by
nurses’ views about pain medication, nurses’ attitudes, besides limited knowledge, resources and also limited time for assessing children because nurses must do other
activities beside caring for patients. Asri asserted that: Another factor is that some nurses believe that pain relief is a quick and simple
method for managing children’s pain and some nurses just know that medication is a tool for treating pain, also the total number of nurses is insufficient for the number of
patients.
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Mayang assumed that nurses’ attitude to children’s pain influences ineffective pain management on this ward. She explained that:
…Some nurses are too lazy to do assessment of children experiencing pain because they think that it was time consuming and some nurses on this ward do not know
exactly the meaning of pain, they assume that pain occurred due to any hurt Meanwhile, Tiara argued that nurses have tried to do pain management in
children as best as they can. However, Tiara believed that: ‘caring for children in pain needs a special approach’. Further, she revealed: The main problem is that nurses’
workload is too heavy compared to the total number of patients. Another factor is that some nurses assume that they cannot care for the patients properly because they have
to do routine activities such as giving injections, bed making and wound care. They thought that they have to do tasks routinely
Nurses’ role in dealing with children experiencing pain
All participants agreed that because nurses are primary care givers and are in close and frequent contact with patients, they have a good understanding of the
patient’s condition as well. Thus, nurses have primary responsibility to assess and manage children’s pain. For instance, Mayang explained her opinion by stating that: It
is exactly true that a nurse is a person who is really in close and more frequent contact with the patients, and nurses know the patients’ condition well.
Meanwhile, Asri revealed her opinion by asserting that: A nurse is a person who is really close to the patients, and I believe that pain is a patient’s problem, it should
be resolved so that it does not interfere with children’s activities.
Discussion
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Results of this study provided a comprehensive picture of nurses’ attitudes, beliefs and perceptions regarding certain aspects of children’s pain and revealed
complex factors that influenced nurses’ practices around children’s pain in a general teaching hospital in Bandung. In results of study found some themes related to the
following headings: nurses’ views on assessment of pain in children; nurses’ views on pain management in children and nurses’ role in dealing with children experiencing
pain.
Nurses’ views on assessment of pain in children 1. Assessing pain in children is difficult because infant and younger children
usually crying
An important theme that emerged from this study was the view that assessing pain in children is difficult. Some of the nurse participants explained that pain
assessment in younger children and infants was quite difficult because they usually respond to painful procedures only by crying. The results indicated that the nurses
could not distinguish between a cry expressing pain and a cry expressing a response to another sensation in infants such as hunger or being wet. These findings are consistent
with previous studies Salantera et al 1999; Jacob Puntillo 1999; Allcock 1996; Brunier et al 1995 which showed the difficulty of assessing pain in children.
Another reason for the difficulty of assessing pain is because pain perception is complex and pain is highly subjective therefore objective assessment of pain may be
difficult. The language and behavioral responses used by pediatric patients to describe their experience may bring a different message from that which is proposed because
patients and nurses use language in different ways owing to their experience and perspective Thomas 1997. Problems with assessment of pain were evident from this
study, but this is not be too surprising because other researchers have also highlighted
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the difficulty of objectively assessing pain Zacharias Watts 1998; Thomas 1997; Carr 1997. Therefore, in order for nurses to be able to assess pain in children, it is
important they are more aware of signs and symptoms of pain in infants and young children.