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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.
2. The assessment tools for pain in children are too times consuming to use
Another important theme that arose from this study was regarding the assessment tools for pain assessment in children. The results of this study indicated that although
the participants knew about several pain scales such as the Facial Analog Scale, Visual Analog Scale and Numeric Scale, these tools were not applied in their clinical
practice. These findings also are consistent with earlier studies Wallace et al 1995; Margolius et al 1995; Clarke et al 1996; Jacob Puntillo 1999; Salantera et al 1999.
Participants in this study said they did not use the assessment tools because they were too times consuming to use, not available on the ward and some nurses did not know
how to use them. Another reason was that the nurses believed the child’s facial expression and behaviour response are important and sufficient signals of pain.
Findings of this study indicated that some of the nurses had limited knowledge about several valid and reliable tools for measuring children’s pain, such as behavioral
scales and the Facial Analog Scale.
3. Children’s facial expressions and behavior responses as indicators of pain
Regarding how nurses went about assessing pain, the findings of this study indicated that children’s behavioral responses, verbal reports, facial expressions and
psychological responses were the major criteria frequently used by the nurse participants to assess children’s pain. They usually observed children’s facial
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expressions and asked children how the experience felt. An important result of this study is that the nurses rarely considered physiological signs of pain when assessing
their patients. The results of this study are consistent with a previous study Jones 1989 which
found that behavioral signs such as crying, grimacing, and facial expression were commonly noticed as indicators of pain in children. Ideally, the nurses must consider
not only children’s behavior but also physiologic signs for example, change in vital signs especially in infants, small children and preverbal children to determine the
presence and quantity of children’s pain. I agree with the view of Atkinson 1996; Stevens 1998; McGrath Unruh
1987 that because pain is a subjective phenomenon it is difficult to quantify and qualify, and should be assessed by a variety of subjective and objective measurement
approaches including
self-report, behavioral and
physiological indicato
rs. Physiological measurements have been proved useful in acute pain Soetenga et al
1999. However, the findings of this study indicated that some of the participants seemed to be less concerned about physiological indicators. This might be because
they were not familiar with the physiological indicators of pain. Another important finding of this study was that some of the nurses also asked
parents about their children’s pain to obtain information. This is a good approach because involvement of the parents is essential in caring for children with pain;
parents may be an important source of information in the assessment of children’s pain, as indicated by McCaffery Beebe 1994. However, Hamers et al 1994
indicated that parent information about their children’s pain is not always to be trusted and that nurses should check and verify parents’ statements.
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Although the nurses in this study tried to assess children’s pain by using behavioral signs, the findings indicated that the nurses had limited knowledge about
pain assessment, especially about pain scales and physiological measurements. A lack of knowledge may contribute to an inability to assess patients systematically and may
impact negatively on management and treatment of pain. Indeed, accurate assessment of pain is vital if effective pain management is to be achieved. Formal pain
assessment tools help in providing effective communication and assessment by avoiding the chance of error or bias Carr Mann 2000.
Nurses’ views on pain management in children 3. Pharmacological approaches are usually used first for dealing children’s pain
because more effective than non pharmacological approaches
In response to the questions about pain management in children, all the nurse participants asserted that both pharmacological agents and non-pharmacological
intervention such as distraction or comfort techniques could reduce pain in children, particularly acute pain, and that these approaches were used to relieve pain in
children. However, most of the nurses tended to use pharmacological pain relief first before trying a non-pharmacological approach.
Results of this study indicated that most participants knew about some non- pharmacological interventions. The majority of the nurses ha
d applied non- pharmacological approaches for reducing children’s pain, for example, distraction
techniques such as reading books, conversation, comfort measures and relaxation techniques, such as deep breathing exercise. Most of the participants believed that
these strategies reduce pain by helping children to forget about their pain. The literature suggests that strategies such as distraction, play therapy and
relaxation, act by increasing children’s physical activity, decreasing anxiety and
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enhancing adaptive coping behavior McGrath 1990. The effectiveness of these strategies in reducing pain and distress in children has been investigated and
confirmed by several studies Good et al 2001; Mediani et al 1997; Vessey Carlson 1996. However, strategies such as music intervention, play therapy, hypnosis and
acupuncture were not used in this study due to lack of facilities on the ward. According to some participants, they had tried to use music intervention with
postoperative patients when they were involved in a previous study Mediani et al 1997, which suggests that it effectively reduced intensity of postoperative pain in
children. But music therapy was not applied anymore on the ward because facilities were unavailable. The nurses only used other non-pharmacological techniques such as
distraction, relaxation and comfort measures to reduce pain.
4. Non-pharmacological interventions were used less often as a nur sing
